Abdominal pain in children
Madesa Espana, MD
Pediatric EM Section
St. Joseph’s Regional Medical Center
Abdominal pain: evidence-based data
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Incidence
5 % of patients presenting to the pediatric
clinic and ED (2 – 12 years old, <72 hours
duration)
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1% of patients with abdominal pain had surgical
intervention
84 % of patients were diagnosed to have
 URI and/or Otitis Media
 Pharyngitis
 Viral syndrome
 Abdominal pain or uncertain etiology
 Gastroenteritis
 Acute febrile illness
Abdominal pain: evidence-based data
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Incidence
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7.4% had return visits
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1% had treatable medical conditions
0.3% needed surgical intervention on
subsequent visits
Abdominal pain: evidence-based data
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Incidence
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1.7 % were hospitalized
Diagnoses when abdominal pain was first complaint
 Appendicitis
 Abdominal pain of uncertain etiology
 Intussusception
 Abdominal adhesions
 Gastroenteritis
 Acute Febrile Illness
 Pyelonephritis
 Sickle cell painful crisis
 Henoch-Schonlein purpura
Abdominal pain: evidence-based data
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Incidence
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1.3 % were hospitalized
Diagnoses when abdominal pain was second complaint
 Gastroenteritis/Dehydration
 Abdominal abscess after appendectomy
 Pneumonia
 Viral syndrome
 Pyelonephritis
 Sickle cell pain crisis and fever
 Hematochezia
 Hematemesis
 URI and seizure
 Reactive airway disease
Abdominal pain: evidence-based data
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Associated symptoms
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Fever
Vomiting
Decreased appetite
Cough
Headache
Sorethroat
Historical Data
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Duration of the pain
Location of the pain
Radiation of the pain
General appearance of the patient
Associated symptoms
Sick contacts
Recent travel
Historical data
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Associated symptoms
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Vomiting
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Diarrhea
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Duration
Type of emesis: bile, blood
bloody
Fever
Rash
Genitourinary symptoms
Physical Examination
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General appearance
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Ill-appearing or toxic
Dehydrated
Shock
Vital signs
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Febrile
Tachycardic
Tachypneic
Hypotensive
Physical Examination
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Head/Face
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Fontanels
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Sunken
Bulging
Signs of inflicted injury
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Bruising/swelling
Physical Examination
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Eyes
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Icteric sclera
Abnormal eye movements
Sunken appearance
Periorbital swelling
Physical Examination
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ENT
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Mucus membranes
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Moist vs dry
Lesions/ulcerations
Teeth and Gums
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Swelling
Bleeding
Physical Examination
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ENT
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Nose
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Rhinorrhea
Nose bleed
Throat
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Erythema
Exudates
Physical Examination
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Chest/Axilla
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Appearance
Tenderness
Swelling/Masses
Physical Examination
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Cardiovascular
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Heart sounds
Rhythm
Pulses
Edema
Physical Examination
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Abdomen
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Appearance
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Distension
Scars
Bruises
Physical Examination
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Abdomen
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Palpation
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Tenderness
Organomegaly
Masses
Physical Examination
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Abdomen
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Tenderness
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Localized
Diffuse
Rebound
Rovsing’s sign
Guarding
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Voluntary
Non-voluntary
Physical Examination
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Abdomen
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Rectal exam
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Stool Guaic
Other findings
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Psoas sign
Obturator’s sign
Murphy’s sign
Physical Examination
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Pelvis/inguinal area
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Males
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Scrotum and testicles
Urethral discharge
Phymosis/paraphymosis
Females
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Vaginal bleeding
Speculum exam
Physical Examination
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Skin
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Color
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Pale
jaundice
Rashes
Signs of injury/abnormal bleeding
Turgor
Peripheral circulation
Physical Examination
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Neurologic examination
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Mental status
Cranial nerves
Motor
Sensorory
Cerebellar
Physical examination
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Psychiatric evaluation
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Mental status
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Depression
Anxiety
Suicidal ideation/attempt
Homicidal ideation/attempt
Hallucinations/delusions
Differential diagnosis
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Infants
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Gastroenteritis
Constipation
Malrotation +/- Volvulos
GERD
Infantile Colic
Intussuception
Urinary tract infection
Testicular torsion
Differential diagnosis
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Children
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Gastroenteritis
Constipation
Intussuception
Torsion
UTI
Kidney stones
Sickle cell crisis
DKA
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Testicular torsion
Incarcerated Hernia
Pneumonia
Strep throat
Henoch-Schonlein
Purpura
Meningococcemia
Toxic ingestions
Diferrential Diagnosis
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Adolescent Males
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Testicular torsion
Varicocele
Pyelonephritis
Kidney stones
Gallstones
Pancreatitis
Hepatitis
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Incarcerated Hernia
Constipation
DKA
IBD
STD
GERD
Toxic ingestions
Differential diagnosis
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Adolescent females
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Ovarian torsion
Ruptured ovarian
cyst
PID
UTI
Gallstones
Cholecystitis
Kidney stones
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DKA
Toxic ingestions
Pre-/menstrual
cramps
Complications of
pregnancy
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Ectopic
Threatened AB
Missed AB
Abdominal pain: evidence-based data
Abdominal pain: appendicitis or not?
Abdominal pain: evidence-based data
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Appendicitis
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Incidence
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11/10,000 population per year
Highest in males 10-14 years (27/10,000)
Highest in females 15-19 years (20/10,000)
Male:female ratio: 1.4:1
Life time risk:
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Males: 8.6%; Females: 6.7%
Perforation: 18% ; highest in < 5 and >65 y.o.
Appendicitis: evidence-based data
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Signs and symptoms
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Neonates:
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Abdominal distension
Vomiting
Fever
Hypothermia
Respiratory distress
Appendicitis: evidence-based data
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Signs and symptoms
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3 years and under
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Diffuse abdominal pain
Fever
Vomiting
Diarrhea
Abdominal distension
Diffuse abdominal tenderness
Appendicitis: evidence-based data
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Signs and symptoms
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Older children
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Abdominal pain
Vomiting
Fever
Anorexia
Pain with movement or cough
Localized RLQ tenderness
Diffuse/rebound tenderness
Abdominal pain: evidence-based data
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Laboratory studies
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CBC, differential
ESR
C-reactive protein
Urinalysis
 Poor sensitivity and specificity
Abdominal pain: evidence-based data
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Radiologic studies
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Plain films
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Small bowel obstruction
Fecalith
Pneumoperitoneum
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Poor sensitivity and specificity
Abdominal pain: evidence-based data
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Radiologic studies
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Ultrasound
 Appendiceal diameter or >6 mm
 Target sign with 5 concentric layers
 Distension or obstruction of the lumen
 High echogenicity around the appendix
 Pericecal or perivesical fluid
 Appendix wall > 2 mm
 Absence of appendiceal peristalsis
 Can confirm but not exclude appendicitis
Abdominal Pain: Evidence-based
Data
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Radiologic studies
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CT scan
 Enlarged appendiceal diameter (> 6 mm)
 Appendiceal wall thickening (> 1 mm)
 Periappendiceal inflammatory changes
including fat streaks, phlegmon, fluid collection,
and/or extraluminal gas
 Other findings: appendicalith, abscess,
arrowhead sign, or cecal bar
 Sensitivity 87 – 100 %, Specificity 89 – 98%
Abdominal pain: evidence-based data
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Radiologic studies
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CT scan
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Advantages
 Establish alternative diagnoses
 Differentiates between perforated and
non-perforated appendicitis
 Reduces length of stay and cost of
care
 Reduces perforation rate
 Useful in obese, uncooperative
patients
Abdominal pain: evidence-based data
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Radiologic studies
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CT scan
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Disadvantages
 Higher cost compared to ultrasonography
 Risks associated with contrast
administration
 Potential need for sedation
 Exposure to ionizing radiation
 False negative rate 10%
Diagnostic work-up
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History and physical examination
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Serial abdominal exams
Surgical consultation
Laboratory data
Radiologic evaluation
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Ultrasound
CT scan
Treatment of appendicitis
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Surgery
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Laparoscopic
Open
Conservative management
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Antibiotics
IV hydration
Treatment of appendicitis
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Conservative management
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IV and oral antibiotics
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Cefotaxime + (ofloxacin +tinidazole)
Ciprofloxacin and metronidazole +
(ciprofloxacin + tinidazole)
Treatment of appendicitis
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Conservative management
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Advantages
Less pain
 Shorter recovery time
 Avoid complications of surgery
and anesthesia
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Treatment of appendicitis
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Conservative management
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Disadvantages
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High recurrence rate
Abdominal pain: evidence-based data
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Use of analgesics in patients with
abdominal pain
Will analgesics mask the signs of acute
abdomen and cause a delay making the
diagnosis?
What medications are effective and safe?
Abdominal pain: evidence-based data
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Use of analgesics in patients with
abdominal pain
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56% of patients with abdominal pain were
not given pain medication
Studies in adults show that opioids are
effective in reducing pain without
significant adverse effects or delay in
diagnosis of acute abdomen
Abdominal pain: evidence-based data
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Use of analgesics in pediatric
patients with abdominal pain
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Morphine 0.1 mg/kg vs. normal saline
 Reduction of pain score by 2 points (1 –
10)
 No change in the area(s) of tenderness
 Tenderness persisted in patients with
surgical conditions
 No change in the diagnostic accuracy
 No significant complications
Abdominal pain: evidence-based data
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Follow up care of discharged
patients
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Return or follow up visit in 8 – 12 hours
Will identify serious medical conditions
presenting as abdominal pain and detect
surgical conditions that may have
presented early in the disease process.
Thank you!
Have a great day.