What is the problem?
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Approach to Abdominal pain in
children
Ibrahim Alsaif
Pediatric Emergency Consultant
Al-Yamamah Hospital
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Goals and Objectives
 Be Systematic
 Evaluate then identify the problem then
intervene.
 Anatomic and Path physiology of pain
 Is the pain acute or chronic?
 Causes of pain
 Approach to reach the diagnosis
 Red flags
 Indications for Surgical consultation.
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Systematic Approach to a sick child
Initial impression
(appearance, work of breathing, circulation)
Is the child need Resuscitation(CPR)?
Yes
No
C A B
Evaluate
• Primary assessment (ABCDE approach)
• Secondary assessment (focused H&P)
• Diagnostic tests
Intervene
Identify
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What is the abdominal pain?
 Abdominal pain is a common complaint in all
settings of medical practice.
 Pain may be a symptom of a severe, lifethreatening disease or
 Of a benign underlying condition.
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Anatomic origin of pain
 The classic division of abdomen:
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Anatomic origin of pain
 Abdomen is divided into 9 regions:
 2 vertical lines (RT&LT midclavicular)
 2 horizontal lines (subcostal and intertubercular)
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Pathophysiology
Types of pain
 Visceral pain:
Due to irritation of visceral peritonium
Dull
Poorly localized
Usually periumbilical
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Pathophysiology
 Parietal (somatic) pain:
Due to irritation of parietal peritonium
Sharp
Intense
Discrete
localized
Aggravated by coughing or movement
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Pathophysiology
 Referred pain:
Same feature as parietal.
It results from shared central pathways for
afferent neurons from different sites.
The classic example is pneumonia
(the T9 dermatome distribution is shared by
the lung and the abdomen).
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Is the pain acute or chronic?
 Acute abdominal pain:
A sudden, severe abdominal pain of unclear
cause lasts less than one week.
 chronic abdominal pain:
Intermittent or constant abdominal pain
(of functional or organic etiology) last for at
least two months
 Chronic abdominal pain occur in 10 to 20 % of
children.
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Is the pain acute or chronic?
Chronic abdominal pain classically defined by
four criteria:
 ≥3 episodes of abdominal pain
 Pain sufficiently severe to affect activities
 Episodes occur over a period of ≥2 months
 No known organic cause.
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Causes of abdominal pain
Age is a key factor in the evaluation of
abdominal pain.
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Causes
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Approach to reach the diagnosis
In fact:
Based on history and a physical exam alone,
physicians were able to correctly differentiate
between organic and nonorganic causes of
abdominal pain nearly 80% of the time.
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History
 Place/Location ask child to use one finger to locate
the pain.
 Quality: pain can be a sharp stabbing pain (i.e.
trauma) or diffuse, poorly, localized pain (i.e. chronic
or visceral pain).
 Radiation: pain can radiate from its point of origin in
any direction.
 Severity: degree of pain on a scale of 10
 Timing/Onset: onset of the pain, duration of pain,
course during the day, does it wake them at night, and
the frequency of episodes.
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History
 Alleviating Factors:
Anything that reduces the pain like
body position, movements ,medications.
 Aggravating Factors:
Anything that increases the pain like body position,
movements, relation to food intake.
 Associated Symptoms:
Hematemesis, vomiting, nausea, melena, diarrhea,
fever, and weight loss.
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Associated symptoms for abdominal pain
Associated Symptom
Relevance
Diarrhea
Gastroenteritis, Protein losing enteropathy
Bloody stool
Ulcerative colitis, necrotizing enterocolitis,
dysentery, constipation
Hematemesis
Peptic Ulcer Disease, Gastritis
Bilious emesis
Small bowel obstruction
Jaundice
Hepatitis or Biliary obstruction
Joint pain/swelling
IBD, HSP
Skin Lesions
IBD, HSP, Liver disease
Testicular pain
Testicular torsion
Dysuria/polyuria/hematuria
Urinary tract infection/Pyelonephritis
Vaginal/Penile discharge
STI
Dysmenorrhea
Endometriosis
Shortness of breath
Pneumonia or empyema
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History
Ask about:
 Bowel movement patterns and stool quality
(size, hard/soft, odour).
 Ingestion of toxin or foreign object accidental
or non-accidental trauma.
 Dietary history: in young children, too much
milk can lead to constipation.
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History
Ask about:
 Past medical history and medical illness:
Cystic fibrosis predisposes to gallstones.
Spina bifida/cerebral palsy/developmental delay
predisposes to constipation.
Sickle cell disease predisposes to splenic autoinfarction.
Recurrent respiratory tract infections suggest
mesenteric adenitis.
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History
Ask about:
 Family medical history, especially
inflammatory bowel disease.
 Travel history, social and psychiatric (potential
stressors) history.
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Physical exam
 General exam: ABCDE
Including vital signs and growth parameters,
is there evidence of failure to thrive?.
 Inspection:
Iook for contour, symmetry, pulsations,
peristalsis, skin markings, wall protrusions
(hernias), any signs of trauma (ie. bruising,
swelling), and abdominal distension.
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Physical exam
 Auscultation:
Auscultate before palpation in the abdominal
exam.
Iisten for bowel sounds, abdominal bruits.
Pressure of the stethoscope also tests for
tenderness.
 Percussion:
(tympanic vs non-tympanic).
Percuss for liver span and spleen tip.
Assess for ascites.
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Physical exam
 Palpation:
Tenderness with light and deep palpation.
Guarding and rebound tenderness
Palpate for liver, spleen, kidney and
abdominal masses (including fecal mass).
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Physical exam
 Digital rectal exam:
First exam the anus for fissures and skin tags.
Then assess for tone, stool, and blood.
 Special Tests:
There are a number of special tests for each
differential diagnosis.
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findings on physical exam for common differential diagnoses
Medical Condition
Findings on Physical Exam
Constipation
Abdominal tenderness, palpable fecal mass, look for imperforate anus or
stenosis, spina bifida, developmental delay, cerebral palsy
Acute appendicitis
Patient avoids movement, rebound tenderness, McBurney sign (pain at
2/3 between umbilicus and right ASIS), Rovsing sign (pain in right lower
quadrant on left-sided palpation), Psoas sign (pain in right lower
quadrant when child on left and right hip hyperextended), obturator sign
(pain in right lower quadrant on internal rotation of flexed right thigh)
Gastroenteritis
Diffuse pain with no rebound tenderness, abdominal distension,
hyperactive bowel sounds
Irritable bowel syndrome
Periumbilical tenderness, no rebound tenderness
Trauma
Signs of bruising and tenderness
Celiac Disease
Growth failure, distended abdomen, diffuse abdominal tenderness.
Inflammatory bowel disease
Appears thin, abdominal tenderness, anal skin tags, possible sign of
bloody stool on DRE, examine for skin lesions (erythema nodosum,
pyoderma gangrenosum), iritis, and joint inflammation
Urinary tract infection
Fever, suprapubic and costovertebral angle tenderness, irritability, foulsmeling urine, gross hematuria
Primary dysmenorrhea
Lower abdominal tenderness
Pneumonia and Empyema
Tachypnea, cyanosis, decreased breath sounds, crackles and rales,
dullness on percussion, febrile
Associated Signs
 Jaundice suggests hemolysis or liver disease.
 Pallor and jaundice point to sickle cell crisis.
 Psoas & Obturator test If positive:
Inflamed retrocecal appendix
Ruptured appendix or
Iliopsoas abscess.
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Associated Signs
 Murphy's sign:
(interruption of deep inspiration by pain when
the physician's fingers are pressed beneath
the right costal margin).
Suggests acute cholecystitis.
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Associated Signs
 Cullen's sign (bluish umbilicus)
 Grey Turner's sign (discoloration in the flank)
Unusual signs of internal hemorrhage.
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Associated Signs
 Purpura and arthritis:
Henoch-Schönlein purpura
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Uncommon differential diagnoses and potential complications
Medical Condition
Relevant Findings and Potential Complications
Intussusception
Colicky pain, flexing of legs, fever, lethargy, vomiting, peak incidence in
children at 6 months of age
Mekel’s diverticulum
Similar presentation to appendicitis, profuse GI bleeding, can develop to
diverticulitis
Mesenteric adenitis
Can present like acute appendicitis, recurrent respiratory tract infections
Hirschsprung disease
Vomiting, abdominal distension, enterocolitis, primarily in first year of life
Small bowel obstruction
Bloating, vomiting, failure to pass flatus or stool, bilious emesis
Volvulus
Can present like small bowel obstruction, due to intestinal twisting
Large bowel obstruction
Abdominal distension, hard feces and rectal bleeding, can lead to bowel
perforation
Necrotizing enterocolitis
Feeding intolerance, apnea, lethargy, bloody stools, abdominal distension
and tenderness, abdominal erythema, bradycardiac, primarily in premature
infants
Peptic ulcer disease
Epigastric tenderness, pain related to eating a meal, ulcer can perforate
Viral hepatitis
Fever, malaise and jaundice, consider fecal-oral or vertical transmission
Acute pancreatitis
Steady and sudden-onset pain radiating to the back, nausea, vomiting
Splenic infarction
Personal or family history of sickle cell disease
Nephrolithiasis
Acute renal colic, flank pain radiating to groin
Testicular torsion
Testicular pain with acute onset, nausea, vomiting
Laboratory investigations for common differential diagnoses
Medical Condition
Relevant Diagnostic Tests
Constipation
None if history does not suggest an alternative diagnosis.
Acute appendicitis
CBC (WBC normal or elevated), urinalysis, urine pregnancy
Gastroenteritis
Serum electrolytes, stool culture, stool for virology
Irritable bowel syndrome
None, based on history and clinical findings
Trauma
CBC for blood loss, abdominal CT with contrast
Celiac Disease
IgA
Inflammatory Bowel
Disease
CBC, ESR/CRP, electrolytes, albumin, LFTs, Bilirubin, Stool
culture, AXR
Urinary tract infection
Urine dipstick (for leukocyte esterase and nitrite), urine
microscopy, urine culture (best if suprapubic aspirate)
Primary dysmenorrhea
None, based on history and clinical findings
Pneumonia and Empyema
CBC, Chest x-ray, sputum culture
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Red flags in abdominal pain
 Certain historical and examination findings
should raise ‘‘red flags’’ that a severe lifethreatening underlying abdominal process is
present and prompt early triage to an
emergency department.
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Red flags in abdominal pain
History
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Inability to maintain po intake
Projectile vomiting
Overt gastrointestinal blood loss
Syncope
Pregnancy
Recent surgery or endoscopic procedure
Fever
Caustic or foreign body ingestion
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Red flags in abdominal pain
Physical examination
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Pathologic changes in vital signs
Bloody, melenic stool
Hernia (incarcerated and tender)
Hypoxia
Cyanosis
Change in level of consciousness
Jaundice
Peritoneal signs
Abdominal pain out of proportion to examination
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Red flags in abdominal pain
Laboratory results
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Renal failure
Metabolic acidosis
Leukocytosis
Elevated transaminases
Elevated alkaline phosphatase and bilirubin
Anemia or polycythemia
Hyperlipasemia/hyperamylasemia
Hyperglycemia/hypoglycemia
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Red flags in abdominal pain
Radiography
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Abdominal free air
Gallbladder wall thickening
Pericholecystic fluid
Dilated biliary tree
Bowel obstruction
Dilated small bowel loops ± air fluid levels
Intra-abdominal abscess
Bowel wall thickening
Air in the portal venous system
Pneumatosis intestinalis
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Indications for Surgical Consultations
 Severe or increasing abdominal pain with progressive
signs of deterioration
 Bile-stained or feculent vomitus
 Involuntary abdominal guarding/rigidity
 Rebound abdominal tenderness
 Marked abdominal distension with diffuse tympany
 Signs of acute fluid or blood loss into the abdomen
 Significant abdominal trauma
 Suspected surgical cause for the pain
 Abdominal pain without an obvious etiology
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Any question ?
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