Abdominal Pain

Abdominal Pain
A common and difficult diagnostic
and therapeutic problem

3 Forms
Acute
Recognizable organic entities; aim to prevent tissue damage
Recurrent
Recognizable organic entities are less common
The patient will probably continue living with this symptom
without the MD knowing the cause
Chronic
A physical disease usually coexists with significant functional
disability that is only partially responsive to therapy
Understand disease process, promote optimal psychosocial
functioning

Clinical Classification
Organic
Intraabdominal origin of a specific disease; TREAT.
Psychogenic
Pain seems not to originate in intraabdominal sensory
nerve endings; pain is related to psychological events
Dysfunctional
Pain originates intraabdominally from normal
physiologic processes, but still interferes with normal
activity (may be specific or nonspecific)

Gastritis
Esophagitis
Hiatal hernia
Volvulus
Obstruction
IBD
Meckel diverticulum
Neoplasms
Yersinia enterocolitica infection
Hepatitis
Intussusception
Gallstones
Hirschsprung
disease
Traumatic hemobilia
Pancreatitis
Malrotations
Pancreatic pseudocyst
Infestations
Lead poisoning
Subserosal
intestinal
Abdominal
epilepsy/migraine
Annular
pancreas
Acute
intermittent
hemorrhage
Anorexia
Polyps
porphyria
Abdominal wall strain
Sickle
cell
disease
Foreign
body
Hereditary
angioedema
Familial
fever
Mesenteric
adenitis
Familial Mediterranean
hyperlipidemia
Riley-Day
syndrome
Malformations
Multiple
endocrine adenomatosis
Hydronephrosis
Blood
Lower dyscrasias
tract obstruction
Lymphomas
Pyelonephritis
Coxsackievirus
Renal stones infection
Meconium
ileus syndrome
Ovarian cyst
Brain/spinal
cord neoplasm
Testicular/ovarian
torsion
Epilepsy
Hematocolpos

Organic Etiologies of Abdominal

Pain (5%)

Gastrointestinal
Hepatobiliary
Trauma
Metabolic
Miscellaneous

Dysfunctional Etiologies of
Chronic stool
Abdominal
Pain (85%)
retention
Heightened
awareness of
intestinal motility
Spontaneous
Lactose intolerance
resolution
Sucrose
Persistent
intolerance
unresolved
Alcohol sugars
intolerance
Intestinal gas
syndromes
Menses
Primary
dysmenorrhea
Mittelschmerz
Pregnancy
Reaction to normal
stress and anxiety
Overeating
Irritable colon

Specific (35%)
Nonspecific (50%)

Psychogenic Etiologies of
Abdominal Pain (10%)

Reaction anxiety
(acute or chronic)
Complaint modeling
Maintenance or manipulation for
Depression
secondary gain
Conversion
Hypochondriasis
reaction
School phobia
Factitious

Stress related
Behavioral
Psychiatric
Other

General principles in the

approach to diagnosis
1. In acute pain, the primary question
concerns the necessity for and
timing of surgical intervention or
specific medical therapy; in
recurrent pain, definition of the
syndrome, identification of
secondary anxiety sources or
dysfunction and staged evaluation
of potential causes are paramount.

General principles in the

approach to diagnosis
2. In acute pain the primary concern
is prevention of tissue damage; in
recurrent pain, prevention of
secondary dysfunction is an
appropriate and achievable
therapeutic goal.

General principles in the

approach to diagnosis
3. Clinical presentations of disease entities
are a function of age.
4. In infants and toddlers, both acute and
recurrent pain complaints should be
considered organic until proven otherwise.
In school-aged children, dysfunctional
abdominal pain is predominant.
5. Specific diagnostic and therapeutic
strategies are relevant for each clinical
category.

History

PQRST
Precipitating factors
Quality of pain
Radiation
Severity
Timing

Organic Disease
More likely if pain is well localized,
constant, wakes the child from sleep,
or is located in an area other than
the periumbilical region
Associated SSx may contribute to the
suspicion of organic disease, eg UTI
Pain becomes more localized as the
patient gets older increasing
language facility vs maturation of
pain mechanism?

Dysfunctional Pain
Ask about constitutional and
environmental factors, remember
physiologic changes
GI motility: eg chronic stool retention
Enzyme activity: eg lactose intolerance
Menstrual cycle: dysmenorrhea

Psychogenic Pain
Pain may be associated with special
meaning
Anger, separation, punishment
(unpleasant)
Anticipation of increased attention
(pleasure and relief)
It is easier for patients to discover
emotionally significant feelings than
to describe them in response to
direct questioning

Physical Examination

Inspection
Palpation
Percussion
Auscultation
Rectal examination
Gynecologic evaluation

Differential Diagnosis
1. In acute pain presentations, first
consider entities with potentially
severe consequences requiring early
definitive treatment, then move
down the differential diagnosis list
2. In recurrent presentations, first
consider entities that are most
common, then move up the
differential diagnosis list

Differential Diagnosis
3. Noninvasive baseline tests should
be used for occult common disease
processes early in the investigation
4. More invasive procedures should be
used selectively, and the
investigation should be staged
according to relative priorities

Differential Diagnosis
5. In recurrent pain, further
investigation for organic disease
seldom will be indicated if the
complaint of pain is the only
symptom
6. In both acute and recurrent
presentations, repeat observation
and examinations often are
essential once the acute surgical

Likelihood of presentation

Laboratory Evaluation
of
Acute
Recurrent
Nonspecific Abdominal Pain
Common Causes
Conditions to
consider

Tests to be
performed

Urinary tract
pathology

UA, Urine CS

Inflammatory
Causes

ESR, WBC

Anemia, blood
loss

CBC, PBS, retic ct

Liver disease

++++

++++

++++

++++

++++

++++

Liver function
tests

++

Pancreatitis

Amylase

++

Lactose
intolerance

Lactose breath H
test

+++

Stool retention,
renal stones,
pancreatic
calcification,
spinal
dysrhaphism

Plain abdominal xray

++

+++

Conditions to
consider

Tests to be
performed

Likelihood of presentation
Acute

Recurrent

Uncommon Causes
Inflammatory
bowel disease

Barium enema,
UGIS

++

Appendicitis

Barium enema

+++

Urinary tract
pathology

Intravenous
pyelogram

+++

PID

Cultures, UTZ
laparoscopy

+++

+++

Esophagitis,
ulcer

Esophagoscopy,
culture

++

Pregnancy

HCG

++

++

Gallbladder
disease

Ultrasound

++

Abdominal
masses
detected on PE

Ultrasound
+

+++

Pneumonia

Chest radiography

Strep throat

Strep throat

Treatment
Diagnose the disease
Treat the organic disease
Deal with factors predisposing the
child to the symptom
Diary of symptoms
Focus parental anxiety rather than
dismissing it

Treatment
Drugs are usually not indicated in
nonorganic pain
Psychotherapy/counseling
Dietary modification

Conclusion
History and PE
Focused diagnostic workups
Modification of environmental,
dietary factors predisposing to
symptoms
Counsel the patient and their
caregivers