Abdominal Pain Kurt A. Brown M.D. Database DEFINITION Abdominal pain is a frequent complaint in the pediatric age group.

Pain may be acute or chronic, focal, or nonspecific. A child's complaint of abdominal pain can originate from gastrointestinal (GI) and non-GI causes but also commonly can be the manifestation of referred pain from extraabdominal sites. Differential Diagnosis CONGENITAL/ANATOMIC Incarcerated hernia Intestinal adhesions

Intussusception Malrotation with volvulus Ovarian torsion Testicular torsion Uteropelvic junction obstruction

INFECTIOUS Cystitis and urinary tract infections Fitz-Hugh-Curtis syndrome

Gastroenteritis (bacterial, viral, or parasitic) Helicobacter pylori gastritis Mononucleosis with splenic enlargement/rupture Otitis media Pharyngitis Pelvic inflammatory disease Peritonitis Pneumonia Psoas abscess Sepsis Tuboovarian abscess Varicella

TOXIC, ENVIRONMENTAL DRUGS Anticholinergic drugs Caustic ingestions

Intestinal foreign body

Heavy metal (i.e., lead) ingestion Mushroom poisoning Sympathomimetic drugs

TRAUMA Child abuse Duodenal hematoma

Perforated viscus Splenic hematoma/rupture

TUMOR Any tumor, benign or malignant, leading to viscous obstruction Leukemia

Lymphoma Nephroblastoma Wilms tumor

GENETIC/METABOLIC Diabetic ketoacidosis ALLERGIC/INFLAMMATORY Appendicitis Cholecystitis

Eosinophilic gastroenteritis Hemolytic-uremic syndrome Henloch-Schonlein purpura Hepatitis Inflammatory bowel disease Mesenteric adenitis Necrotizing enterocolitis Pancreatitis Peptic ulcer or gastritis Esophagitis or duodenitis

FUNCTIONAL Depression Functional abdominal pain

Malingering

Munchausen syndrome (+/- by proxy)

MISCELLANEOUS Abdominal migraine Cholelithiasis

Colic Constipation Dysmenorrhea Ectopic pregnancy Endometriosis Ileus Intestinal pseudoobstruction Irritable bowel syndrome Lactose intolerance Mittelschmerz Nephrolithiasis Ovarian cyst Pregnancy Porphyria Sickle-cell disease Typhlitis

Approach to the Patient GENERAL GOALS One must decide if abdominal pain complaints require emergent, urgent, or nonimmediate intervention. Phase 1: Careful and complete history and physical examination to narrow this extensive DDx.

Phase 2: Directed laboratory evaluations should be made to support more likely portions of the DDx. 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: CBC ESR Comprehensive metabolic panel (i.e., Na+, K+, Cl, CO2, BUN, Creatinine, glucose, total protein, albumin, ALT, Uric acid, LDH)

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.

P.5 Data Gathering HISTORY Question: Location of pain? Significance: Pain etiology. See Table 2. Question: Duration of pain? Significance: Acute versus chronic illness Question: Onset and progression of symptoms? Significance: Evolution of painful process Question: Frank hematochezia? Significance: Colonic bleeding or massive upper GI 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) 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, decrease in frequency or change in caliber? Significance: Constipation Question: Relationship to emesis Significance: Usually upper intestinal tract disorders Physical Examination Finding: Location of pain Significance: See Table 2.

Finding: Reexamination by the same healthcare 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, further localization of pain, masses, presence and consistency of stool, and/or occult heme Laboratory Aids Test: CBC with differential

Significance: Total white count is nonspecific and may be a poor indicator of intestinal inflammation Test: ESR Significance: Nonspecific 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 ensuring that the patient is well enough for potential discharge. ISSUES FOR REFERRAL Persistent abdominal pain without clear etiology or chronic gastrointestinal diseases should be referred to a pediatric gastroenterologist. CLINICAL PEARLS The farther the complaint of pain is away from the periumbilical region, the more likely the pain etiology represents organic disease. True nighttime waking with pain is more often correlated with organic disease than functional pain.