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Acute Abdominal Symptoms in Children

Essentials

  • Most abdominal symptoms in children can be treated by the general practitioner. The most common one is ”dolor abdominis NUD” that has no known aetiology but apparently is a disease in its own.
  • It is important to identify diseases requiring surgical treatment.
  • Acute appendicitis is by far the most common cause of abdominal pain requiring urgent treatment.
  • The cause of abdominal pain may also be located outside the abdominal region, e.g. in respiratory infections.
  • Of non-surgical diseases, urgent treatment is indicated in severe bacterial infections (pyelonephritis, meningitis).

History

  • Age
  • How acutely did the symptoms begin and how long have they lasted?
  • Type of pain (continuous or paroxysmal?)
  • Associated symptoms

Physical examination

Palpation of the abdomen

  • If the child is frightened the examination is best performed with the child lying in the parent's arms on his/her back with the knees flexed.
  • Testing for local tenderness should be started as far as possible from the expected site of pain.
  • Defence of the abdominal wall is a sign of tenderness. The sign should be elicited several times to confirm its presence and location.

Digital rectal examination

  • May be a frightening and painful experience for the child. Hence the examination should not be performed without an indication.
  • If the suspicion of appendicitis is so strong that the child is referred to a hospital in any case, there is no need for digital rectal examination by the referring physician.
  • Routine digital rectal examination is not useful in the diagnosis of acute appendicitis, but it is often indicated for assessing the quality of the faeces if invagination (children < 2 years of age) or severe constipation (usually in older children) is suspected.

General physical examination

  • Ears and respiratory tract (infections)
  • Genitals (testes), inguinal region (hernias)
  • Skin (Henoch-Schönlein purpura)
  • Weight loss should always be estimated in a child who is vomiting or has diarrhoea (see Diarrhoea and Vomiting in Children). In addition to the physical examination, measurements performed at the child health clinic should be used for reference (by extrapolating from the growth sheet, if necessary).

Laboratory investigations

Urine test

  • A few per cent of children presenting with abdominal pain have a urinary tract infection.
  • A dipstick test for chemical urine analysis is sufficient as a screening examination.
  • Microscopy and bacterial cultures are performed if necessary. The diagnosis of a urinary tract infection must always be based on a properly taken urine sample and bacterial culture Urinary Tract Infection in a Child.
  • Some patients with appendicitis have pyuria but the presence of nitrites always suggests urinary tract infection.

Blood leucocytes and serum CRP

  • Important examinations in cases where the symptoms have started rather acutely if they are mild but appendicitis is not ruled out.
  • The clinical picture and its development in follow-up are the most important grounds for referral or treatment decisions, and a child with severe symptoms should never be discharged home even if the results of the laboratory tests are normal.
  • If both serum CRP and blood leukocytes are normal, the pain has lasted for at least 12 hours, and is not severe, acute appendicitis is unlikely, and the child can be followed up at home.
  • If one or both test results are abnormal the child should be referred to a hospital.
  • If the pain has only lasted for a short time even normal laboratory results do not rule out appendicitis. On the other hand, advanced disease is improbable, and a few hours of follow-up is usually safe.
  • Comparing axillar and rectal temperatures is of no use in the diagnosis of appendicitis.
  • In painful constipation the blood leucocyte count may be high but serum CRP is normal.

Diagnostic clues

  • The most important specific causes and diagnostic clues for abdominal pain in different age groups are presented in the table T1.

The most important specific causes of abdominal pain, and diagnostic clues in different age groups

Age groupCause of painDiagnostic clues
0-2 yearsPyloric stenosis*Jet-like vomiting; age 2-8 weeks
Invagination*Paroxysmal pain, some diarrhoea, "meat water" and empty rectal ampulla at DRE
Incarcerated hernia*Reposition is neither easy nor successful
Testis torsion*Testicular pain, visible swelling (but intra-inguinal torsion is possible in retention)
GastroenteritisDiarrhoea or vomiting are the first and dominant symptoms
Otitis mediaEar status
Urinary tract infection or other serious infectionFever and vomiting without evident diarrhoea; urine test
3-11 yearsAppendicitis*Transfer of pain, pin-point tenderness, jumping test
Dolores abdominis NUDThe most common entity; important to differentiate from appendicitis
Mesenterial lymphadenitisClues do not differ from those of appendicitis
GastroenteritisDiarrhoea at onset, non-existent or slight tenderness on palpation
ConstipationHistory, hard stools; pain is often severe
PneumoniaCough, findings on auscultation, chest radiograph
SinusitisLocal symptoms, ultrasonography, sinus radiograph
TonsillitisInspection of the pharynx
Urinary tract infectionUrine test
Henoch-Schönlein purpuraPetechial rash
>11 yearsAppendicitis*See above
GastroenteritisSee above
SalpingitisOnly in the sexually active
Ovarian cystMay burst at exertion
Urinary tract infectionUrine test
* Diseases needing surgical treatment are indicated with an asterisk.
Pyloric stenosis
  • Develops gradually from the second week of life and causes jet-like vomiting.
  • The child should be referred to hospital at the latest when weightgain stops.

Invagination Management for Intussusception in Children

  • Typical symptoms include severe, paroxysmal cramping attacks between which the child can be almost asymptomatic.
  • The general condition deteriorates rapidly.
  • Watery, blood-stained stools ("meat water") is a typical finding.
  • A sausage-like abdominal mass is often felt on palpation (right and upper mid-abdomen).
  • On digital rectal examination the rectal ampoule is empty or there may be a small amount of watery and bloody stools.
  • Repositioning of the bowel in a radiological procedure with air or contrast media is usually successful.

Incarcerated hernia

  • Typically seen in children below 6 months of age, rarely in older children.
  • The main symptom is pain, and in prolonged condition womiting and symptoms of occlusion.
  • The most important finding is a tender, hard, reddish mass in the area of the inguinal canal above or medial to the lower or middle part of the inguinal ligament.
  • See separate article for hernias in children Hernias in Children.

Acute testis

  • Differential diagnoses
    • Testicular torsion
    • Acute hydrocoele
    • Torsion of appendix testis
    • Epididymitis/epididymo-orchitis
  • The peaks of incidence are in the neonates and prepubertal boys.
  • Torsion of the epididymis and epididymitis are more common than testicular torsion and may occur at any age.
  • Frequently the initial symptom is abdominal pain.
  • In all above-listed conditions inspection and palpation of the testes reveals swelling and tenderness. In testicular torsion the testis is usually retracted to the upper part of the scrotum or the opening of the inguinal canal.
  • Acute scrotum requires urgent surgery unless torsion is excluded with certainty.

Acute appendicitis

  • The initial symptom is nearly always pain in the umbilical region.
  • Location of the pain in the right lower quadrant suggests a more advanced disease causing peritoneal irritation.
  • If there is palpable tenderness at McBurney's point in a very small area (pin-point tenderness), appendicitis should be highly suspected.
  • Pain elicited by movements and vibration is typical of appendicitis.
  • Jumping is a good provocation test: ask the child to jump on both heels, or down from a small chair. If this does not cause any pain appendicitis is improbable.
  • Vomiting is a typical symptom in appendicitis. Unlike gastroenteritis it usually begins only after the pain has lasted for a relatively long time.
  • Diarrhoea is less frequent than vomiting, and it is never profuse.

Gastroenteritis

  • A common cause of abdominal pain in children
  • Gastroenteritis is the most probable diagnosis if diarrhoea and vomiting are the main symptoms, and (mild) oscillating abdominal pain presents simultaneously.
  • There is usually no tenderness on palpation.

Respiratory infections

  • Pneumonia, sinusitis, otitis media, and sometimes also tonsillitis may cause abdominal pain.
    • Upper respiratory tract and ear status and readily also chest and sinus x-rays or sinus ultrasonography are indicated if findings suggesting appendicitis are not quite clear.
  • In particular, pneumonia of the right lower lobe may cause referred pain at McBurney's point.

Urinary tract infection and other serious bacterial infections

  • Infections often present with fever and vomiting.
  • Do not make a diagnosis of gastroenteritis if the child does not have obvious diarrhoea.

Constipation

  • Strong pains are most often associated with acute constipation; in chronic constipation they are rare.
  • The pain is fluctuating and is felt in mid-abdomen.
  • In acute constipation a palpable mass of retained faeces is usually not felt. On digital rectal examination the rectal ampoule is however filled with hard faeces.
  • The initial treatment of painful coprostasis is one enema (bisacodyl mini-enema or a 120 ml enema). Large-volume water enemas should be avoided. In addition to dietary advise, other therapy is usually not needed.

Henoch-Schönlein purpura

  • See Henoch-Schönlein Purpura
  • The initial symptom is paroxysmal abdominal pain.
  • A papular, and later petechial rash on the buttocks and lower extremities is a clue to the diagnosis.
  • Invagination is a rare complication of the disease.

Other causes

  • A teenaged, sexually active girl may pose a diagnostic problem. Potential causes of abdominal pain include
    • appendicitis
    • causes of genital origin
      • rupture of a cyst in the ovary (causes sudden abdominal pain, sometimes associated with physical exertion. The pain subsides during follow-up and laboratory test results are normal.)
      • extrauterine pregnancy Ectopic Pregnancy.