JNP Differential Diagnosis of Abdominal

Pain and GI Complaints in Children

HOT TOPICS

IN PRIMARY CARE

Laurel Halloran,

PhD, APRN

Parents are scared (and frustrated) when their child vomits repeatedly. In his
presentation at the Hot Topics conference last year, Dr. Robert Yetman used case
studies to explore the differential diagnosis of abdominal pain and
gastrointestinal (GI) complaints in children. The first case was a happy 4-month-
old child of normal height and weight who was experi-encing frequent vomiting
(without blood or bile), especially after feeds. The first pearl Yetman offered was
to follow evidence-based medicine. A good his-tory and physical examination in such
a case usually can diagnose simple gastroesophogeal reflux, iden-tify
complications, help direct management, and eliminate other serious conditions.

An upper GI exam is neither sensitive nor spe-cific, is costly and uncomfortable,

and helpful only if an anatomical problem is suspected. In con-trast, an esophageal
pH probe might be indicated to demonstrate an association of the reflux episodes
and frequent symptoms of other more serious conditions (such as apnea) and to
deter-mine if therapy is working.
If gastroesophageal reflux disease (GERD) is diagnosed, treatments suggested
include a 2-week trial of hypoallergenic formula (not simply a change to one cows
milk formula from another), supine positioning for sleep, and possible trial of
proton pump inhibitors. Surgery generally results in favor-able outcomes (as a last
resort) and only when other complications of the reflux (failure to thrive,
pneumonia) are found. If vomiting persists by about 18 months, further testing
should be done. The issue of the happy spitter should be viewed in context of the
total development of the childand treat the baby, not the parents!

The second case presented was a 2-week-old infant with frequent, bile-stained
emesis, especially after feeding. This baby had poor weight gain, was fussy, and
had a slightly distended abdomen. Yetman went straight to the point: a baby less
than a month old with bile in the emesis generally needs a surgical consult. This
baby is likely going to need surgery.

Three cases involving children swallowing dif-ferent substances were discussed. In

the first case, an 8-month-old boy ingested a bottle of Drano (a corrosive
substance). Over the next 3 hours he started to drool and refused to swallow. This
is a medical emergency. You might have the child drink small amounts of water or
milk to dilute the corrosive but do not induce emesis! Closely observe the airway
and immediately go to the hospital. Esophagogastroscopy is usually done within 48
hours to determine the extent of damage, prednisone therapy may be considered, and
close follow-up is indicated to evaluate stric-ture development.
Another child was found drinking from a bottle of bleach. The child had no
respiratory symptoms and was acting normally, and the parents asked whether to
administer ipecac. Since bleach rarely causes strictures or serious injuries, the
better advice is to tell them to call the poison control line.
Ipecac and activated charcoal are out! Their risks outweigh their benefits.
In the third case, a child swallowed a small nail. In an asymptomatic child with an
unremarkable abdominal exam and an abdominal x-ray showing the nail in the
duodenum, how should an NP pro-ceed? Yetman suggested a high fiber diet and mon-
itoring the childs stools for the expelled nail as the only treatment. Most
children will safely pass the object in the stool. The difficulty is to convince
the family of this!

Yetman also presented the case of an 8-month-old child with a fever of 101 and
loose stools (no blood or mucous) who was still taking in fluids and active but
subdued. The provider first should consider the probability of serious or chronic
disease. In this absence, consider the benefits of testing. Yetman

330 The Journal for Nurse Practitioners - JNP Volume 7, Issue 4, April 2011

maintained that doing a complete blood count, uri-nalysis, stool samples, and
electrolytes rarely will alter therapy, and they are not useful or essential tests
to perform in this case. Treatment of simple gastroenteritis in children like this
can be accom-plished with oral rehydration (except in cases of severe dehydration,
persistent vomiting, and altered mental status). Progression to a regular diet as
soon as it can be tolerated should be encouraged. The BRAT diet (Bananas, Rice,
Applesauce, Toast) is out-dated, as is slow reintroduction of milk-based for-
mulas and cows milk. Medications (eg, Imodium) are not indicated for
gastroenteritis.

Abdominal pain was presented in 2 cases. First was an 8-year-old with intermittent
abdominal pain for a few weeks. His mother died in a car accident 1 month earlier.
His grandmother, now the primary caregiver, said, He has been a really good boy
since his mother died. Here it is suggested to start with the basics. Do a good
history and physi-cal exam. Children can have appendicitis. Remember developmental
stages; history may need to come from various caregivers (grandma, schoolteacher).
Why is he behaving really good? Does he understand the concept of death? How is
the family coping with the grieving process? The child may need counseling. In this
case the childs cause of pain was psychological, not physical.

Next, a 17-year-old girl presented with abdomi-nal pain (periumbilical and

suprapubic), tempera-tures to 101F, cervical motion tenderness (CMT), and a
negative pregnancy test. The clinical diagno-sis of pelvic inflammatory disease has
been liber-

alized and now can be made on the criteria of sex-ually active teen with CMT,
abdominal tenderness, and adenexal tenderness. Supporting criteria include fever,
increased erythrocyte sedimentation rate, vaginal discharge, white blood count on
microscopy, lab evidence of cervical infection, or laparoscopic abnormalities.
Outpatient treatment is an option. If the patient has severe nausea and vomiting,
is pregnant, or is not reliable, inpatient treatment should occur initially.
Treatments change periodically; CDC guidelines and resist-ance patterns in the
geographic area should be considered.

Yetmans take-home message was to think before intervening. Practice evidence-based

medi-cine. Rely on history and physical examination skills and use appropriate
testing only to add to decision making or therapy. Teens are sexually active, kids
grieve, babies vomit and put anything within reach into their mouthsand all these
things usually are expected developmental behaviors!

Section Editor Laurel Halloran, PhD, APRN is a professor of nurs-ing at Western

Connecticut State University and a family nurse practitioner. She can be reached at
laurelnp@yahoo.com.

Robert J. Yetman, MD, presented the session on which this column was based. He is a
professor of pediatrics and direc-tor of the division of community and general
pediatrics at the University of Texas Medical School at Houston.

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