Abdominal Pain

Abdominal Pain: Excerpt from In A Page: Pediatric Signs and Symptoms

Abdominal pain is a frequent complaint and associated with an enormous number of causes. Many causes of acute abdominal pain require surgical intervention, so a prompt diagnosis is needed. Diagnostic clues would include the location of the pain. Traditionally, the farther away the pain is from the umbilicus, the more likely one is to find an organic cause. Chronic pain without associated vomiting, weight loss, or bloody diarrhea is often functional in origin.

Differential Diagnosis

Epigastric pain

• Peptic ulcer disease/GERD
  –May be due to Helicobacter pylori or NSAID use
• Gallbladder disease
  –Most commonly with hemolytic disorders
• Pancreatitis
  –Trauma and idiopathic are common causes

Periumbilical pain
• Functional abdominal pain/IBS
  –Most common cause of nonorganic pain
  –Occurs in children 3–15 years old
• Appendicitis
  –Periumbilical pain moves to RLQ
• Gastroenteritis (virus, bacteria, parasite)
• Carbohydrate intolerance
  –Lactase, fructase, trehelase deficiency
• Abdominal migraine
• Drugs
  –Antibiotics, anticonvulsants, bronchodilators
• Small bowel bacterial overgrowth
• Streptococcal pharyngitis
  Suprapubic pain
• Urinary tract infection
  –With dysuria, fever, foul-smelling urine
  –Pyelonephritis may have CVA tenderness
• Constipation
  –Accounts for 3% of visits to pediatrician
  –May have a palpable fecal mass
• Urinary retention
• Hydrometrocolpos
  –Associated with imperforate hymen
  –Cyclic pain with onset of menstrual cycle

Right lower quadrant pain
• Appendicitis
• Ovarian torsion
• Pelvic inflammatory disease
• Ectopic pregnancy
• Mittelschmerz
  –Pain midcycle with ovulation
• Inflammatory bowel disease
  –Classic for terminal ileal Crohn disease
• Iliopsoas abscess
• Inguinal hernia
• Right lower lobe pneumonia

Workup and Diagnosis

• History
  –Type of pain, location, radiation, duration
  –Relieving and worsening factors including foods
  –Awakens from sleep, activity level, emesis, diarrhea
  –Nausea, hematochezia, melena, fever, dysuria, hematuria
  –Sexual activity, anorexia, headache, cough, rashes
  –Stool frequency, joint complaints
• Surgical history: Previous abdominal surgery
• Social history: Stressors, changes in school or family
• Physical exam
  –Height, weight, temperature, pulse
  –General appearance, hydration status
  –Pharyngeal erythema/exudates, abdominal tenderness
  –Psoas sign, obturator sign, palpable masses
  –Rectal exam including hemoccult
  –Rashes, joint swelling, vaginal exam
• Labs: Geared toward history and physical findings
  –Consider CBC with differential, urinalysis, and culture
  –stool for culture and O&P
  –Amylase and lipase, LFTs, H. pylori antibody (IgG)
  –Hydrogen breath test for sugar intolerance
  –Pregnancy test, vaginal cultures
  –Throat culture
• Consider KUB or obstruction series
• Abdominal CT scan with contrast versus ultrasound
• Pelvic ultrasound for torsion, ectopic pregnancy, abscess, hydrometrocolpos

Treatment

• If concerned about “surgical abdomen,” consult surgery
  –Appendicitis, ovarian torsion, hydrometrocolpos
• Treat infections with antibiotics
• Eliminate offending carbohydrate in intolerance
  –Lactase supplementation for lactose intolerance
• Irritable bowel syndrome or functional pain
  –Identifying stressors may be helpful
  –Antispasmodics have similar action to placebo
  –Tricyclic antidepressants at low doses are helpful particularly if pain is associated with diarrhea
• Counseling may be needed for chronic pain
• Stop offending drugs if possible
• Constipation
  –Disimpaction if significant fecal mass
  –Stool softeners/laxatives, increased dietary fiber
• Drain abscess
• PUD/GERD: Acid blockade therapy
• Pancreatitis: Bowel rest, pain management

Book Source Details

• Book Title: In A Page: Pediatric Signs and Symptoms
• Author(s): Jonathan E. Teitelbaum, Kathleen O. Deantonis, Scott Kahan
• Year of Publication: 2007
• Copyright Details: In A Page: Pediatric Signs and Symptoms, Copyright © 2007 Lippincott Williams & Wilkins.

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Copyright notice for book excerpts: Copyright © 2008 Lippincott Williams & Wilkins. All rights reserved.

More About This Book: Title: In A Page: Pediatric Signs and Symptoms Authors: Jonathan E. Teitelbaum, Kathleen O. Deantonis, Scott Kahan Publisher: Lippincott Williams & Wilkins Copyright: 2007 ISBN: 1-4051-0427-9

 » Next page: MUSCULAR CRAMPS (Differential Diagnosis in Primary Care)

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• MUSCULAR CRAMPS (Differential Diagnosis in Primary Care)
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