This document discusses non-traumatic abdominal pain in children. It begins by noting the variation in how children perceive and tolerate abdominal pain. It then describes the two types of nerve fibers that transmit painful stimuli in the abdomen - A fibers which mediate sharp localized pain and C fibers which transmit poorly localized, dull pain. It explains how somatic pain tends to be intense and well-localized while visceral pain is dull, aching and experienced in the dermatome of the affected organ. Referred pain from other areas like the lungs can also cause abdominal pain. Certain characteristics of the pain can provide clues to diagnosis.
2. There is considerable variation
among children in their perception
and tolerance for abdominal pain.
A specific cause may be difficult to
find, but the nature and location of
a pain-provoking lesion can
usually be determined from the
clinical description.
3. Two types of nerve fibers transmit
painful stimuli in the abdomen. In
skin and muscle, A fibers mediate
sharp localized pain; C fibers from
viscera, peritoneum, and muscle
transmit poorly localized, dull pain.
4. Somatic pain
Intense and is usually well localized. When the
inflamed viscus comes in contact with the somatic
organ like the parietal peritoneum or the
abdominal wall, pain is localized to that site.
Peritonitis gives rise to generalized abdominal
pain with rigidity, involuntary guarding, rebound
tenderness, and cutaneous hyperesthesia on
physical examination.
5. Visceral pain
tends to be dull and aching and is
experienced in the dermatome from which the
affected organ receives innervations. So,
most often, the pain and tenderness is not felt
over the site of the disease process.
6. Painful stimuli originating in the liver, pancreas,
biliary tree, stomach, or upper bowel are felt in
the epigastrium
Pain from the distal small bowel, cecum,
appendix, or proximal colon is felt at the
umbilicus
Pain from the distal large bowel, urinary tract, or
pelvic organs is usually suprapubic
Pain from the cecum, ascending colon, and
descending colon sometimes is felt at the site of
the lesion due to the short mesocecum and
corresponding mesocolon
7. The shifting (localization) of pain is a pointer
toward diagnosis; for example; Periumbilical pain
of a few hours localizing to the right lower quadrant
suggests appendicitis.
Radiation of pain can be helpful in diagnosis;
for example, in biliary colic the radiation of pain is
toward the inferior angle of the right scapula,
pancreatic pain radiated to the back, and the renal
colic pain is radiated to the inguinal region on the
same side.
8. Referred pain
due to shared central projections with the
sensory pathway from the abdominal wall,
can give rise to abdominal pain, as in
pneumonia when the parietal pleural pain is
referred to the abdomen.
9. Pain that suggests a potentially serious
organic etiology is associated with
Age <5 yr; fever; weight loss; bile or blood-
stained emesis; jaundice;
hepatosplenomegaly; back or flank pain or
pain in a location other than the umbilicus;
awakening from sleep in pain; referred pain
to shoulder, groin or back; elevated ESR,
WBC, or CRP; anemia; edema; or a strong
family history of inflammatory bowel disease
(IBD) or celiac disease.
12. NONORGANIC
Hx and PE; tests
as indicated
Nonspecific pain, often periumbilical
Functional
abdominal
pain
Hx and PE
Intermittent cramps,diarrhea, and
constipation
Irritable
bowel
syndrome
Hx;
esophagogastrod
uodenoscopy
Peptic ulcer–like symptoms without
abnormalities on evaluation of the upper GI
tract
Non-ulcer
dyspepsia
13. GASTROINTESTINAL TRACT
Hx and PE; plain x-ray of
abdomen
Hx of stool retention,
evidence of constipation on
examination
Chronic
constipation
Trial of lactose-free diet; lactose
breath hydrogen test
Symptoms may be
associated with lactose
ingestion; bloating, gas,
cramps, and diarrhea
Lactose
intolerance
Stool evaluation for O&P;
specific immunoassays for
Giardia
Bloating, gas, cramps, and
diarrhea
Parasite
infection
(especially
Giardia)
Large intake of apples, fruit juice,
or candy or chewing gum
sweetened with sorbitol
Nonspecific abdominal pain,
bloating, gas, and diarrhea
Excess
fructose or
sorbitol
ingestion
14. Esophagogastroduodenoscopy or
upper GI contrast x-rays
Burning or gnawing epigastric
pain; worse on awakening or
before meals; relieved with
antacids
Peptic ulcer
Esophagogastroduodenoscopy
Epigastric pain with
substernal burning
Esophagitis
Meckel scan
Periumbilical or lower
abdominal pain; may have
blood in stool
Meckel's
diverticulum
15. Identify intussusception during
episode or lead point in intestine
between episodes with contrast
studies of GI tract
Paroxysmal severe cramping
abdominal pain; blood may be
present in stool with episode
Recurrent
intussusception
PE, CT of abdominal wall
Dull abdomen or abdominal
wall pain
Internal,
inguinal, or
abdominal wall
hernia
Barium enema, CT
Recurrent RLQ pain; often
incorrectly diagnosed, may be
rare cause of abdominal pain
Chronic
appendicitis or
appendiceal
mucocele
16. GALLBLADDER AND PANCREAS
Ultrasound of gallbladder
RUQ pain, might
worsen with meals
Cholelithiasis
Ultrasound or CT of RUQ
RUQ pain, mass ?
elevated bilirubin
Choledochal
cyst
Serum amylase and lipase ? serum
trypsinogen; ultrasound or CT of
pancreas
Persistent boring
pain, might radiate
to back, vomiting
Recurrent
pancreatitis
17. GENITOURINARY TRACT
Urinalysis and urine
culture; renal scan
Dull suprapubic pain,
flank pain
Urinary tract
infection
Ultrasound of kidneys
Unilateral abdominal or
flank pain
Hydronephrosis
Urinalysis, ultrasound,
IVP, CT
Progressive, severe pain;
flank to inguinal region
to testicle
Urolithiasis
Ultrasound of kidneys
and pelvis; gynecologic
evaluation
Suprapubic or lower
abdominal pain;
genitourinary symptoms
Other
genitourinary
disorders
18. MISCELLANEOUS CAUSES
HxNausea, family Hx migraine
Abdominal
migraine
EEG (can require >1 study,
including sleep-deprived EEG)
Might have seizure prodrome
Abdominal
epilepsy
Serum bilirubin
Mild abdominal pain (causal or coincidental?); slightly
elevated unconjugated bilirubin
Gilbert syndrome
Hx and PE during an episode,
DNA diagnosis
Paroxysmal episodes of fever, severe abdominal pain,
and tenderness with other evidence of polyserositis
Familial
Mediterranean
fever
Hematologic evaluationAnemiaSickle cell crisis
Serum lead levelVague abdominal pain ? constipationLead poisoning
Hx, PE, urinalysis
Recurrent, severe crampy abdominal pain, occult blood
in stool, characteristic rash, arthritis
Henoch-Schonlein
purpura
Hx, PE, upper GI contrast x-rays,
serum C1 esterase inhibitor
Swelling of face or airway, crampy pain
Angioneurotic
edema
Spot urine for porphyrinsSevere pain precipitated by drugs, fasting, or infections
Acute intermittent
porphyria
20. COMMENTSQUALITYREFERRALLOCATIONONSETDISEASE
Nausea, emesis,
tenderness
Constant,
sharp, boring
Back
Epigastric, left
upper quadrant
AcutePancreatitis
Distention, obstipation,
emesis, increased
bowel sounds
Alternating
cramping
(colic) and
painless
periods
Back
Periumbilical-
lower abdomen
Acute
or
gradual
Intestinal
obstruction
Anorexia, nausea,
emesis, local
tenderness, fever with
peritonitis
Sharp, steady
Back or
pelvis if
retrocecal
Periumbilical, then
localized to lower
right quadrant;
generalized with
peritonitis
AcuteAppendicitis
21. Hematochezia, knees
in pulled-up position
Cramping, with
painless
periods
None
Periumbilical-
lower abdomen
AcuteIntussusception
Hematuria
Sharp,
intermittent,
cramping
GroinBack (unilateral)
Acute,
sudden
Urolithiasis
Fever, costo-vertebral
angle tenderness,
dysuria, urinary
frequency
Dull to sharpBladderBackAcute
Urinary tract
infection
25. Definition of Hernia
Descriptive: Swelling in the anatomical
region of the hernias, giving expansile
impulse on cough.
Pathologic: Protrusion of a sac of
peritoneum together with preperitoneal fat
or an organ through a congenital or
acquired defect in the muscles of the
abdominal wall through which they do not
normally pass.
26. Classification of Hernias in Children
Congenital Inguinal Hernia
Umbilical Hernia
Diaphragmatic Hernia
Incisional Hernia
Rare Hernias :
Epigastric, Lumber, Femoral and
Spigellian
28. PROCESSUS VAGINALIS
An out-pouching of the peritoneum
extending through the IR, ER and
reaching the scrotum.
Closes at 6 months of age.
Doesn’t mean inguinal hernia (in
minority it remains patent and
assymptomatic).
Potential space.
29. Incidence:
0.8 - 4.4% in full term
16-25% in premature infants
3-10 times more than females
Type: Indirect inguinal
hernia
Content:
Intestine, omentum
30. Site: Bilateral < 50%, in unilatera
cases: Right side predominates
(mostly due to later descent of the
right
testis).
Complications:
Irreducibility, Testicular atrophy,
Strangulation, obstruction,
Hydrocoele
35. Incidence:
0.8 - 4.4% in full term
16-25% in premature infants
3-10 times less than males
Type: Indirect
Content: Ovary
Site: Bilateral more than 50%, in unilateral cases:
Right side
predominates.
39. Testicular Torsion
Torsion occurs when an abnormally mobile testis
twists on the spermatic cord, obstructing its
blood supply.
Patients present with acute onset of severe
testicular pain.
The ischemia can lead to testicular necrosis if not
corrected within 5-6 hours of the onset of pain.
Torsion can be intermittent and can undergo
spontaneous de-torsion.
40.
41. Clinical Picture
Age:
Testicular torsion is most common in neonates and postpubertal
boys, although it can occur in males of any age.
Symptoms:
Acute onset of painful hemiscrotum.
Sometimes with nausea and vomiting.
On examination:
The testis is usually elevated as a result of the torsion and the
shortening of the cord itself and may be in a transverse lie.
The affected side can be larger from the other side due to:
The swollen testis itself, a hydrocele or skin thickening.
42. Duplex may help to confirm diagnosis.
Yet if in doubt or not available, explore.
48. In a child with an acute scrotum, testicular torsion is not the most
common condition yet the most important one.
Torsion of testicular appendices represents the more common
cause of scrotal pain.
Typically, it has a more gradual onset than testicular torsion and patients
may endure pain for several days before seeking medical attention.
Duplex may help
