Introduction to the assessment and management of a child with abdominal pain

1. The Child with Abdominal Pain

2. Objectives
 To understand the systematic approach
to assessing a child with abdominal
pain.
 To identify the common specific
conditions that present with abdominal
pain.

3. Background Information
 Abdominal pain in children can be
recurrent or acute.
 Recurrent abdo pain affects 10% of
school children and is generally less
urgent than acute abdominal pain.
 Recurrent abdo pain is defined as three
episodes in a 3-month period.

4. History
 Nature of the Pain
 Location
 Severity
 Periodicity: Persistent or Colicky
 Precipitating Factors
 Associated Symptoms

5. Examination
 Inspection
 Infants and toddlers have a protuberant
abdomen. (Not to be confused with
pathological distension)

6. Inspection
 True distension could be caused by:
 Fat
 Fluid
 Faeces
 Flatus
 Visceromegaly
 Muscle Hypotonia
 Exaggerated Lordosis

7. Inspection Contd.
 Faeces suggests Constipation
 Flatus suggests air swallowing.
 Fluid Suggests Ascites (e.g Nephrotic
Syndrome)
 Respiration is usually abdominal up to school
age.
 Small umbilical hernias and hydroceles are a
frequent finding. Separation of the rectus
muscle is normal.
 Visible loops of bowel are sometimes seen in
malnourished infants. Visible peristalsis may
be a sign of pyloric stenosis.

8. Palpation
 Be clam and careful. Start away from the painful site.
Palpate in quadrants.
 Try to avoid making the child cry; you may have to
palpate with the infant crawling or standing.
 In an anxious child use you hand over the child’s
hand to palpate.
 You may have to elicit tenderness by using a
stethoscope to apply pressure; pretending to listen.
 Spleen and liver may be palpable in infants. Normal
kidneys are rarely felt.
 Rebound tenderness should never be elicited.

9. Unilateral pain is likely to be
significant.
The further the pain is from
the umbilicus the more likely it
is to be organic.

10. Auscultation
 Note presence or absence and type of
bowel sounds.

11. Rectal Examination
 This should not be routine in children.

12. Examination of Genitalia
 The scrotum may be swollen in Henoch-
Schonlein purpura and idiopathic scrotal
oedema.

13. If the testicle is painful,
swollen, tender or red
consider testicular torsion.

14. Investigations
 Basic observations should be recorded
including blood pressure.
 The hydration state must be assessed and
evidence of shock sought.
 Consider:
 FBC
 Sickle Test
 Blood Chemistry including Glucose and Amylase
 Blood Culture
 Urine Microscopy and Culture
 Radiography

15. Management and Referral
 Ensure adequate analgesia.
 Commence fluid replacement and
adequate resuscitation.
 Obvious surgical causes should be
referred to a paediatric surgeon.
 Where there is diagnostic doubt refer to
a senior paediatrician. Often a period of
observation is helpful.

16. Specific Conditions
 Acute appendicitis.
 Typically the pain moves from central
abdomen to RIF.
 It is associated with vomiting (usually after
the pain).
 There is a low-grade fever and raised
pulse.
 Localised tenderness may beassociated
with peritonism and guarding.

17. Acute Appendicitis
The clinical course may be modified in in
pre-school children, particularly if
antibiotics have been prescribed for a
presumed respiratory infection.

18. Non-Specific Abdominal Pain
 NSAP is a tem applied to children whose
presentation is similar to appendicitis.
 The pain is more diffuse with absence of
peritonism and guarding.
 Mesenteric adenitis is included in this group.
 The condition settles without treatment over
24-48h.
 Hospital admission is sometimes necessary
because of diagnostic difficulty.

19. Constipation
 This may present as rectal bleeding or
‘diarrhoea’ (Overflow)
 Palpation of a loaded descending colon and
rectum full of faeces make the diagnosis.
 Treatments involve:
 Softeners
 Stimulants
 Enemas
 Advice about diets should be routine.

20. Constipation
Hirshspung’s disease should be
considered in any child in whom the
history is of ‘always’ constipated with
poor growth, particularly if usual
treatments are ineffective.

21. Acute Obstruction
 May be congenital (bowel atresias,
volvulus due to malrotation, or
hirschprung’s disease).
 May be acquired (Strangulated inguinal
hernia, adhesions)
 Vomiting is an early feature of
intussusception, obstruction is a late
complication.

22. Acute Obstruction
 Clinical Signs:
 Abdominal Pain with signs of Peritonitis
 Distension
 Absent or high-pitched bowel sounds
 Bile-stained or faeculent vomiting

23. Others
 Respiratory Tract Infection
 Diabetes
 Intussusception
 Urinary Tract Infection
 Gynaecological Problems
 Infectious Mononucleosis

24. Common Causes of Abdo Pain by Age
Infancy Surgical Medical
Relatively Common Strangulated Hernia
Intussusception
Midgut Volvulus
UTI
Pneumonia
Less Common Appendicitis
Testicular Torsion
Cow’s Milk Intolerance
NAI
Rare Meckel’s Diverticulus
Hirschpring’s Disease
Other Obstruction
Porphyria
Lead poisoning

25. Common causes of abdo pain by age
Childhood Surgical Medical
Relatively Common Appendicitis
Trauma
Psychological
Mesenteric adenitis
UTI
Respiratory tract Infection
Constipation
Infectious Mononucleosis
Less Common Testicular Torsion Hepatitis
HSP
Diabetes
Sickle Cell
Rare Meckel’s
Diverticulitus
Pancreatitis
Ulcerative Colitis
Peptic Ulcer

26. Summary
 Medical causes account for 90% of
cases of children with abdominal pain.
 Use a systematic approach to
assessment. Modifiy for individual
needs.
 Consider the differential diagnoses.