Pediatric Abdominal Pain

Aka: Pediatric Abdominal Pain, Abdominal Pain in Children

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II. Epidemiology

  1. Abdominal Pain accounts for 9% of primary care visits for children
  2. Incidence of acute surgical presentations of Abdominal Pain
    1. Emergency Department: 10-30% of acute Abdominal Pain in Children requires surgery
    2. Overall: 2% requires surgery

III. Types

  1. Acute Abdominal Pain
    1. Characteristics
      1. Less than 4-6 weeks (subacute less than 12 weeks)
      2. Single episode, self limited and treatable
      3. Episodic localized pain, sharp, stabbing
    2. Common Causes
      1. Urinary tract disease
      2. Peptic Ulcer Disease
      3. Inflammatory Bowel Disease
      4. Gastroesophageal Reflux Disease
  2. Chronic Abdominal Pain
    1. Characteristics
      1. Three episodes over 3 months
      2. Continuous, dull, vague and diffuse Abdominal Pain
      3. Recurrent, Associated with debilitation
    2. Common Causes
      1. Constipation
      2. Lactose intollerance
      3. Mittelschmerz
      4. Psychogenic (See Recurrent Abdominal Pain Syndrome)
        1. Secondary Gain
        2. Sexual abuse
        3. School Phobia

IV. History: Red Flags

  1. Acute
    1. Bilious Vomiting
    2. Fever
      1. Especially if onset after the Abdominal Pain onset (higher risk of peritonitis)
    3. Localized pain away from midline
    4. Bloody Diarrhea
  2. Chronic
    1. Altered bowel habits
    2. Growth disturbance
    3. Nocturnal episodes
    4. Radiation of pain
    5. Incontinence urine or stool
    6. Systemic symptoms

V. History: Abdominal Pain

  1. Timing
    1. Onset of Abdominal Pain
    2. Frequency, Duration and time of day
    3. Which days of the week
  2. Location and radiation of Abdominal Pain
  3. Intensity and character
    1. Change in stool consistency or frequency
  4. Hydration status
    1. Level of alertness (lethargy vs alert and attentive)
    2. Tolerating oral intake without Emesis? How much intake?
    3. Adequate Urine Output (>3/day under age 1, and >2/day over age 1)
  5. Food associations
    1. Milk or cheese
    2. Spicy food
    3. Caffeinated soda, tea
  6. Exacerbating and relieving features
    1. Relationship to activity and school
    2. Attempted therapies
    3. Relieved with movement (esp. poorly localized pain)
      1. Visceral pain (e.g. Volvulus)
    4. Worse with movement (esp. sharp and localized)
      1. Abdominal Wall Pain
  7. Associated symptoms
    1. Fatigue
    2. Syncope
    3. Headache
    4. Upper Respiratory Infection or Pharyngitis
      1. Consider Streptococcal Pharyngitis
      2. Consider Pneumonia
  8. Vomiting
    1. Vomiting (before or after pain?)
    2. Bilious Vomiting suggests obstruction
  9. Bloody stool?
    1. Peptic Ulcer
    2. Bowel ischemia

VI. History: Review of Systems

  1. Genitourinary and gynecological symptoms
  2. Respiratory symptoms (esp. cough, Pharyngitis)
  3. CNS symptoms
  4. Musculoskeletal symptoms

VII. History: Past Medical History

  1. General history
    1. Surgical history (esp. abdominal surgeries)
    2. Medications
    3. Major illnesses or hospitalizations
    4. Growth and development
  2. Sickle Cell Disease
    1. Splenic Sequestration
    2. Vaso-Occlusive Pain Crisis
    3. Gall Bladder disorder
    4. Intrahepatic cholestasis
  3. Immunosuppression
    1. Immunosuppressed patients with subtle findings despite severe underling abdominal abnormalities
    2. Neutropenia
      1. Neutropenic Enterocolitis (Typhlitis) presents as Right Lower Quadrant Abdominal Pain
  4. Anorexia or other condition causing rapid weight loss
    1. Superior Mesenteric Artery Syndrome may present with severe Abdominal Pain with Vomiting
  5. Cerebral Palsy
    1. Constipation (most common)
    2. Sigmoid Volvulus

VIII. History: Family History

  1. Ethnic Background
  2. Migraine Headache
  3. Seizure Disorder
  4. Gastroesophageal Reflux disease (GERD)
  5. Peptic Ulcer Disease (PUD)
  6. Inflammatory Bowel Disease (IBD)
  7. Irritable Bowel Syndrome (IBS)
  8. Pancreatitis
  9. Hepatitis

IX. History: Social History (Mnemonic: HEADSS)

  1. Home
    1. Death, divorce, serious illness, care providers, siblings
  2. Education
  3. Activities
  4. Drug Use
  5. Suicidal Ideation
  6. Sexual activity

X. Exam

  1. Perform in comfortable, non-threatening environment
  2. Appearance
    1. See Inconsolable Crying in Infants
    2. Moaning in discomfort
    3. Motionless or lethargy (peritonitis)
    4. Writhing (e.g. Renal Colic)
  3. Vital Signs
    1. Fever
    2. Tachycardia
    3. Weight (compare with prior)
  4. Comprehensive exam
    1. Heart, lung and general exam should be performed before abdominal exam
    2. Evaluate for referred pain
      1. Throat exam
        1. Streptococcal Pharyngitis
        2. Mononucleosis
      2. Lung Exam
        1. Pneumonia
      3. Hip Exam
        1. Toxic Synovitis
        2. Septic hip
  5. Abdominal exam
    1. Test rebound as "Jump on and off table" or bump the side of the table
    2. Consider asking parents to push on Abdomen (with examiners hands on top)
    3. Use stethoscope to apply pressure
    4. Avoid removing hand rapidly (loses patient trust)
    5. Examine the most painful area last (as with all patients)
  6. Genitourinary exam
    1. Perform in all cases of Pediatric Abdominal Pain
    2. Girls
      1. Ovarian Torsion
      2. Ectopic Pregnancy (adolescent)
      3. Pelvic Inflammatory Disease (adolescent)
    3. Boys
      1. Testicular Torsion
      2. Undescended Testicle
      3. Inguinal Hernia
      4. Epididymitis or Orchitis
  7. Rectal Exam
    1. Strongly consider

XI. Labs

  1. Screening
    1. Complete Blood Count
    2. Comprehensive Metabolic Panel (including Liver Function Tests)
    3. Serum Lipase
    4. C-Reactive Protein (or ESR)
    5. Urinalysis
      1. Clean catch urine or catheterized urine
    6. Post-pubertal girls
      1. Urine Pregnancy Test (Urine HCG)
      2. Consider Gonorrhea PCR and Chlamydia PCR
  2. Consider additional testing
    1. Streptococcal Rapid Antigen Test
      1. Epigastric Pain often accompanies Streptococcal Pharyngitis in children
    2. Monospot
      1. Mononucleosis may also present with Abdominal Pain
    3. Stool Cultures (bloody Diarrhea or Dysentery)
      1. Escherichia coli
      2. Campylobacter
      3. Salmonella
      4. Shigella
      5. Yersinia
    4. Parasite evaluation (Chronic Diarrhea)
      1. Ova and Parasites
      2. GiardiaAntigen
      3. Cryptosporidium (Immunocompromised Children)
    5. Helicobacter Pylori titer (Peptic Ulcer Disease)
    6. Transaminase increase
      1. Hepatitis Serologies (Hepatitis A, and if risks, Hepatitis B and Hepatitis C)
    7. Lead Level

XII. Imaging

  1. Flat and Upright abdominal XRay (KUB)
    1. Typically low yield, but low radiation exposure
    2. Ingested Foreign Body
    3. Small Bowel Obstruction
    4. Abdominal free air
    5. Constipation
  2. Abdominal Ultrasound
    1. Preferred first-line study for Pediatric Abdominal Pain imaging
    2. Appendicitis or intussception
    3. Cholecystitis
    4. Hydronephrosis or Renal Mass
    5. Testicular Torsion
    6. Ovarian Torsion, Ectopic Pregnancy or Tuboovarian Abscess
    7. Pyloric Stenosis (Projectile Vomiting in young infants)
  3. Upper GI with Small Bowel follow through
    1. Evaluate for Volvulus
  4. Other studies
    1. Abdominal CT (avoid if possible due to significant radiation exposure)
      1. See CT-associated Radiation Exposure
    2. Ultrafast 3T MRI (3 Tesla MRI)
      1. Focused MRI can complete Appendicitis imaging in 6 minutes
      2. Johnson (2012) AJR Am J Roentgenol 198( 6): 1424-30 [PubMed]
    3. Skeletal Survey (assess physical abuse)
    4. Upper endoscopy (EGD)
    5. Colonoscopy
      1. Inflammatory Bowel Disease

XIII. Differential Diagnosis: Acute Pain

  1. See Pediatric Abdominal Pain Causes
  2. Intussusception
    1. Most common cause of acute Intestinal Obstruction in ages 3-12 months old
    2. Ultrasound is preferred imaging modality (high Test Sensitivity and Specificity)
  3. Volvulus
    1. Presents with Bilious Emesis and Abdominal Pain in newborns, infants and young children
    2. Congenital malrotation of the bowel allows for Volvulus
    3. Upper GI series is preferred imaging modality
  4. Appendicitis
    1. Classic signs and symptoms of Appendicitis warrant surgical evaluation without imaging
    2. Ultrasound is typically performed as first-line study in unclear cases
    3. Surgical Consultation and serial examinations should be considered when Ultrasound is non-diagnostic
  5. Urinary Tract Infection
    1. Pyelonephritis
  6. Gynecologic causes
    1. Ovarian Torsion
    2. Ovarian Cyst
    3. Ectopic Pregnancy
    4. Pelvic Inflammatory Disease
  7. Males
    1. Testicular Torsion
    2. Inguinal Hernia
    3. Epididymitis or Orchitis
  8. Abdominal mass
    1. See Abdominal Mass in Children
    2. See Abdominal Mass in Newborns
  9. Trauma
    1. See Pediatric Abdominal Trauma
  10. Non-abdominal causes
    1. Streptococcal Pharyngitis
    2. Pneumonia
    3. Abdominal Migraine

XIV. Management: Acute Abdominal Pain

  1. See Acute Abdominal Pain
  2. See Acute Pelvic Pain
  3. See Functional Abdominal Pain in Children (Recurrent Abdominal Pain Syndrome)
  4. Initiate fluid Resuscitation early
  5. Do not delay Analgesics in Acute Abdominal Pain
    1. Use Opioid Analgesics where appropriate (as you would for adult patients with Abdominal Pain)
  6. Obtain early surgical Consultation when acute red flag findings are present
    1. Bilious Vomiting
    2. Bloody Diarrhea
    3. Fever
    4. Concerning abdominal exam findings (absent bowel sounds, Rebound Tenderness, rigidity or guarding)
  7. Constipation is a diagnosis of exclusion
    1. Consider all serious Abdominal Pain causes first (and exclude based on a careful history and exam)
    2. Normal labs (including CBC, CRP) do not exclude Appendicitis or intussception
  8. Serial re-examination in 12 hours in uncertain cases
    1. Diagnosis changes in 30% of cases
    2. Toorenvliet (2010) World J Surg 34(3):480-6 [PubMed]

XV. References

  1. Park (2015) Crit Dec Emerg Med 29(8): 2-8
  2. Majoewsky (2012) EM:Rap-C3 2(3):1
  3. Leung (2003) Am Fam Physician 67(11):2321-6 [PubMed]
  4. Reust (2016) Am Fam Physician 93(10): 830-6 [PubMed]

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