approach to a child with abdominal pain

1. DR. MADAN KUMAR TIMALSENA
RESIDENT (PEDIATRICS DEPARTMENT)

2. OBJECTIVES: To be able to
 Understand the causes and frequency of abdominal pain in
childhood
 Develop a differential diagnosis based on age and symptoms
 Formulate a plan for evaluation and management of abdominal
pain
 Choose the appropriate imaging study for various diagnoses and
avoid when not
 Identify patients with serious cause of abdominal pain that
require early intervention

3. DIAGOSTIC CHALLENGES:
 children are limited in their ability to give an accurate
history
 parents or guardians may also have difficulty
interpreting the complaints of small children
 In many cases, the causes are benign an often no cause
is found
 some require rapid diagnosis and treatment in order to
prevent significant morbidity or mortality

5. TYPES OF ABDOMINAL PAIN IN CHILDREN
Acute
O Organic
O Inorganic/ Idiopathic/ functional
Chronic
o Organic
o Inorganic/ Idiopathic/ functional

6. Abdominal Pain
Abdominal pain can result from:
• injury to the intra-abdominal organs
• injury to overlying somatic structures in the
abdominal wall
• extra-abdominal diseases.

7. Visceral pain
• nerves within the gut detect injury
• nonmyelinated nerve fibers are responsible
• mediate pain sensation, which is vague, dull, slow in
onset, and poorly localized
• Lower degrees of activation may result in perception of
nonpainful or perhaps vaguely uncomfortable sensations
• more intensive stimulation of these fibers results in pain
• Overactive sensation may be the basis of functional
abdominal pain

8. Somatic Pain
• results when overlying body structures are injured
• include the parietal peritoneum, fascia, muscles,
and skin of the abdominal wall
•fibers are myelinated and are capable of rapid transmission of well-
localized painful stimuli
• When intra-abdominal processes extend to cause inflammation or
injury to the parietal peritoneum or other somatic structures, poorly
localized visceral pain becomes well-localized somatic pain
Eg: In acute appendicitis, visceral fibers are activated initially by the
early phases of the infection. When the inflammatory process
extends to involve the overlying parietal peritoneum, the pain
becomes more acute and localizes generally to the right lower
quadrant. This is called somatoparietal pain.

9. Referred pain
• Referred pain is a painful sensation in a body region distant from the true
source of pain
• activation of spinal cord somatic sensory cell bodies by intense signaling
from visceral afferent nerves, located at the same level of the spinal cord
• predictable based on the locus of visceral injury
• Cardiac visceral pain is referred to left-sided T1-5 somatic
segments, causing left shoulder and arm pain
• Stomach pain is referred to the epigastric and retrosternal regions
• liver and pancreas pain is referred to the epigastric region
• Gall-bladder pain often is referred to the region below the right scapula
• Somatic pathways stimulated by small bowel affect the periumbilical area,
and a noxious event in the colon results in infraumbilical referred pain

11. Assessment of pain severity in pre-verbal child:
0 = Relaxed and comfortable 1-3 = Mild discomfort 4-6 = Moderate pain 7-10 = Severe
discomfort/pain

12. Acute Abdominal Pain
Distinguishing Features:
• Acute abdominal pain can signal the presence of a dangerous intra-abdominal process,
such as appendicitis or bowel obstruction
• may originate from extraintestinal sources, such as lower lobe pneumonia or urinary
tract stone
• Not all episodes of acute abdominal pain require emergency intervention
• Appendicitis must be ruled out as quickly as possible; the evaluation must be
efficient, properly focused, and rapid
• Only a few children presenting with acute abdominal pain actually have a surgical
emergency.
• These surgical cases must be separated from cases that can be managed conservatively

13.  most of the emergency visits presenting with acute abdominal pain are self-
limited and benign
 AGE is the most common cause in all pediatric age group
 surgical etiology may be present in up to 20%
 below 1 year of age, the most common surgical etiology was reported to be
incarcerated inguinal hernia (45.1%), followed by intussusception (41.9%)
 These etiologies were uncommon in school-age and adolescent children
 In children above 1 year of age, the most common causes of acute surgical
diagnoses have been reported to be
 acute appendicitis (64.0%)
 incarcerated hernia (7.5%)
 trauma (16.3%)
 intussusception (6.3%)
 intestinal obstruction (1.3%)
 ovarian torsion (1.3%)

15. Initial Diagnostic Evaluation
• Important clues to the diagnosis can be
determined by History and physical examination
• The onset of pain can provide some clues
• Events that occur with a discrete, abrupt onset,
such as passage of a stone, perforation of a
viscus, or infarction, result in a sudden onset
• Gradual onset of pain is common with infectious
or inflammatory causes, such as appendicitis and
IBD

16. • A standard group of laboratory tests usually is
performed for abdominal pain
• An abdominal x-ray series also is usually
obtained
• Further imaging studies may be warranted to identify
specific causes
• CT can visualize the appendix if the examination and
laboratory findings suggest a possibility of appendicitis
but the diagnosis remains in doubt
• If the history and other features suggest
intussusception, a barium or pneumatic (air) enema
may be the first choice to diagnose and treat this
condition with hydrostatic reduction

17. Diagnostic Approach to Acute
Abdominal Pain
History
Onset
Sudden or gradual, prior episodes, association with
meals, history of injury
Nature Sharp versus dull, colicky or constant, burning
Location
Epigastric, periumbilical, generalized, right or left
lower quadrant, change in location over time
Fever Presence suggests appendicitis or other infection
Extraintestinal
symptoms
Cough, dyspnea, dysuria, urinary frequency, flank
pain
Course of symptoms
Worsening or improving, change in nature or
location of pain

18. Physical Examination
General Growth and nutrition, general
appearance, hydration, degree of
discomfort, body position
Abdominal Tenderness, distention, bowel sounds,
rigidity, guarding,
mass,hepatosplenomegaly
Genitalia Testicular torsion, hernia, pelvic
inflammatory disease, ectopic pregnancy
Surrounding structures Breath sounds, rales, rhonchi, wheezing,
flank tenderness, tenderness of
abdominal wall structures, ribs,
costochondral joints
Rectal examination Perianal lesions, stricture, tenderness,
fecal impaction, blood
Diagnostic Approach to
Acute Abdominal Pain

19. Laboratory
CBC, C-reactive protein, ESR Evidence of infection or inflammation
AST, ALT, GGT, bilirubin Biliary or liver disease
Amylase, lipase Pancreatitis
Urinalysis Urinary tract infection, bleeding due to stone,
trauma, or obstruction
Pregnancy test (older
females)
Ectopic pregnancy
Radiology
Plain flat and upright
abdominal films
Bowel obstruction, appendiceal fecalith, free
intraperitoneal air, kidney stones
CT scan Rule out abscess, appendicitis, Crohn disease,
pancreatitis, gallstones, kidney stones
Barium enema Intussusception, malrotation
Ultrasound Gallstones, appendicitis, intussusception,
pancreatitis, kidney stones
Endoscopy
Upper endoscopy Suspected peptic ulcer or esophagitis

20. Differential Diagnosis
• With acute pain, the urgent task of the clinician is
to rule out surgical emergencies
• In young children, malrotation, incarcerated
hernia, congenital anomalies, and
intussusception are common concerns
• In older children and teenagers, appendicitis is
more common
• An acute surgical abdomen is characterized by
signs of peritonitis, including tenderness,
abdominal wall rigidity, guarding, and absent or
diminished bowel sounds

21. Differential Diagnosis of Acute
Abdominal Pain
Traumatic
Duodenal hematoma
Ruptured spleen
Perforated viscus
Functional
Constipation*
Irritable bowel syndrome*
Dysmenorrhea*
Mittelschmerz (ovulation)*
Infantile colic*
Infectious
Appendicitis*
Viral or bacterial gastroenteritis/adenitis*
Abscess
Spontaneous bacterial peritonitis
Pelvic inflammatory disease
Cholecystitis
Urinary tract infection*
Pneumonia
Bacterial typhlitis
Hepatitis
Genital
Testicular torsion
Ovarian torsion
Ectopic pregnancy
Genetic
Sickle cell crisis*
Familial Mediterranean fever
Porphyria
Metabolic
Diabetic ketoacidosis
Inflammatory
Inflammatory bowel disease
Vasculitis
Henoch-Schönlein purpura*
Pancreatitis
Obstructive
Intussusception*
Malrotation with volvulus
Ileus*
Incarcerated hernia
Postoperative adhesion
Meconium ileus equivalent (cystic
fibrosis)
Duplication cyst, congenital
stricture
Biliary
Gallstone
Gallbladder hydrops
Biliary dyskinesia
Peptic
Gastric or duodenal ulcer
Gastritis*
Esophagitis
Renal
Kidney stone
Hydronephrosis

23. Distinguishing Features of
Abdominal Pain in Children
Disease Onset Location Referral Quality Comments
Functional: irritable
bowel syndrome
Recurrent Periumbilical,
splenic and
hepatic
flexures
None Dull, crampy,
intermittent;
duration 2 hr
Family stress, school
phobia, diarrhea and
constipation;
hypersensitive to pain
from distention
Esophageal reflux Recurrent,
after meals,
at bedtime
Substernal Chest Burning Sour taste in mouth;
Sandifer syndrome
Duodenal ulcer Recurrent,
before
meals, at
night
Epigastric Back Severe burning,
gnawing
Relieved by food, milk,
antacids; family history
important; GI bleeding
Pancreatitis Acute Epigastric-
hypogastric
Back Constant, sharp,
boring
Nausea, emesis,
marked tenderness

24. Distinguishing Features of Abdominal
Pain in Children
Disease Onset Location Referral Quality Comments
Intestinal obstruction Acute or
gradual
Periumbilical-lower
abdomen
Back Alternating
cramping (colic)
and painless
periods
Distention,
obstipation, bilious
emesis, increased
bowel sounds
Appendicitis Acute Periumbilical or
epigastric; localizes
to right lower
quadrant
Back or
pelvis if
retrocecal
Sharp, steady Nausea, emesis,
local tenderness, ±
fever, avoids
motion
Meckel diverticulum Recurrent Periumbilical-lower
abdomen
None Sharp Hematochezia;
painless unless
intussusception,
diverticulitis, or
perforation
Inflammatory bowel
disease
Recurrent Depends on site of
involvement
Dull cramping,
tenesmus
Fever, weight loss,
± hematochezia
Intussusception Acute Periumbilical-lower
abdomen
None Cramping, with
painless periods
Guarded position
with knees pulled
up, currant jelly
stools, lethargy

25. Distinguishing Features of
Abdominal Pain in Children
Disease Onset Location Referral Quality Comments
Lactose intolerance Recurrent with
milk products
Lower
abdomen
None Cramping Distention, gaseousness,
diarrhea
Urolithiasis Acute, sudden Back Groin Severe,
colickypain
Hematuria
Pyelonephritis Acute, sudden Back None Dull to sharp Fever, costochondral
tenderness, dysuria, urinary
frequency, emesis
Cholecystitis and
cholelithiasis
Acute Right upper
quadrant
Right
shoulder
Severe,
colickypain
Hemolysis ± jaundice, nausea,
emesis

26. Recurrent (Chronic) Abdominal Pain
• Recurrent abdominal pain is defined as the occurrence of
multiple episodes of abdominal pain over at least 3 months
that are severe enough to cause some limitation of activity
• Recurrent abdominal pain is a common problem in
children, affecting more than 10% of children at some time
during childhood
• The peak incidence occurs between ages 7 and 12 years
• Although the differential diagnosis of recurrent abdominal
pain is fairly extensive , most children with this condition
are not found to have a serious (or even identifiable)
underlying illness causing the pain

28. Differential Diagnosis of Recurrent Abdominal Pain
 Functional abdominal
pain*
 Irritable bowel syndrome*
 Chronic pancreatitis
 Gallstones
 Peptic disease
 Duodenal ulcer
 Gastric ulcer
 Esophagitis
 Lactose intolerance*
 Fructose malabsorption
 Inflammatory bowel
disease*
 Crohn disease
 Ulcerative colitis
 Constipation*
 Obstructive uropathy
 Congenital intestinal
malformation
 Malrotation
 Duplication cyst
 Stricture or web
 Celiac disease*

29. Differential Diagnosis
• The most common disorder to consider is functional
abdominal pain
• characteristically occurs daily or nearly every day
• not associated with or relieved by eating or defecation
• associated with significant loss of the ability to function
normally
• typically have personality traits that include a tendency
toward anxiety and perfectionism, which result in stress at
school and in social situations
• pain often is worst at the start of the school day and before
returning to school after vacations
• A child with suspected functional pain must be evaluated
carefully to exclude other causes of discomfort

30. • Functional abdominal pain differs from irritable
bowel syndrome (IBS) in minor ways
• Children with IBS have pain beginning with a
change in stool frequency or consistency
• a stool pattern fluctuating between diarrhea
and constipation, and relief of pain with
defecation.
• Pain is commonly accompanied in both groups of
children by school avoidance, secondary gains,
anxiety about imagined causes, lack of coping
skills, and disordered peer relationships

31. Distinguishing Features..
• One needs to distinguish between functional pain
and IBS and more serious underlying disorders
• should ask about the warning signs for
underlying illness
• If any warning signs are present, further
investigation is necessary
• Even if the warning signs are absent, some
laboratory evaluation is warranted

32. Warning Signs of Underlying Illness in
Recurrent Abdominal Pain
•Vomiting
•Abnormal screening laboratory study
•Fever
•Bilious emesis
•Growth failure
•Pain awakening child from sleep
•Weight loss
•Location away from periumbilical region
•Blood in stools or emesis
•Delayed puberty

33. • The physician and the parents must feel assured that
no serious illness is being missed
• a judicious laboratory evaluation after a careful
history and complete physical examination can
accomplish this
• One mistake that must be avoided in treating recurrent
pain is performing too many tests
• The initial evaluation recommended in avoids these
problems.

34. • While waiting for laboratory and ultrasound results, a 3-day trial of
a lactose-free diet should be instituted to rule out lactose
intolerance
• If tests are normal and no warning signs are present, testing should
be stopped
• If there are warning signs, worrisome symptoms, progression of
symptoms, or laboratory abnormalities that suggest a specific
diagnosis, additional investigation may be necessary
• If antacids consistently relieve pain, an upper GI endoscopy is
indicated
• If the child is losing weight, a barium upper GI series with a small
bowel follow-through or contrast CT is a good idea to look for
evidence of CD
• Celiac disease also should be considered

35. Suggested Evaluation of Recurrent
Abdominal Pain
Initial Evaluation Follow-up Evaluation*
Complete history and physical
examination
CT scan of the abdomen and pelvis with
oral, rectal, and intravenous contrast
Ask about "warning signs" Celiac disease serology-endomysial
antibody or tissue transglutaminase
antibody
Determine degree of functional
impairment (e.g., missing school)
Barium upper GI series with small bowel
follow-through Endoscopy of the
esophagus, stomach, and duodenum
CBC Colonoscopy
ESR
Amylase, lipase
Urinalysis
Abdominal ultrasound-examine liver,
bile ducts, gallbladder, pancreas,
kidneys, ureters
Trial of 3-day lactose-free diet

36. Treatment of Recurrent Abdominal Pain
• A child who is kept home or sent home from school
because of pain receives a lot of attention for the
symptoms, is excused from responsibilities, and
withdraws from full social functioning
• This situation rewards complaints and increases the child's
anxiety about health
• When the child observes that the adults are worried, the
child worries too
• To break this cycle of pain and disability, the child must return
to normal activities immediately, even before all test results
are available.

37. Treatment of Recurrent Abdominal Pain
• The child should not be sent home from school with stomachaches;
rather, the child may be allowed to take a short break from class in the
nurse's office until the cramping abates
• It is useful to inform the child and the parents that the pain is likely to be
worse on the day the child returns to school
• Anxiety worsens dysmotility and pain perception
• Sometimes, medications can be helpful
• Fiber supplements are useful to manage symptoms of IBS
• In difficult and persistent cases, amitriptyline or a selective serotonin
reuptake inhibitor may be beneficial

38. Outcome of recurrent abdominal pain in
children…
 After 5 years,
 1/3 of children with RAP will have resolution of
their pain,
 1/3 continue to complain of the same
symptoms, and
 1/3 will have a different recurrent pain
complaint.
31

39. References :
 www.uptodate.com
 Nelson textbook of pediatrics 21st edition
 https://www.aafp.org/afp/2003/0601/p2321.html
 https://pedsinreview.aappublications.org/content/39/3/130
 www.longdom.org/open-access/epidemiological-aspects-
of-abdominal-pain-in-children-at-the-el-rapha-polyclinic-
in-libreville--gabon-2572-0775-
1000126.pdf&ved=2ahUKEwifxeW8mIjwAhWI8HMBHZLS
CGgQFjADegQIEBAC&usg=AOvVaw1ideiFTTF2mupjh09C
Xamn&cshid=1618762607420
 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5774593/