An introductory talk on acute abdominal pain in children for people starting work in an emergency department.

1. +
Abdominal Pain
in Children
Updated 5/2/2015
Arjun Rao

2. +
Outline
 Clinical evaluation – tips and tricks
 Appendicitis
 Ovarian Torsion
 Intussusception
 “Constipation”
 Medical Causes
 Extra-abdominal causes

3. +
Epidemiology of Abdominal
Pain
 ~ 5% of all presentations to PED
 Surgery only required in 1-7%
 No specific diagnosis in up to 15%

4. +
History – the basics 1
 Maintain empathy at all times, no matter how tired
you are
 Parents are anxious and worried – don’t let this
frustrate you
 Open ended questions to start – let the parents
speak, don’t interrupt early
 Acknowledge that they might be exhausted,
especially if they have been transferred from
another hospital and have had a long day
 Age appropriate engagement of child

5. +
History – the basics 2
 History of pain – if child is old enough can ask
them
 Temporal history important
 Associated symptoms
 Red flags
 Bile stained vomiting
 Flank or back pain
 Waking at night
 Not walking

6. +
History – tips
 Ask about journey to hospital – when the car went
over bumps
 When asking about nature and severity let the
child know that the questions are hard and not to
worry too much if they can’t answer
 If the history is long try to establish if they had any
days when they were well
 Ask about stool frequency (beware assuming
“constipation”)
 Ask about family history of appendicits

7. +
Examination – the basics
 Distraction, be non-threatening, keep parents close
 Positioning
 Observation – RR (measure yourself), work of
breathing, movement, level of distress “well v
unwell”, Sa02 if monitored
 Vital signs – measure HR, CR
 All systems including ENT
 Inspection, Palpation, Percussion, Auscultation

8. +
Examination - tips
 Don’t stand over child, kneel or sit next to bed
 Keep arm horizontal, palpate with palm not tips of fingers
 Look at their face
 Distraction
 Ask about age, siblings, school, movies, parents, pets
 If you think the abdomen is distended measure
 Don’t forget hernia, testes
 Mobility, don’t be afraid to try to walk them but don’t push

9. +
Examination – the abdomen
Superficial palpation away from site of
reported pain – look at face
Deep palpation
Liver, spleen, kidneys
Masses
Percussion

10. +
Appendicitis in Children
 Most common non-traumatic surgical
emergency
 Peak 12-18 yrs
 Classic appendicitis easy
 “Atypical” appendicitis common in
children
 Beware false localising signs – diarrhoea,
dysuria

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12. +
Appendicitis - Investigations
 No single diagnostic test
 Aim:
 high sensitivity/specificity
 minimise missed appendicitis
 minimise normal appendicectomy rate
 minimise delay to OT

13. +
Appendicitis - Investigations
• Urinalysis
– Pyuria in ~ 30%
• FBC
– Neither sensitive nor specific
• U/S
– Sensitivity 87%, Specificity 89%
– Not visualised 10%
• CT
– Sensitivity 91%, Specificity 94%
– RIM risk (single CT in 5yo -> 20-25:100000)
•Klein, M. D. (2007). "Clinical approach to a child with abdominal pain who might have appendicitis."
Pediatric Radiology 37(1): 11-14
•Doria, A. (2009). "Optimizing the role of imaging in appendicitis." Pediatric Radiology 39(Suppliment 2):
S144-148.

14. + Appendicitis scores – Alvarado
Score
Clinical Feature Score
M Migration of pain to RIF 1
A Anorexia 1
N Nausea 1
T Tenderness in RLQ 2
R Rebound pain 1
E Elevated temperature 1
L Leukocytosis 2
S Shift to left of WBC 1
10
<5: Rule out
>7: Rule in
Probably - good at ruling out, not great at ruling in,
overestimates appendicitis in children with intermediate
scores

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Intussusception
 Telescopic invagination of one
section of the bowel into
another
 Usually ileo-colic
 Can be a great “mimic”
Image Definition
http://yoursurgery.com

16. +
Intussusception
• Mostly idiopathic but consider lead point
• Vomit / pain / blood [classic triad < 30%]
• Most common 5-10mths – “any age”
• M:F 3:1, 1-4:1000
• X-ray may show signs
• US (sensitivity ~ 100%)
• Air enema
• Consider pathological lead point in very young or older
children
Del-Pozzo et al (1996). “Intussusception: US findings with pathologic correlation – the cresent in doughnut sign. Radiology
199: 688-792

17. + Intussusception
Liver edge not well defined
“Cresent” in right upper quadrant
Paucity of gas on right side of abdomen
Distended loop of transverse colon

18. +
Meckel’s Diverticulum
• Omphalomesenteric duct vestige (vitelline duct)
• Contain gastric mucosa
• Can mimic appendicitis
http://www.health.act.gov.au

19. +
Meckel’s Diverticulum
 “Rule of 2s”
 2% population
 2% symptomatic (actually ~ 4%)
 2 inches long
 2 ft prox to terminal ileum
 2 times more common in boys
 2 types of ectopic tissue (gastric and pancreatic)
 Pain, bleed, perforation, obstruction
 Classic presentation -> painless bleeding
 Can be lead point for intussusception
 Meckel’s scan
 ~ 80% sensitivity, 95% specific
 Surgical excision

20. +
Ovarian Torsion
• Rare in children
• Usually seen with ovarian pathology
• Usually colicky lower pain
• Acute onset
• Right > Left
• May be associated nausea, vomiting,
raised WCC
• Ultrasound has high specificity /
sensitivity

21. +
Formulating a provisional and
differential diagnosis
 Be systematic
 Most likely to least likely
 Anatomical
 Most serious
 Surgical v Non-surgical
 Abdominal v extra-abdominal
Pnemonic
V Vascular
I Inflammatory/infectious
N Neoplastic
D Drugs
I Iatrogenic
C Congenital
A Autoimmune
T Traumatic
E Endocrine / Environmental
M Metabolic

22. +
Formulating a provisional and
differential diagnosis
 Constipation is not a diagnosis
 Rare but serious
 Discitis
 ALL
 Intra-abdominal abcess
 Tumour
 Anatomical approach
 Systems approach

23. +
Differential
Appendicitis
UTI/Pyelonephritis
Testicular torsion
Cholecystitis
Pneumonia
Pancreatitis
Intussusception
Bowel obstruction
Meckel’s Diverticulum
Poor diet -> constipation
http://www.lifescript.com

24. +
Extra-abdominal causes
• Tonsillitis / pharyngitis
• Pneumonia
• Pericarditis

25. +
“Medical” causes
• DKA
• HSP
• HUS
• Iron ingestion
• FMF
• Abdominal migraine

26. +
Neonates and Infants
• Hernia
• Torsion
• Appendicitis
• NEC
• Volvulus
• Intussusception
• Hirschprung

27. +
Management in ED - Analgesia
Assessment of pain
• Can be difficult – pain vs anxiety
• Age dependent
• Pain scales,Visual analogue scale

28. +
Management in ED - Analgesia
• Simple analgesia as appropriate
• Are opioids contra-indicated?
• No RCT
• Practice is to not withhold analgesia
• Intranasal Fentanyl (1-2mcg/kg)
• Intravenous Morphine (0.1-0.2mg/kg)
Sharwood, L. N. and F. E. Babl (2009). "The efficacy and effect of opioid analgesia in undifferentiated abdominal pain in
children: a review of four studies." Paediatric Anaesthesia 19(5): 445-451.

29. +
Disposition
 Admission v Discharge
 Solid plan for discharge and follow up
 “Obs admit” – try to avoid prolonged observation admission
 Admission for observation and serial examination is a good
option in equivocal cases

30. +
Guidelines
 SCH
 CHW
 RCH
 NSW Health

31. +
Essentials
1. Only a small percentage have surgical
cause
2. Age influences diagnostic possibilities
3. Abdominal examination critical
4. Don’t withhold analgesia
5. Aetiology may be intra or extra abdominal
6. Serial examination useful
7. Definitive diagnosis not always possible
8. Clear follow up important