EVALUATION OF THE PEDIATRIC PATIENT WITH ABDOMINAL PAIN
A detailed history should be performed only after the practitioner has evaluated and stabilized the patient, and established that no life-threatening conditions are present. A meticulous history is crucial in guiding the practitioner in the management of abdominal pain including laboratory and radiographic evaluations, differential diagnosis, necessity for specialist consultation, and disposition. Depending on the age of the child, obtaining a detailed history of abdominal pain can be challenging. In younger children, parents often perceive that their child’s abdomen hurts based on facial expression or body movements such as writhing or drawing up the knees. Localization of pain may prove difficult based on history alone. Key features of history include presence, duration, and location of pain; presence or absence of fever; feeding and bowel habits; last oral intake; frequency and character of stools and vomitus; presence of blood in stools or vomitus; urinary symptoms; menstrual history; vaginal discharge/bleeding; respiratory symptoms; travel history, and changes in weight.
Special attention should be paid to significant past medical history including history of prematurity, congenital anomalies, inborn errors of metabolism, sickle cell disease, necrotizing enterocolitis, cystic fibrosis, and intussusception. A thorough review of systems is mandatory as abdominal pain is often a symptom of disorders originating in other organ systems such as ear, nose, and throat (ENT [pharyngitis]), genitourinary(GU [UTI, ectopic pregnancy, hernia]), vascular (Henoch-Schönlein purpura), and pulmonary (lower lobe pneumonia). The discriminating practitioner keeps in mind an age-appropriate differential during the history as common causes of abdominal pain vary significantly in the pediatric population, especially among infants. The differential diagnosis of common causes of acute abdominal pain is listed in Table 15–1.
Differential diagnosis of acute abdominal pain.
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Table 15–1. Differential diagnosis of acute abdominal pain.
|Disease ||Characteristics of pain ||Epidemiology ||Associated Symptoms ||Physical examination ||Laboratory and radiographic evaluation |
|Appendicitis +/- perforation ||Periumbilical gradually localized to RLQ becoming acute and persistent ||Peaks in adolescence (due to maximal lymphoid hyperplasia) & rare < 2 y; often presents with peritonitis or sepsis due to delayed diagnosis in young children; perforation: (90% < 3 y, < 15% adolescents) ||Fever, vomiting, diarrhea, diffuse pain, distention, right hip complaints, lethargy, or irritability ||Fever, RLQ, or periumbilical tenderness ||Leukocytosis not sensitive; abdominal ultrasound (sensitivity, 80-92%; specificity, 86-98%; appendix not visualized in 10% with appendicitis); abdominal CT (sensitivity, 87-100% and highest with both oral and colonic contrast; specificity 83-97%) |
|Intussusception ||Colicky, severe, and intermittent. Child may draw legs up to abdomen and kick legs in air. Child appears calm and relieved between attacks. ||Peak at 10 mo; rare < 3 mo; 2-4 times more common in males ||Intermittent pain, fever, vomiting, poor feeding, lethargy, bloody or mucous stools ||“Dance sign” or “sausage” in RLQ; abdominal mass ||Barium or water-soluble enema gold standard for diagnosis and therapy; US (sensitivity, 95-98%; specificity 88-94%) as adjunct to monitor therapeutic effect |
|Malrotation/midgut volvulus ||Vague, diffuse, or nonexistent || |
75% diagnosed by 1 y;
Peak at < 1 mo (50%)
|Feeding intolerance, bilious emesis, abdominal pain, peritonitis and shock ||Normal ...|
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