| Abdominal Pain | ||
Kurt A. Brown
| Database Differential Diagnosis Approach to the Patient Data Gathering Physical Examination Laboratory Aids Emergency Care Common Questions and Answers Bibliography |
| DATABASE | ||
DEFINITION
Abdominal pain is a frequent complaint in the pediatric age group (see table below). Pain may be acute or chronic, focal or non-specific. A child's complaint of abdominal pain can originate from gastrointestinal and non-gastrointestinal sources within the abdomen, or can be the manifestation of referred pain from extra-abdominal sites. A careful, complete history and physical examination are required to elucidate the origins of this chief complaint.
 |
More Common Causes of Abdominal Pain by Age
| DIFFERENTIAL DIAGNOSIS | ||
CONGENITAL/ANATOMIC
INFECTIOUS
TOXIC, ENVIRONMENTAL, DRUGS
TRAUMA
TUMOR
METABOLIC
ALLERGIC/INFLAMMATORY
FUNCTIONAL
MISCELLANEOUS
| APPROACH TO THE PATIENT | ||
GENERAL GOALS
Decide if abdominal pain complaints require emergent, urgent or non-immediate intervention.
Phase 1: Careful and complete history and physical examination to narrow this extensive differential diagnosis.
Phase 2: Directed laboratory evaluations should be made to support more likely portions of the differential diagnosis. If a narrowed differential is difficult to formulate, every effort should be made to assure that the patient is clinically stable. A limited blood and/or radiographic evaluation screening with a CBC, ESR, comprehensive metabolic panel (i.e., Na+, K+, Cl-, CO2, BUN, creatinine, glucose, total protein, albumin, ALT, uric acid, LDH) and/or abdominal x-ray for significant abnormalities could be made to ensure there are no significant abnormalities above one's clinical suspicion.
Phase 3: Institute appropriate therapy related to diagnosis.
| DATA GATHERING | ||
HISTORY
Question: Location of pain?
Significance: Pain etiology (see
table
below)
 |
Etiology of Abdominal Pain Based on Most Common Symptom Location*
Question: Duration of pain?
Significance: Acute versus
chronic illness
Question: Onset and progression of symptoms?
Significance:
Evolution of painful process to help discriminate the exact pathological
process
Question: Frank hematochezia?
Significance: Colonic bleeding
or massive upper gastrointestinal bleeding
Question: Abdominal distension?
Significance: Distension of
an abdominal viscus by air, stool, or fluid
Question: Radiation of pain?
Significance: Certain entities
characteristically have radiation of pain (i.e., pancreatitis to the back,
appendicitis to the right lower quadrant, gallstones to the shoulder).
Question: Pain relieved by bowel movements?
Significance:
Etiology may be related to colonic distension (by air or stool) or inflammation
(colitis).
Question: Bowel movement pattern?
Significance:
Constipation
Question: Relationship to emesis?
Significance: Usually
upper intestinal tract disorders
| PHYSICAL EXAMINATION | ||
Finding: Location of pain
Significance: See table
Etiology of Abdominal Pain Based on Most Common Symptom Location, below
Finding: Re-examinations by the same health care provider for changing
characteristics
Significance: Evolution of abdominal process
Finding: Rebound tenderness
Significance: Peritonitis and
the potential need for surgical intervention
Finding: Rectal examination
Significance: Peritoneal
irritation, additional localization of pain, masses, presence and consistency of
stool, and/or heme positive stools
| LABORATORY AIDS | ||
Test: CBC with differential
Significance: Total white count
is non-specific and may be a poor indicator of intestinal inflammation.
Test: Erythrocyte sedimentation rate (ESR)
Significance:
Non-specific indicator of systemic inflammation
Test: Urinalysis
Significance: General screen for urinary
tract abnormalities
Test: Two position abdominal x-ray
Significance: Possible
clue to ileus, intussusception, intestinal obstruction, retained feces, or
gas.
| EMERGENCY CARE | ||
Every effort should be made to ensure that the patient is clinically stable. Frequent evaluation of vital signs and physical examination are a means of assessing evolving pain and ensure the patient is well enough for potential discharge.
| COMMON QUESTIONS AND ANSWERS | ||
Q: What is the most common cause of abdominal pain in
children?
A: Constipation is probably still the most common
presentation of abdominal pain. It can easily imitate the presentation of any
organic disease, with localization of pain to any quadrant with any symptoms,
including vomiting, diarrhea, or reflux.
Q: What are some of the physical findings associated with various
abdominal pain syndromes?
A: In the presence of acute pancreatitis,
there may be discoloration of the umbilicus (Cullen sign) and/or flank area
(Grey Turner) sign. These are seen only in severe hemorrhagic pancreatitis. The
presence of Murphy's sign is associated with gallbladder pathology. Tenderness
over McBurney's point could suggest a process in the appendix.
Q: What is Rovsing sign?
A: This is tenderness over the left
lower quadrant, which also causes pain in the right lower quadrant. This is
highly suspicious for appendicitis.
Issues for Referral
Persistent abdominal pain without clear etiology or chronic gastrointestinal diseases should be referred to a pediatric gastroenterologist.
Clinical Pearls
| BIBLIOGRAPHY | ||
Apley J. Psychosomatic aspects of gastrointestinal problems in children. Clin Gastroenterol 1977;6:311–320.
Hatch EI. The acute abdomen in children. Pediatr Clin North Am 1985;32:1151–1164.
Mason JD. The evaluation of acute abdominal pain in children. Emerg Med Clin North Am 1996;14:629–643.
Pearigen PD. Unusual causes of abdominal pain. Emerg Med Clin North Am 1996;14:593–613.
Copyright
© 2000 Lippincott Williams & Wilkins
M. William
Schwartz, Louis M. Bell, Jr., Peter M. Bingham, Esther K. Chung, David F.
Friedman and Andrew E. Mulberg, The 5 Minute Pediatric Consult