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should undergo further diagnostic evaluation The important clues provided by a thorough history and physical examination along with an understanding of the multiple sources of abdominal pain and the formulation of a limited differential diagnosis is crucial for the pediatric patient presenting with either acute, subacute, or chronic abdominal pain (Fig. 21.1). A number of conditions may cause abdominal pain and may lead to a specialist referral. This chapter deals with common sources of abdominal pain among pediatric patients, their etiology and management in primary/emergency care. Indications for referral will be highlighted.
21.2 Common Sources of Abdominal Pain
21.2.1 Children
1.Gastroenteritis: Acute gastroenteritis (AGE) is inflammation of the mucous membranes of the gastrointestinal tract, and is the most common cause of abdominal pain in children. The most common causes are viruses (rotavirus,
Norwalk virus, adenovirus, and enterovirus), but bacterial (Escherichia coli, Yersinia, Campylobacter, Salmonella, and
Shigella), protozoal and helminthic GE may be responsible for AGE in developing countries
2.Constipation: A common and distressing pediatric problem. Cause is usually functional (stool retention) but may also have organic etiologies such as Hirschsprung’s disease, appendicitis, pseudo-obstruction, spinal cord abnormality, hypothyroidism, diabetes insipidus, cystic fibrosis, gluten enteropathy, or congenital anorectal malformation.
3.Appendicitis: The most common surgical disease of the abdomen in children. Approximately one in 15 people develop appendicitis and the disease may vary considerably in its clinical presentation, contributing to delay in diagnosis and increased morbidity.
4.Intussusception: The most common cause of intestinal obstruction in children between 3 months and 6 years.
Right upper quadrant
Biliarydisease: Biliary colic, cholecystitis, choledocholithiasis, cholangitis
Hepatic: Hepatitis, neoplasm, abscess, congestive hepatopathy
Colonic: Colitis, right-sided diverticulitis Pulmonary: Pneumonia, subphrenic abscess, embolism, pneumothorax Abdominal wall: Herpes zoster, muscle strain Renal: Nephrolithiasis, pyelonephritis, perinephri cabscess
Right lower quadrant
Small intestine: Meckel’s diverticulum, IBD, mesenteric adenitis, intussusception Colonic: Appendicitis, colitis diverticulitis, IBD, IBS
Gynecologic/Testicular: Ectopic pregnancy, ovarian tumor/torsion, endometriosis, hematocolpos, PID, testicular torsion/tumor
Renal: Nephrolithiasis, pyelonephritis, ureteropelvic junction obstruction Abdominal wall: Herpes zoster, muscle strain, incarcerated/strangulated hernia
Hematologic/Metabolic/ Drugs
Sickle cell anemia, Henoch-Schonlein purpura, hemolytic uremic syndrome, diabetic ketoacidosis, hypoglycemia, porphyria, acute adrenal insufficiency, uremia, hypercalcemia, erythromycin, salicylates, lead poisoning, venoms, opiate withdrawl
Left upper quadrant
Gastric: gastritis, esophagitis, peptic ulcer
Spleen: infarction or rupture, Pancreas: pancreatitis or mass Pulmonary: Pneumonia, subphrenic abscess, embolism, pneumothorax
Renal: Nephrolithiasis, pyelonephritis, perinephric abscess
Left lower quadrant
Colonic: Colitis, diverticulitis, IBD, IBS
Gynecologic/Testicular: Ectopic pregnancy, ovarian tumor/torsion, endometriosis, hematocolpos, PID, testicular torsion/tumor
Renal: Nephrolithiasis, pyelonephritis, ureteropelvic junction obstruction Abdominal wall: Herpes zoster, muscle strain, incarcerated/strangulated hernia
Miscellaneous
Infantile colic, functional pain, pharyngitis, hereditary angioedema, malingering, lactose intolerance, Famial Mediterranean fever
FIGURE 21.1. Selected differential diagnosis of pediatric abdominal pain by anatomic region.
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Intussusception occurs when a more proximal portion of bowel invaginates into more distal bowel. These patients often present with a wide range of non-specific symptoms, with less than one quarter presenting with the classic triad of vomiting, abdominal pain, and bloody stools.
5.Bowel obstruction: Intestinal obstruction in the newborn infant and older child may be due to a variety of conditions, including atresia and stenosis, annular pancreas, malrotation, duplication cyst, meconium ileus, meconium plug syndrome and neonatal small left colon syndrome, Hirschsprung’s disease, neoplasia, trauma, and other rarer causes.
6.Incarcerated hernia: results when bowel becomes swollen, edematous, engorged, and trapped outside of the abdominal cavity. Incarceration is the most common cause of bowel obstruction in infants and children and the second most common cause of intestinal obstruction in North America (second only to intra-abdominal adhesions from previous surgeries).
7.Meckel’s diverticulum: The most common congenital malformation of gastrointestinal tract. It can cause complications in the form of ulceration,hemorrhage,intussusception, intestinal obstruction, perforation and, rarely, vesicodiverticular fistulae and tumors.
8.Ovarian torsion:A problem in the pediatric age group that must be included in the differential diagnosis of any girl with abdominal pain or a pelvic or abdominal mass.
9.Ureteropelvic junction (UPJ) obstruction: Frequent in pediatric age and is a common cause of upper urinary tract obstruction that can be clinically silent or lead to symptoms such as pain, chronic urinary tract infections, and urinary stone disease.
21.2.2 Infants
1.Colic: a syndrome of persistent crying in infants, with multiple causes.
2.Hypertrophic pyloric stenosis:Is a gastrointestinal tract disorder common in infancy.The disorder causes projectile vomiting, weight loss, and fluid and electrolyte abnormalities.