Approach to Abdominal Pain in Children

Abdominal Pain Introduction Epidemiology Etiology History Taking Physical Examination Investigations Management Red Flags

Introduction to Abdominal Pain in Children

Abdominal pain is a common complaint in pediatric practice, accounting for 5-10% of all pediatric emergency department visits. The challenge lies in distinguishing between benign, self-limiting conditions and those requiring urgent intervention. A systematic approach is crucial for accurate diagnosis and appropriate management.

Key points to remember:

• The etiology of abdominal pain varies widely based on the child's age.
• A thorough history and physical examination are cornerstones of diagnosis.
• The pattern, location, and associated symptoms of pain provide valuable diagnostic clues.
• Always consider non-abdominal causes of abdominal pain (e.g., pneumonia, diabetic ketoacidosis).

Epidemiology of Pediatric Abdominal Pain

Understanding the epidemiology of abdominal pain in children helps in formulating appropriate differential diagnoses:

• Prevalence: 10-15% of school-aged children experience recurrent abdominal pain.
• Age distribution:
  • Infants: Often related to feeding issues or infections
  • Toddlers and preschoolers: Increased risk of intussusception and urinary tract infections
  • School-aged children: Higher incidence of appendicitis and functional abdominal pain
  • Adolescents: Increased risk of ovarian pathologies in females
• Gender differences: Some conditions, like abdominal migraines, are more common in girls.
• Seasonal variations: Certain infectious causes may have seasonal patterns (e.g., gastroenteritis more common in winter months in temperate climates).

Etiology of Abdominal Pain in Children

The causes of abdominal pain in children can be broadly categorized as follows:

1. Gastrointestinal:
   • Acute: Gastroenteritis, appendicitis, intussusception, volvulus
   • Chronic: Inflammatory bowel disease, celiac disease, constipation
2. Genitourinary:
   • Urinary tract infection, renal colic, testicular torsion
3. Hepatobiliary:
   • Hepatitis, cholecystitis (rare in children)
4. Gynecological (in females):
   • Ovarian torsion, ectopic pregnancy (in adolescents)
5. Metabolic:
   • Diabetic ketoacidosis, acute intermittent porphyria
6. Extra-abdominal:
   • Pneumonia, myocarditis, sickle cell crisis
7. Functional:
   • Irritable bowel syndrome, abdominal migraine

History Taking in Pediatric Abdominal Pain

A detailed history is crucial in evaluating abdominal pain in children. Key elements include:

1. Pain characteristics:
   • Onset: Sudden vs. gradual
   • Location: Quadrant, diffuse, migratory
   • Quality: Sharp, dull, crampy
   • Severity: Use age-appropriate pain scales
   • Duration and frequency
   • Aggravating and relieving factors
2. Associated symptoms:
   • Gastrointestinal: Nausea, vomiting, diarrhea, constipation
   • Systemic: Fever, weight loss, fatigue
   • Urinary: Dysuria, frequency
   • Respiratory: Cough, difficulty breathing
3. Past medical history:
   • Previous episodes of similar pain
   • Chronic medical conditions
   • Surgical history
4. Family history:
   • Inflammatory bowel disease, celiac disease
   • Hereditary conditions (e.g., familial Mediterranean fever)
5. Psychosocial history:
   • School performance, bullying
   • Family dynamics, stress factors
6. Dietary history:
   • Recent changes in diet
   • Food intolerances or allergies

Physical Examination in Pediatric Abdominal Pain

A thorough physical examination is essential and should include:

1. General appearance:
   • Level of distress, posture, activity level
   • Signs of dehydration or malnutrition
2. Vital signs:
   • Temperature, heart rate, blood pressure, respiratory rate
3. Abdominal examination:
   • Inspection: Distension, visible peristalsis, scars
   • Auscultation: Bowel sounds (hyperactive, hypoactive, absent)
   • Palpation: Tenderness, guarding, masses
   • Percussion: Tympany, dullness (ascites)
   • Special maneuvers: Psoas sign, obturator sign, Rovsing's sign
4. Rectal examination (when indicated):
   • Assess for masses, fissures, fistulas
   • Check stool for occult blood
5. Genital examination (when indicated):
   • Males: Testicular torsion, hernias
   • Females: Pelvic inflammatory disease, ovarian pathologies
6. Extra-abdominal examination:
   • Chest: Rule out lower lobe pneumonia
   • Skin: Rashes (e.g., Henoch-Schönlein purpura)
   • Joints: Arthritis associated with inflammatory bowel disease

Investigations for Pediatric Abdominal Pain

The choice of investigations depends on the clinical presentation and suspected diagnosis. Common investigations include:

1. Laboratory tests:
   • Complete blood count: Assess for infection, anemia
   • C-reactive protein and erythrocyte sedimentation rate: Markers of inflammation
   • Liver function tests and lipase: Evaluate hepatobiliary and pancreatic causes
   • Urinalysis and urine culture: Rule out urinary tract infection
   • Stool studies: Occult blood, culture, ova and parasites
2. Imaging studies:
   • Abdominal X-ray: Useful for obstruction, constipation
   • Ultrasound: First-line for appendicitis, intussusception, ovarian pathologies
   • CT scan: Reserved for cases where ultrasound is inconclusive or unavailable
   • MRI: Useful for chronic abdominal pain, evaluation of inflammatory bowel disease
3. Endoscopy:
   • Upper endoscopy: Evaluate for esophagitis, gastritis, peptic ulcer disease
   • Colonoscopy: Diagnose inflammatory bowel disease, polyps
4. Special tests:
   • Hydrogen breath test: Diagnose lactose intolerance or small intestinal bacterial overgrowth
   • Celiac serology: Screen for celiac disease
   • Fecal calprotectin: Non-invasive marker for intestinal inflammation

Management of Pediatric Abdominal Pain

Management strategies depend on the underlying cause and severity of the condition:

1. Acute management:
   • Pain control: Age-appropriate analgesia (acetaminophen, ibuprofen, opioids if severe)
   • Fluid resuscitation: Correct dehydration if present
   • Empiric antibiotics: For suspected bacterial infections (e.g., appendicitis)
   • Surgical intervention: For conditions like appendicitis, intussusception, or volvulus
2. Chronic management:
   • Dietary modifications: For conditions like celiac disease, inflammatory bowel disease
   • Medications: Proton pump inhibitors for gastroesophageal reflux, laxatives for constipation
   • Psychological interventions: Cognitive behavioral therapy for functional abdominal pain
   • Regular follow-up: Monitor disease progression and treatment response
3. Patient and family education:
   • Explain diagnosis and management plan
   • Provide dietary and lifestyle advice
   • Discuss red flag symptoms requiring urgent medical attention
4. Multidisciplinary approach:
   • Involve gastroenterologists, surgeons, psychologists as needed
   • Consider pain management specialists for complex chronic pain

Red Flags in Pediatric Abdominal Pain

Certain signs and symptoms warrant immediate attention and further investigation:

• Severe, sudden onset of pain
• Peritoneal signs (rebound tenderness, guarding)
• Bilious vomiting
• Gastrointestinal bleeding (hematemesis, melena, hematochezia)
• High fever (>39°C or 102.2°F)
• Significant weight loss
• Palpable abdominal mass
• Jaundice
• Nocturnal pain waking the child from sleep
• Family history of inflammatory bowel disease or celiac disease
• Delayed puberty or growth failure
• Pain associated with urination or in males, testicular pain

The presence of these red flags should prompt urgent evaluation and may necessitate immediate intervention or referral to a specialist.

Abdominal Pain in Children

1. What is the most common cause of acute abdominal pain in children?
   Answer: Gastroenteritis
2. Which condition is characterized by intermittent abdominal pain around the navel in children?
   Answer: Functional abdominal pain
3. What is the term for inflammation of the pancreas that can cause severe abdominal pain?
   Answer: Pancreatitis
4. Which of the following is NOT a typical symptom of appendicitis in children?
   Answer: Diarrhea
5. What is the most common surgical cause of abdominal pain in children?
   Answer: Appendicitis
6. Which condition is characterized by severe abdominal pain, vomiting, and a palpable abdominal mass?
   Answer: Intussusception
7. What is the term for twisting of the testicle that can cause abdominal pain in boys?
   Answer: Testicular torsion
8. Which of the following is a common cause of chronic abdominal pain in children?
   Answer: Irritable bowel syndrome (IBS)
9. What is the most appropriate initial imaging study for a child with suspected appendicitis?
   Answer: Abdominal ultrasound
10. Which condition is characterized by recurrent abdominal pain, often triggered by fatty foods?
    Answer: Cholelithiasis (gallstones)
11. What is the term for inflammation of the urinary bladder that can cause abdominal pain?
    Answer: Cystitis
12. Which of the following is a potential complication of untreated constipation in children?
    Answer: Fecal impaction
13. What is the most common cause of abdominal pain in adolescent girls?
    Answer: Dysmenorrhea (menstrual cramps)
14. Which condition is characterized by abdominal pain, blood in stools, and weight loss in children?
    Answer: Inflammatory bowel disease
15. What is the term for inflammation of the renal pelvis and kidney that can cause abdominal pain?
    Answer: Pyelonephritis
16. Which of the following is NOT a typical symptom of gastroesophageal reflux disease (GERD) in children?
    Answer: Bloody stools
17. What is the most common cause of acute pancreatitis in children?
    Answer: Biliary tract disease
18. Which condition is characterized by severe abdominal pain and jaundice in children?
    Answer: Cholangitis
19. What is the term for a collection of pus in the abdominal cavity that can cause pain?
    Answer: Intra-abdominal abscess
20. Which of the following is a potential cause of recurrent abdominal pain in school-aged children?
    Answer: School avoidance
21. What is the most appropriate initial management for a child with suspected gastroenteritis?
    Answer: Oral rehydration therapy
22. Which condition is characterized by severe abdominal pain radiating to the back in children?
    Answer: Acute pancreatitis
23. What is the term for a painful ovarian cyst that has twisted on its pedicle?
    Answer: Ovarian torsion
24. Which of the following is NOT a typical sign of peritonitis in children?
    Answer: Increased bowel sounds
25. What is the most common cause of mechanical small bowel obstruction in children?
    Answer: Adhesions
26. Which condition is characterized by recurrent abdominal pain and headaches in children?
    Answer: Abdominal migraine
27. What is the term for inflammation of the diverticulum of the cecum or ascending colon?
    Answer: Diverticulitis
28. Which of the following is a potential complication of Henoch-Schönlein purpura in children?
    Answer: Intussusception
29. What is the most appropriate initial diagnostic test for a child with suspected urinary tract infection?
    Answer: Urinalysis and urine culture
30. Which condition is characterized by abdominal pain and bloody diarrhea following ingestion of undercooked meat?
    Answer: Enterohemorrhagic E. coli (EHEC) infection

Further Reading

• Chronic Abdominal Pain in Children: a Clinical Report of the American Academy of Pediatrics and the North American Society for Pediatric Gastroenterology, Hepatology and Nutrition
• Evaluation of Acute Abdominal Pain in Adults
• Acute abdominal pain in children: Approach to evaluation (UpToDate, subscription required)
• Pediatric Abdominal Pain (StatPearls)