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Acute Gastroenteritis
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Vomiting, with or without diarrhea, frequently accompanies the chief complaint of abdominal pain. Surgically correctable causes of abdominal pain and other medical mimickers of gastroenteritis, such as diabetic ketoacidosis (DKA), dehydration ketosis, streptococcal pharyngitis, pneumonia, and urinary tract infections (UTIs), must first be ruled out. When a diagnosis of acute gastroenteritis is made, focus on rehydration and electrolyte repletion, preferably in the form of oral fluids.6
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Diabetic Ketoacidosis
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Children younger than 5 years commonly present in DKA when first diagnosed with diabetes. DKA manifests with increased urinary frequency, abdominal pain, vomiting, lethargy, and tachypnea.7 Tachypnea from a compensatory respiratory alkalosis, along with abdominal pain from ketosis and dehydration, may be the only clinical clues to the diagnosis of DKA. Once the diagnosis of DKA is made, provide fluid resuscitation with electrolyte repletion and insulin therapy to correct the metabolic disturbance. Do not give insulin as a bolus, but infuse at 0.1 U/kg/h.
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Dehydration in the pediatric population accounts for approximately 5% of pediatric hospital admission, and more than 300 annual deaths in United States.8 Dehydration and ketosis in infants and young children can cause abdominal pain and vomiting. The magnitude of volume depletion can be assessed most accurately by the percentage of body weight lost (Table 69-6).6 Send a basic metabolic panel for severely dehydrated children where electrolyte abnormalities are a concern; carefully correct hypernatremia to avoid iatrogenic cerebral edema.6
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Streptococcal Pharyngitis
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Streptococcal pharyngitis is most common in children 5 to 15 years of age and has the risk of postinfectious sequelae of poststreptococcal glomerulonephritis and rheumatic fever. Although the classic symptoms of pharyngitis include throat pain, fevers and malaise, common presentations in younger children are fever, abdominal pain, and vomiting. Streptococcal pharyngitis may occur with scarlet fever, manifested by a “sandpaper” erythematous rash. Treatment options include penicillins, cephalosporins, and macrolides.9
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Urinary Tract Infections
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A common source of abdominal discomfort in children is both upper and lower UTIs, manifestations which can include fever, nausea, emesis, abdominal pain, and accompanying urinary frequency, urgency, and dysuria. An oral course of antibiotics is appropriate treatment for nontoxic children who are able to tolerate oral intake. Strongly consider parenteral antibiotics and admission in infants younger than 3 months as well as those with signs of systemic disease (see Chapter 84).
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Constipation is one of the most common causes of colicky abdominal pain in children, and is associated with significant behavioral overlay. The pain may limit their everyday function and progress to cause nausea and vomiting. Some patients will present with recurrent UTIs secondary to bladder compression and incomplete emptying with voiding. Patients with long-standing constipation can derelop encopresis or liquid stools from leakage around impacted stool in the distal colon and rectum.
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Bleeding and Abdominal Pain
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Abdominal pain associated with bleeding is discussed in detail in Chapter 72. Infants and toddlers may present with hard stools streaked with blood from anal fissures. A more serious disease process is hemolytic uremic syndrome (HUS) that presents with anemia, thrombocytopenia, and renal failure. Abdominal pain with bloody diarrhea may precede HUS, the causative agent of which is often Escherichia coli O157:H7. Patients with HUS require aggressive fluid resuscitation and treatment of their hemolytic anemia and coagulation disorders. The characteristic rash of Henoch–Schöenlein purpura (HSP) can also present with abdominal pain, arthralgias, and blood in the stool.
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With increases in childhood obesity, gallstones are becoming more frequent in the pediatric population, particularly among children of Hispanic origin, with rates estimated prevalence as high as 4%.10 Some children are at particularly high risk for gallbladder disease, including patients with ongoing hemolytic disease such as sickle cell anemia. Due to the fact that gallbladder disease remains less common in the pediatric population, there is a paucity of evidence regarding the optimal treatment, but NSAIDS and opioids are options for initial pain management (Please refer to Chapter 73).3
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Although uncommon in the pediatric population, the incidence of pancreatitis appears to be increasing with escalating obesity rates. Patients may present with abdominal pain radiating to the back after high-fat meals (Please refer to Chapter 74, Pancreatitis).
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Jaundice and abdominal pain may be the first manifestations of hepatitis, the etiology of which can be from infection, drug exposure (especially acetaminophen), systemic disease, or intrinsic diseases of the liver and biliary tree. Please refer to Chapter 73 for a detailed hepatitis discussion.
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Renal colic typically presents as an acute onset of severe unilateral flank pain. Although historically considered uncommon in the pediatric population, incidence in children is increasing, particularly in the southern portions of the United States known as the “stone belt.”11 Hospitalizations from renal stones account for 1 in 1000 to 1 in 7600 pediatric hospital admissions. Although there is a paucity of research on the medical management of children with nephrolithiasis, NSAIDS and opioids are recommended for the ED setting.3
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Inflammatory Bowel Disease
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Inflammatory bowel disease (IBD) is a consideration for the undiagnosed patient with repeated ED visits for abdominal pain. IBD pain may be vague in nature, possibly associated with melena or frankly bloody stools (Please refer to Chapter 75, Inflammatory Bowel Disease).