ABDOMINAL  PAIN

DR.M ABBAS. SUBHANI
MBBS DCH

Abdominal pain is very common. Usually it is not a serious problem but at times may be manifestation of life threatening illnesses. The problem causing pain may be outside the abdomen.

COMMON CAUSES: GIT and urinary Infections and infestations (intestinal-helminthes). Treatable conditions are Amoebiasis, Giardiasis, Typhoid, and Helminthes. Tuberculosis abdomen is also common  and treatable. Majority of the urinary infections are treatable. Prodromal stage of viral hepatitis may present with pain. Food allergy and irritable bowel syndrome are also common. Basal pneumonia and mesenteric adenitis are the common extra abdominal causes.

UNCOMMON CAUSES  Glomerulonephritis, urinary stones, anaphylactoid purpura, hemolytic crises and malignancies

CLINICAL  APPROACH cry, irritability, or loss of appetite may be presumed (by the attendants) due to pain abdomen. First make sure the problem is a fact not presumption  (it is pain abdomen) then analyze it. It is done with history and examination.
Ask for
Vomiting and lose motions(gastroenteritis) * Mucous and blood in stools( amoebiasis) * Fever(UTI Typhoid mesenteric adenitis and Tuberculosis) * Recent loss of appetite(hepatitis) * Blood stained OR coffee colored urine( stones, glomerulonephritis) * Rash (anaphylactoid purpura) *Recent change in diet and temperament
Recurrent vomiting, distension of abdomen, constipation, aggravation of pain on changing the posture may be signs of serious problems (illnesses)

Look for
Fever,*Pharyngeal,inflammation(mesentericadenitis)*Respiratory rate and breath-sounds(pneumonia) Urticarial rashes* Distension, movement of abdominal wall, visible bowel loops and peristalsis, rigidity, tenderness and bowel sounds.

FURTHER  APPRAISAL
Consider following illnesses if no abnormal finding is detected
*worms *amoebiasis *giardiasis *mesenteric adenitis *UTI * food allergy *irritable bowel syndrome *prodromal stage of hepatitis *early stage of abdominal tuberculosis
Appendicitis, intussusception,obstruction, peritonitis and perforation are not common but should be ruled out after proper evaluation as these may be life threatening.
Tenderness shifts with change in patient’s position in mesenteric adenitis. It is fixed in appendicitis
IF THE DIAGNOSIS IS NOT CLEAR &SERIOUS PROBLEMS / ILLNESSES CAN NOT BE RULED OUT WITH SURETY

-  Observe the patient for 12-24 hours or more
- Take the opinion of Pediatrician/Surgeon or both
- Advise investigations CP, URINE D/R , X-RAY ABDOMEN(look for gas under diaphragm, radio-opaque calculi, distended bowel loops , evidence of intussusception and multiple fluid levels in abdomen) and ULTRA-SOUND ABDOMEN analyze the results thoroughly and logically. In some patients x-ray chest may be helpful (if pneumonia is suspected)
PRIMARY  MANGEMENT
If there is no evidence/suspicion of serious problems antispasmodics may suffice. Dicylomine, Oxyphenonium bromide, Pipenzolate are used orally Hyoscine can be given orally or intramuscularly depending upon the severity of pain. These drugs should not be used in very young children and for long time. The side effect is Atropinism(dry mouth, blurred vision , dizziness, fatigue, tremors and urinary retention. Benefits of” carminative mixtures”, “gripe-water”, and ”ghutti” have not been proved so far.
THERE IS NO HARM IN USING ANTI-HELMINTHICS (e.g-Mebendazole) ON SUSPICION      *Infantile-colic will be discussed separately

COMMON PITFALLS--Treatment without examining the patient (on the description of attendant) -Consideration that the only reason of irritability or cry in infants is pain abdomen - Exclusion of pain abdomen in absence of findings (clinical or laboratory)- Either no or undue consideration of functional pain abdomen –Not considering extra abdominal causes - Not giving therapeutic trial with de-worming drugs in suspected cases