Abdominal pain in children

By
Dr saad shalaby
Pediatric specialist
 Preface
Abdominal pain is a common problem in *
children
* Although most children with acute
abdominal pain have self-limited
conditions, the pain may herald a surgical
.or medical emergency
 Pathophysiology
Clinically, abdominal pain falls into three categories: **
visceral (splanchnic) pain, parietal (somatic) pain, and
referred pain
Visceral pain occurs when noxious stimuli affect a viscus, **
such as the stomach or intestines
Tension, stretching, and ischemia stimulate visceral
pain fiber .
. Tissue congestion and inflammation tend to
sensitize nerve endings and lower the threshold for
stimuli.
. Because visceral pain fibers are bilateral and
unmyelinated and enter the spinal cord at
multiple levels, visceral pain usually is dull, poorly
. localized, and felt in the midline
Pain from foregut structures (e.g., lower esophagus, .
stomach) generally is felt in the epigastrium
Midgut structures (e.g., small intestine) cause .
periumbilical pain, and hindgut structures (e.g.,
large intestine) cause lower abdominal pain.
** Parietal pain arises from noxious stimulation of the
parietal peritoneum
. Pain resulting from ischemia, inflammation, or
stretching of the parietal peritoneum is transmitted
through myelinated afferent fibers to specific dorsal
root ganglia on the same side and at the same
dermatomal level as the origin of the pain
. Parietal pain usually is sharp, intense, discrete, and
localized, and coughing or movement can
. aggravate it
Referred pain has many of the characteristics of***
parietal pain but is felt in remote areas supplied by
the same dermatome as the diseased organ

It results from shared central pathways for .

afferent neurons from different sites

A classic example is a patient with pneumonia .

who presents with abdominal pain because the T9
dermatome distribution is shared by the lung and
the abdomen
A number of illnesses cannot be readily
explained neurophysiologically as the triggers
of abdominal pain ,including conditions such as
tonsillitis with high fever ,viral syndromes, and
.streptococcal pharangitis
However, diagnostic tools such as ultrasound .
may support that intraabdominal
lymphadenopathy, the mesenteric lymphadenitis
syndrome, explains such pain in some cases
Evaluation and Decision
 Evaluation and decision
Acute abdominal pain in children presents a diagnostic .
.dilemma
Although many cases of acute abdominal pain are benign, .
some require rapid diagnosis and treatment to minimize
morbidity
Numerous disorders can cause abdominal pain .
The most common medical cause is gastroenteritis, and the.
most common surgical cause is appendicitis
In most instances, abdominal pain can be diagnosed through .
the history and physical examination
Age is a key factor in evaluating the cause; the incidence*
and symptoms of different conditions vary greatly over the
pediatric age spectrum
In assessing the child who develops abdominal pain
The first priority is stabilization if the child is seriously ill *
attention to air way breathing ,and circulation is critical

The second priority is to identify the child who requires *

immediate or potential surgical intervention, whether
for appendicitis,intussusception,or other congenital
or acquired lesion

Third ,an effort is directed to diagnose any of the*

medical illnesses from among a large group of acute
and chronic abdominal and extra abdominal
inflammatory disorders that require emergency non
operative management
Infant Younger than 2 years old

The infant younger than 2 years old with

abdominal pain is the most difficult to evaluate
because the child cannot describe or localize
the complaint

To the parent ,the pain may consists of crying out,

of constantly drawing the legs up with sudden
movements or jerks
 Causes of acute abdominal pain in infancy
(<2year)

Common**
colic (age < 3month).
Gastro esophageal reflux disease.
Acute gastroenteritis (viral syndromes).
Less common**
trauma (possible child abuse).
Intussuption.
Intestinal anomalies.
Incarcerated hernia.
Sickling syndrome.
Milk protein allergy.
Rare**
Appendicitis.
Volvulus and tumors.
 Acute pain evaluation
History
onset of pain.
bowel movement pattern (last stool ,consistency, or diarrhea).
presence of fever, and amount of vomiting along with timing are.
.noted
? was pain before vomiting or afterward.
obstruction may be present with isolated vomiting.
diarrhea as an early feature often heralds GE ,yet can be a late.
finding accompanying peritonitis and partial obstruction in acute
abdomen
cough ,may suggest pneumonia,bronchiolitis,or asthma.
Episodic colicky pain with interposed quiet intervals, even in the .
absence of a currant jelly stool makes suspicious of
intussusception or occasionally midgut volvulus
 Physical examination

The physical examination must be used in conjunction *

with the history to determine which diagnosis should be
.pursue aggressively
In infants, use the mechanisms to distract them during *
examination is critical

Observation,auscultation,and gentle palpation are the key *

Ileus ,manifesting clinically with distention and absent * .1
bowel sounds often accompanies surgical conditions, sepsis,
.and infectious enterocolitis
,If an abdominal mass is palpable,intussuception,abscess *
Or neoplasm (commonly of renal origin) is likely
Intussuception and incarcerated hernia are the commonest *
causes of obstruction in this age range
Rectal examination helps define pelvic masses, may yield a *
. current jelly stool in some cases of intussusceptions
On auscultation of chest,localised decreased or tubular breath *
sound suggest pneumonia (as cause of abdominal pain in
febrile infant)
Abdominal pain and pallor can occur in neoplasia,as with *
bleeding into an abdominal Wilms tumor ,hepatoma ,or
neuroplastoma, also can occur with sickling
hemoglobinopathies with the development of a Vass
occlusive crisis,splenic sequestration and a plastic crisis
Abdominal pain with jaundice in liver dysfunction in acute *
hepatitis
If bruising is noted, hemophilia or leukemia may be the cause *
of pain in ill child
Chronic pain in child<2year

when apparent abdominal pain is recurrent or chronic in*

infant younger than 3 month and not accompanied by
other finding or symptoms ,colic is the more likely
diagnosis

Uncommon cause of recurrent abdominal pain**

recurrent intussusceptions*
malrotation with intermittent volvulus*
milk allergy syndrome*
 Laboratory testing
In most instances, the history and physical examination lead to *
the diagnosis

When the cause is GE ,most infant and toddlers have a history *

and examination clearly suggestive of diagnosis and no need
for further evaluation

When clinical evidence of obstruction,perotinitis or mass is*

present, CBC and urinalysis are always indicated

Serum electrolytes, glucose and blood urea nitrogen are not*

always helpful but should be obtained with
peritonitis,obstruction,mass,dehydration,and renal disease
 Imaging

Abdominal radiographs may be useful in confirming*

obstruction or the presence of a mass
Barium is indicated urgently in case of moderate
suspected,uncopmlicated intussusceptions
In low probability setting ultrasound may yield *
preliminary Findings that rule out the need for
therapeutic study for intussusception
 Intussusception
Intussusception is a process in which a segment of
intestine invaginates into the adjoining intestinal
lumen, causing a bowel obstruction

It is a common cause of abdominal pain in *

children
Intussusception presents in 2 variants; *
* idiopathic intussusception; which
usually starts at the ileocolic junction
and affects infants and toddlers
Enteroenteral intussusception *
. jejunojejunal, jejunoileal, ileoileal),
which occurs in older patients
. is associated with special medical
situations; HSP], cystic fibrosis,
hematologic dyscrasias) and can occur
in the postoperative period
**
Idiopathic intussusception, which is the more
common of the 2 variants
 Age
Two thirds of children with intussusception are younger than 1 *
year
** most commonly, intussusception occurs in infants aged
5-10 months **
From a clinical perspective, using a cutoff age of 3 years is
helpful for dividing patients with intussusception into 2
groups;
. Patients aged 5 months to 3 years who have
intussusception rarely have a lead point , and
they are usually responsive to nonoperative

reduction .
Older children and adults more often have a
surgical lead point to the intussusception and
.require operative reduction
 History
Signs and symptoms of intussusception represents one of the
most classic presentations of any pediatric illness
. The classic triad of vomiting, abdominal pain, and passage of
blood per rectum occurs in only one third of patients
** Pain is
. colicky, severe, and intermittent
. The parents or caregivers describe the child as
drawing the legs up to the abdomen and kicking
the legs in the air
** vomiting
. Initially, is no bilious and reflexive, but when the
intestinal obstruction occurs, vomiting becomes
. bilious
Any child with bilious vomiting is assumed to have !!
a condition that must be treated surgically until proven
otherwise
**passage of stools that look like currant jelly ;
* This is a mixture of mucus, sloughed mucosa,
and shed blood
Lethargy is ; **
. a relatively common presenting symptom
with intussusception
. The reason lethargy occurs is unknown
. Lethargy can be the sole presenting symptom,
which makes the diagnosis challenging
. Patients are found to have an intestinal
process late, after initiation of a septic workup
 Physical examination
Upon physical examination, *
. the patient is usually and in good health
. The child is found to have periods of
lethargy alternating with crying spells
. and this cycle repeats every 15-30
minutes
. The infant can be pale, diaphoretic,
and hypotensive if shock has occurred
. a right hypochondrium sausage-shaped
mass and emptiness in the right lower
quadrant (Dance sign
. Abdominal distention frequently is
found if obstruction is complete
Fever and leukocytosis are late signs and can indicate .
transmural gangrene and infarction
Lab Studies
. Laboratory investigation is usually not
helpful in the evaluation of patients with
intussusception
. Leukocytosis can be an indication of
gangrene if the process is advanced
Imaging
Studies
. Plain radiograph findings may be
normal early in the course of
intussusception . As
the disease progresses, earliest
radiographic evidence includes an
absence of air in the right lower
and upper quadrants
Abdominal radiograph shows small bowel dilatation and
paucity of gas in the right lower and upper quadrant
Ultrasonography is a noninvasive modality that
can aid in making the diagnosis of
intussusception

** The traditional and most reliable way to make

the diagnosis of intussusception in children is to
obtain a contrast enema (either barium or air
. Contrast enema is quick and reliable and has
the potential to be therapeutic
Barium enema shows intussusception in the
descending colon
Abdominal ultrasonography reveals the classic target •
sign of an intussusceptum inside an intussuscipiens
Longitudinal ultrasound of a patient with suspected
intussusception shows the layered bowel walls of the
outer and inner loop, the intussuscipiens, and the
intussusceptum
intussusception
 TREATMENT
Medical Care ;
. For all children, start intravenous fluid
resuscitation and nasogastric
decompression as soon as possible
. Therapeutic enema
. The presence of peritonitis and any
evidence of perforation revealed on plain
radiographs are the only 2 absolute
contraindications to an attempt at
no operative reduction with a
. therapeutic enema
Surgical Care

If no operative reduction is unsuccessful or

if obvious perforation is present, promptly
refer the infant for surgical care
Child 2 to 5 years old
 Abdominal pain in child 2 to 5 years

Similar to the infant ,the child who is 2 to 5 years of age *

usually has an organic cause of abdominal pain
The most common causes of abdominal pain are *
inflammatory process ,such as GE,and UTI
As with the younger child, the ER doctor must first ascertain *
whether the abdominal pain is acute or chronic
.With acute pain, the surgical condition should be rule out *

The ill appearing child with subacute symptoms may still *

harbor surgical diseases with complications (rupture
appendix)
In every case ,physician must search for signs of obstruction,*
peritoneal inflammation, or peritonitis before attributing the
cause to a non surgical disease
 Causes of abdominal pain in preschool
age
common*
Acute GE .
UTI.
trauma.
Appendicitis.
Pneumonia ,asthma.
Viral syndromes.
constipation.
Less common**
Meckel diverticulam.
Anaphylactoid purpura.
Toxin .
cystic fibrosis.
Intussusception.
Nephrotic syndrome.
.
Acute pain in preschool child

The preschool child may able to describe pain •

.and other symptoms verbally

Although such history is not reliable, it*

always is to be taken seriously
Classic presentation for surgical disease **
,occasionally may be elicited
Chronic pain in preschool child

:History of recurrent abdominal pain suggest **

UTI *
Chronic infestation such as giardia *
Complication of problem as ,sickle cell anemia *
cystic fibrosis ,or asthma
Chronic constipation *
Psychogenic or other non organic abdominal *
pain is fairly uncommon in this age
 Acute Appendicitis

Acute appendicitis is one of the most common causes of *

abdominal pain in childhood
* This diagnosis must be considered in all age groups but is
more common between the ages of 4 and 15 years
* The function of the appendix is unknown
* However, in rabbits and other animals the cecum is similar
in shape to the appendix and plays a role in digestion of
food
* The middle, inside portion of the appendix may be irregular
and somewhat narrow because of the presence of lymph
nodes in the wall of the appendix
In most patients the appendix is located in the right lower *
area of the abdomen
* However, since the appendix is a fingerlike projection, it
may be in various locations in the right upper area of the
abdomen under the gallbladder, in the pelvis, across the
top of the bladder, and behind the large intestine *
Appendicitis most often results from blockage by feces
which has formed a stone (a fecalith) or, less commonly,
from enlarged lymph nodes caused by a viral infection *
Once a blockage occurs, bacteria located within the
appendix grow *
The pressure in the appendix increases and the appendix
becomes swollen. Eventually the blood vessels to the
appendix close and the appendix dies. Subsequent
perforation will occur
 History
Pain *
. The initial symptom is poorly defined periumbilical
pain
. Acute onset of severe pain is not typical in acute
appendicitis but is seen with acute ischemic
conditions such as volvulus, testicular torsion,
ovarian torsion, or intussusception
. If the pain is initially located in the right lower
quadrant, severe constipation should be considered *
Nausea and vomiting:
. Generally, vomiting that occurs prior to pain is
, unusual
However, in retrocecal appendices , inflammation of .
the appendix irritates the nearby duodenum, resulting
in nausea and vomiting prior to the onset of right
lower quadrant pain
** Diarrhea :
. Likewise, significant diarrhea is atypical in
appendicitis, and the physician should consider
other diagnoses while not ruling out appendicitis
. In patients with an appendix in a pelvic location,
inflammation of the appendix occasionally results in
an irritative stimulation of the rectum **
Shift to right lower quadrant pain :
. After a few hours, pain shifts to the right lower
quadrant because of inflammation of the parietal
. peritoneum
This pain is more intense, continuous, and localized .
than in the initial pain
** Fever:
. Most children with appendicitis are afebrile or
have a low-grade fever and characteristic
flushness of their cheeks
. Severe fever is not a common presenting
feature unless perforation has occurred
. According to one study, vomiting and fever are
more frequent findings in children with
appendicitis than in children with other causes
. of abdominal pain
 PHYSICAL EXAMINATION
The physical examination in children may vary depending on age*

* Older children often seem uncomfortable or withdrawn,

They may prefer to lie still because of peritoneal
irritation
* Teenaged patients often present in a classic or near-
classic fashion

General :
. The patient's general state should be observed
before interacting with them
. The patient's state of activity or withdrawal may
provide information
. A patient with abdominal pain who is in obvious
distress gives the impression of an infectious
. process
Cardiac and pulmonary; *
. The evaluation of the patient's heart
and lungs reflects the patient's overall state
more than it indicates the appendix as a cause
. Patients are often dehydrated or in pain and,
therefore, may be tachycardic or tachypneic
. Pediatric patients have great physiological
reserve and may not show any symptoms until
they are very sick **
Abdominal examination ;
. The child's abdomen should be examined in
the same way an adult's abdomen is
examined
. Full exposure of the abdomen is key
. Localization of the pain is also key but may
. depend on the position of the appendix
Observing the patient cough and asking them to localize
their pain with one finger often localizes their
discomfort to the right lower quadrant
* Typically, maximal tenderness can be found at the
McBurney point in the right lower quadrant.
However, the appendix may lie in many positions
** A medially positioned appendix may present as
suprapubic tenderness
*** A laterally positioned appendix often presents as
flank tenderness
**** A retrocecal appendix may not have any
tenderness until it is advanced or perforated
*
The abdomen should be palpated with a gentle
touch to search for involuntary guarding of the
. rectus or oblique muscles
Rovsing sign is pain in the right lower quadrant in
response to left-sided palpation or
percussion and strongly suggests peritoneal
irritation
The psoas sign
. place the child on the left side and
hyperextend the right leg at the hip
. A positive response suggests an
inflammatory mass overlying the
psoas muscle (retrocecal appendicitis
The obturator sign
. by internally rotating the flexed right
thigh
. A positive response suggests an
inflammatory mass overlying the
obturator space (pelvic appendicitis
 Lab Studies
Laboratory findings may increase suspicion of appendicitis but *
are not diagnostic
** The minimum laboratory workup for a patient with possible
appendicitis includes a WBC count with differential and
urinalysis
CBC count
. The WBC count is elevated in approximately
70-90% of patients with acute appendicitis
. The WBC count is often within the reference
range during the first 24 hours of symptoms.
Therefore, its predictive value is limited
. If the WBC count exceeds 15,000 cells
perforation is more likely
A WBC count within the reference range does not *
exclude appendicitis because this is typical in at least
10% of patients with appendicitis
Urinalysis :
. Urinalysis is useful for detecting urinary tract
disease, including infection and renal stones
. However, irritation of the bladder or ureter
caused by an inflamed appendix may result in few
urinary WBCs
. Normal urinalysis results do not provide any
diagnostic value for appendicitis
Electrolytes:
. Electrolyte assessments and renal function
tests are more helpful for management than
diagnosis
Indications include a significant history of vomiting
or clinical suspicion of significant dehydration .
Additional studies
. Liver function tests and amylase and lipase
assessments are helpful when the
etiology is unclear
. A beta-human chorionic gonadotropin
(beta-HCG) test should be performed to
rule out pregnancy or ectopic pregnancy
in female patients
 Imaging Studies

Abdominal radiography:
. Abdominal radiograph findings are normal in
many individuals with appendicitis. However, plain
films may be helpful in the setting of severe
constipation
. Calcified appendiceal fecalith is present in less than
10% of persons with inflammation, but its presence
confirms the diagnosis of appendicitis .
Radiographic signs suggestive of appendicitis include
convex lumbar scoliosis, obliteration of right psoas
margin, right lower quadrant air-fluid levels, air in
the appendix, or localized ileus
Calcified appendiceal fecalith •
Ultrasonography:
. graded compression ultrasonography was
the preferred imaging modality in the
evaluation of pediatric acute appendicitis
. This technique involves locating the
appendix using ultrasonography and then
attempting to compress the lumen of the
appendix
. In experienced hands, ultrasonography has
an overall sensitivity of 85% and specificity
of 94% in pediatric patients
. Specific ultrasonography findings can
support the diagnosis of appendicitis
supportive findings include;
* appendicolith, fluid in the appendiceal lumen
* focal tenderness over the inflamed appendix
(sonographic McBurney point
* and a transverse diameter of 6 mm or larger
* After perforation, can reveal a abscess
formation
* Ultrasonography is also useful in diagnosing
alternate pathology (eg, tubo-ovarian
abscess, ovarian torsion, ovarian cyst,
. mesenteric adenitis
 Abdominal pain in child age
from 5 to 12 years old
 Abdominal pain in child age from 5 to
12 years old

The preadolescent child add another dimension to the*

spectrum of abdominal pain- that of non organic or
psychogenic illness
The leading organic causes of abdominal pain still are *
inflammatory
and include GE ,appendicitis and UTI

Colicky abdominal pain is more rarely associated with *

intussusception than in younger children
Causes of abdominal pain

Common *
acute GE .Trauma .Appendicitis .
.UTI .Functional abdominal pain
.Sickling syndromes .constipation

Less common**

Pneumonia ,asthma, cystic fibrosis.

IBD .Peptic ulcer disease .DM.
Collagen vascular disease
 Chronic abdominal pain
Chronic and recurrent abdominal pain are common in children *
**
Chronic abdominal pain is defined as pain that has been
present for at least three months **
Recurrent abdominal pain is defined as three or more
episodes of pain that are severe enough to limit a
child's activity or school attendance over the course
of at least three months *
Chronic and recurrent pain occurs in 9 to 15 percent of all
children *
In boys, pain is most common between ages 5 and 6 years
** Girls have pain most commonly between 5 and 6 years
and 9 and 10 years
 CAUSES OF PAIN

There are two major categories of chronic abdominal

: pain in children

A- Those that are clearly related to an organ

system, such as the gastrointestinal, urinary,
or neurologic systems. These are called
organic disorders
B- Those that do not have an identifiable cause.
These are called functional disorders, and are
sometimes considered to have a psychological
origin
 Organic disorders
Organic disorders include conditions caused by an identifiable
structural or biochemical abnormality within the body
* Examples include :
. constipation, musculoskeletal pain,
gastrointestinal infection
. stomach problems (eg, heartburn, ulcer)
Less common causes include urinary tract .
infection, inflammatory bowel diseases. **
Features that suggest an organic disorder :
. Pain that awakens the child
. Significant vomiting, diarrhea, or gas
. Involuntary weight loss
. Changes in bowel or bladder function
. Pain or bleeding with urination
 Functional disorders

Functional disorders cause a variable combination of signs

and symptoms that have no identifiable structural or
biochemical cause

** Examples include :
1-functional dyspepsia (stomach upset)
2- irritable bowel syndrome (IBS)
3-functional abdominal pain
 Functional dyspepsia
Child who can provide an accurate pain history Within **
the preceding 12 months, at least 12 weeks
not necessarily continuous) of :
* Persistent or recurring pain or discomfort
in the upper abdomen And,
* No evidence that organic disease is likely
to explain the symptoms (including upper
endoscopy And,
* No evidence that dyspepsia is exclusively
relieved by defecation or associated with
the onset of a change in stool frequency
or form
 Irritable bowel syndrome

Child who can provide an accurate pain history Within the

preceding 12 month, at least 12 weeks (not necessarily
continuous) of :
* Abdominal discomfort or pain that has two out of three
of the following ;
a- Relieved with defecation, and/or
b- Onset associated with a change in
frequency of stool, and/or
c- Onset associated with a change in
form (appearance) of stool, and

No structural or metabolic abnormalities to explain the *

symptoms
 Functional abdominal pain

Some children have symptoms that do not fit the definition of

organic disorders, functional dyspepsia, or IBS, and are thus
described as having functional abdominal pain

** School-aged child or adolescent

** At least 12 weeks of :
a-Continuous or nearly continuous abdominal pain
and b- No or only occasional relation of pain with
physiologic events (eg, eating, menses,
defecation) c- Some loss of daily functioning ,and
d- The pain is not malingering
e- The patient has insufficient criteria for
other functional gastrointestinal disorders
that would explain the abdominal pain
Indications for Surgical Consultations
in Children with Acute Abdominal Pain

Severe or increasing abdominal pain with progressive *

signs of deterioration
* Bile-stained or feculent vomitus
* Involuntary abdominal guarding/rigidity
* Rebound abdominal tenderness
* Marked abdominal distension with diffuse tympany
* Significant abdominal trauma
* Suspected surgical cause for the pain
* Abdominal pain without an obvious etiology
Thank you