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  • Infants with an abrupt onset of bilious vomiting are likely to have a midgut volvulus complicating malrotation.
  • In the first few months of life, infants with persistent, painless, and forceful vomiting should be evaluated for upper intestinal tract obstruction. Pyloric stenosis is far more common than are congenital bands, antral webs, intestinal duplication, or annular pancreas.
  • Intussusception should be the provisional diagnosis for a child with severe, episodic abdominal pain associated with vomiting.
  • Failure to remove the diaper of infants with deceptively benign vomiting may preclude the diagnosis of incarcerated inguinal hernia.
  • Enterocolitis is a potentially deadly complication of Hirschsprung's disease. It can develop before the diagnosis of Hirschsprung's disease is established or present years after surgical repair.
  • Inflammatory bowel disease should be suspected in any infants or children with prolonged gastrointestinal symptoms. This is especially true when stomatitis or perianal disease is present.
  • The most likely diagnosis of an abdominal catastrophe presenting as peritonitis is appendicitis.


There are a large number of disorders that are associated with abdominal complaints. These include diseases unrelated to the alimentary canal as well as gastrointestinal disorders. A large number of gastrointestinal disease states can lead to an emergency department (ED) visit. It is the responsibility of the emergency physician to accurately assess these patients and establish a working diagnosis. A detailed inquiry that characterizes the nature and course of recent events and elicits the contributing symptoms, as well as past medical history, will usually lead to an appropriate provisional diagnosis for those children beyond infancy. For younger patients without a wide verbal repertoire, observations of the caretaker are of no less importance but may be misinterpreted. Thus, the essential tetrad of the abdominal examination (inspection, auscultation, percussion, and palpation) assumes greater importance in preverbal children.1


There are a small number of nontraumatic abdominal disease states that may present as an “abdominal emergency.” The treating physician must emergently recognize these surgical conditions. The physician must initiate treatment, and in certain circumstances, acquire laboratory studies, including imaging. These may confirm clinical suspicion and provide baseline parameters for surgical consultants.2


The acute abdominal conditions that may require surgical intervention share common historic features and physical examination findings. Vomiting may be the presenting feature and dominant concern to both caretaker and emergency physician in circumstances of an abdominal emergency. The appearance of the emesis (blood tinged, bilious, feculent) is a defining historic feature. The presence or apparent absence of abdominal pain narrows the differential diagnosis. The general appearance of the patient and specific abdominal examination findings from inspection, auscultation, palpation, and percussion are priorities for refining the differential diagnosis. Of the available bedside findings, the presence or absence of abdominal distention further narrows the differential diagnosis. This algorithmic approach to selected abdominal emergencies is depicted in Figure 9–1. An expansion of these entities can be found under headings The Obstructions, Intra-Abdominal Sepsis, Gastrointestinal Foreign Bodies, and Megacolon.

Figure 9-1.
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