Pediatric Primary
Care Management:
Abdominal Pain (Part
3)
Kristina Bohm, DNP, APRN, FNP
Community Faculty
Metropolitan State University: School of Nursing
6-month-old Male
Intussusception
• Epidemiology
• Most commonly occurs between 5 and 10
months of age
• Most common cause of intestinal obstruction
in children 3 months to 6 years of age
• 80% of cases occur before 2 years of age
• Generally idiopathic in younger infants
• Predisposing Factors
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Polyps
Meckel diverticulum
Henoch-schonlein purpura
Constipation
Lymphomas
Lipomas
Parasites
Rotavirus
Adenovirus
Foreign bodies
• Pathophysiology
Intussusception
History
Physical Exam
• Paroxysmal, episodic colicky abdominal pain
• Observe infant’s appearance and behavior
• Currant jelly stool
• Sausage-like mass may be felt in RUQ of
abdomen with emptiness in RLQ (Dance sign)
• Vomiting every 5 to 30 minutes (nonbilious
initially)
• Screaming with drawing up of legs with
periods of calm, sleeping or lethargy between
episodes
• Abdomen often distended and tender to
palpation
• Grossly bloody or guaiac-positive stools
Intussusception
Differential Diagnoses
Diagnostic Tests
Incarcerated
hernia
Testicular
torsion
Acute
gastroenteritis
Appendicitis
Colic
Intestinal
obstruction
• Ultrasound
Intussusception:
Management
• Immediate referral to pediatric radiologist
and pediatric surgeon
12-Year-Old Girl
Appendicitis
Epidemiology
Pathophysiology
Perforation most
common in
children under 5
years of age
Average age in
children is 6 to
10 years old
4 cases per
1000 children
2:1 male to
female ratio
Rare in infancy
• Inflammation of the appendix that leads to
distention and ischemia that can result in
necrosis, perforation, and peritonitis or
abscess formation
Appendicitis
History
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Pain
•
Nausea
•
Anorexia
•
Stool – low volume with mucus
•
Fever
•
Scoring System: 4 or less is highly sensitive in excluding diagnosis of
appendicitis:
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Nausea/emesis (1 point)
Anorexia (1 point)
Migration of pain to RLQ (1 point)
Low-grade fever (1 point)
RLQ tenderness on light palpation (2 points)
Cough/percussion/heel tapping tenderness at RLQ (2 points)
Leukocytosis (>10,000/mm3) (1 point)
Left shift (>75% neutrophilia) (1 point)
Physical Exam
Involuntary guarding, RLQ rebound
tenderness, max pain over McBurney point
Heel-drop jarring test
Positive Psoas sign or obturator sign (or
both)
Rovsing sign or rebound tenderness
Tenderness and possibly a mass on right
side on rectal exam
Appendicitis
Differential Diagnoses
Diagnostic Tests
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Gastroenteritis
Constipation
UTI
Pregnancy
PID
Pneumonia
Duodenal ulcer
Intestinal obstruction
Peritonitis
Intussusception
CBC with differential
Amylase, lipase, liver enzymes
UA
Stool sample
Abdominal Xray
Ultrasound
CT scan with contrast
B-hCG
Surgical consult for
appendectomy
Appendicitis:
Managemen
t
Open
Laparoscopic
Pain Management
Follow-up 2-4 weeks post-op
12-Year-Old Girl
Constipation
Epidemiology
Pathophysiology
• 17-40% of children constipation starts in the
1st year of life
• Many etiologies for constipation
• Functional constipation has no underlying
medical disease responsible
Constipation: History & Physical
Exam
Physical Exam
• Growth charts
• GI
• Skin
• Neuro
http://bowelcontrol.nih.gov/bristol.aspx
(Tabbers, 2014)
Constipation:
Differential
Diagnoses
• (Tabbers, 2014)
Constipation
• To Diagnose:
(Rome Foundation, 2015)
Constipation: Management Infants <
6-months-old
(Tabbers, 2014)
Constipation: Management Infants
>6-months-old
(Tabbers, 2014)
Constipation: Management
(Tabbers, 2014)
6-Month-Old Female
Hernia: Pathophysiology
Umbilical Hernia
Inguinal Hernia
• Weakness or imperfect closure of the
umbilical ring
• Incomplete closure of processus vaginalis
http://drmatthewweiner.com/surgery-for-umbilical-hernias/
• Males 8-10: females 1
http://www.mayoclinic.org/diseases-conditions/inguinal-hernia/multimedia/inguinal-hernia/img-20007189
Hernia: History & Physical Exam
Umbilical
Inguinal
• Swelling peri-umbilical area
• Swelling in inguinal, scrotal, or both
• Direct: push outward through the weakest
point in the abdominal wall
• Indirect: push downward at an angle into the
inguinal canal
• Fussy & distended = incarcerated
Hernia: Management
Umbilical
Inguinal Hernia
• Refer to surgery if
• US if need for dx
• Persists > 5-years-old
• Nonreducible
• Dramatically enlarges
• Incarceration is rare
• Attempt to reduce it
• Refer to surgeon within 1-2 weeks
• Do NOT resolve spontaneously
References
Maaks, D.L. G., Starr, N., & Gaylord, N. (2020). Burns' Pediatric Primary
Care (7th ed.). Elsevier Health Sciences (US).
Rome Foundation. (2015). Rome III diagnostic criteria for functional GI
disorders. Retrieved from http://romecriteria.org/criteria/
Tabbers, et al. (2014). Evaluation and treatment of functional
constipation in infants and children: evidence-based recommendations
from ESPGHN and NASPGHAN. JPGN, 58(2): 258 -274