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Abdominal pain is one of the most common complaints encountered by pediatric hospitalists. Despite this, the evaluation is often exceedingly difficult, and in many cases no definitive diagnosis can be made. The most urgent matter for the hospitalist initially is to rule out a life-threatening surgical emergency. If an acute abdomen is suspected based on history and physical, prompt surgical consultation is imperative.
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Abdominal pain can be caused by inflammation of the abdominal organs themselves (or their visceral peritoneum) or by inflammation of the parietal peritoneum lying in proximity to the underlying inflammation. Irritation of the abdominal wall musculature can also lead to pain, and various extra-abdominal processes have been associated with abdominal pain (e.g. diabetic ketoacidosis or lower lobe pneumonia). Pain due to a process in the small intestine is usually felt in the midline around the umbilicus initially; as the inflammation progresses, the parietal peritoneum in the area of inflammation becomes involved, allowing better localization of pain. The classic example is appendicitis, with a dull periumbilical ache early in the course followed by a progressive shift of pain to the right lower quadrant as the inflammation evolves. Certain elements of the history and physical examination findings may help identify the cause of abdominal pain (Table 17-1).
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The differential diagnosis of abdominal pain is extensive (Table 17-2). In addition to the typical history and physical examination, epidemiologic factors are extremely helpful in narrowing the differential diagnosis, including age, gender, season, locale, and the like. As stated above, a patient with peritonitis requires timely surgical evaluation. With several conspicuous exceptions, most patients with signs of peritonitis on examination progress to that point gradually. On history, these patients, if old enough, may report that the bumps in the road on the trip to the emergency department caused pain. These patients prefer to lie ...