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Abdominal Pain 10 Abdominal Pain Adrian Miranda Acute abdominal pain is usually a self-limiting, benign condition that irritation, and lateralizes to one of four quadrants. Because of the is commonly caused by gastroenteritis, constipation, or a viral illness. relative localization of the noxious stimulation to the underlying The challenge is to identify children who require immediate evaluation peritoneum and the more anatomically specific and unilateral inner- for potentially life-threatening conditions. Chronic abdominal pain is vation (peripheral-nonautonomic nerves) of the peritoneum, it is also a common complaint in pediatric practices, as it comprises 2-4% usually easier to identify the precise anatomic location that is produc- of pediatric visits. At least 20% of children seek attention for chronic ing parietal pain (Fig. 10.2). abdominal pain by the age of 15 years. Up to 28% of children complain of abdominal pain at least once per week and only 2% seek medical ACUTE ABDOMINAL PAIN attention. The primary care physician, pediatrician, emergency physi- cian, and surgeon must be able to distinguish serious and potentially The clinician evaluating the child with abdominal pain of acute onset life-threatening diseases from more benign problems (Table 10.1). must decide quickly whether the child has a “surgical abdomen” (a Abdominal pain may be a single acute event (Tables 10.2 and 10.3), a serious medical problem necessitating treatment and admission to the recurring acute problem (as in abdominal migraine), or a chronic hospital) or a process that can be managed on an outpatient basis. problem (Table 10.4). The differential diagnosis is lengthy, differs from Even though surgical diagnoses are fewer than 10% of all causes of that in adults, and varies by age group. Although some disorders occur abdominal pain in children, they can be life-threatening if untreated. throughout childhood (constipation, gastroenteritis, lower lobe pneu- Approximately 55% of children evaluated for acute abdominal pain monia, urinary tract infections), others are more common in a specific have a specific medical diagnosis; in another 45%, the cause is never age group (see Table 10.2). defined. History PATHOPHYSIOLOGY OF ABDOMINAL PAIN Obtaining an accurate history is critical for making an accurate diag- Abdominal pain results from stimulation of nociceptive receptors and nosis but is dependent both on the ability and willingness of the afferent sympathetic stretch receptors. The pain is classified as visceral child to communicate and on the skill of the parent or guardian as or parietal (somatic). an observer. The person providing an infant’s care is the best source of information about the current illness; the examining physician Visceral Pain should try to elicit as much information from the child as possible. Visceral pain receptors are located on the serosa surface, in the mes- Some children give a good account of their illness when they are entery, within intestinal muscle, and mucosa of hollow organs. Pain is simply asked to describe it; most children must be asked open-ended, initiated when receptors are stimulated by excessive contraction, non-leading questions. To determine the presence of anorexia, the stretching, tension or ischemia of the walls of hollow viscera, the physician must ask questions about food intake, the time the food capsule of a solid organ (liver, spleen, kidney), or of the mesentery. was eaten, and how that behavior compares to the child’s normal Increased contraction of the smooth muscle of hollow viscera may be intake. The answers are often quite different from the responses to caused by infection, toxins (bacterial or chemical agents), ulceration, the more general questions “Are you hungry?” and “Have you eaten inflammation, or ischemia. Increased hepatic capsule tension may be today?” secondary to passive congestion (heart failure, pericarditis) or inflam- During the history taking, the child should remain in the parent’s mation (hepatitis). arms, at play, or comfortably seated beside the parent, as appropriate Afferent fibers involved in processing visceral pain are unmyelin- for the child’s age. While the history is obtained, there is no particular ated C-fibers that enter the spinal cord bilaterally, resulting in dull, reason that the child should be undressed. The clinician must resist the poorly localized pain. Visceral pain is often of gradual onset, and urge to speed things up by examining the child while taking the history. although localization may be imprecise, some general rules may be On occasion, when seeing a seriously ill child, the physician may need helpful (Fig. 10.1). to abbreviate the diagnostic process, but taking short cuts may lead to inaccurate conclusions. Parietal Pain Parietal pain arises from direct noxious (usually inflammation) stimu- Essential Components of the History lation of the contiguous parietal peritoneum (e.g., right lower quad- Time of onset of pain. Pain of fewer than 6 hours’ duration is rant at the McBurney point, appendicitis) or the diaphragm (splenic accompanied by nonspecific findings, and observation is often needed rupture, subdiaphragmatic abscess). Parietal pain is transmitted to determine the nature of the illness. Pain lasting from 6-48 hours is through A-delta fibers to specific dorsal root ganglia and thus is more apt to have a cause that warrants medical intervention, although usually sharp, and more intense. It can usually be exacerbated by delays in presentation and diagnosis in children are not unusual. movement or cough, is accompanied by tenderness over the site of Timing of the progression of symptoms must be detailed. 161 Downloaded for Sarah Barth ([email protected]) at Elsevier - Demonstration Account from ClinicalKey.com by Elsevier on March 09, 2018. For personal use only. No other uses without permission. Copyright ©2018. Elsevier Inc. All rights reserved. 162 Section 3 Gastrointestinal Disorders TABLE 10.1 Distinguishing Features of Abdominal Pain in children Disease onset Location Referral Quality comments Functional: irritable Recurrent Periumbilical None Dull, crampy, intermittent, Caused by unknown physiologic bowel syndrome duration 2 hr factors; diarrhea/constipation are symptoms Gastroenteritis Acute or gradual Periumbilical, rectal- None Crampy, dull, intermittent Emesis, fever, watery diarrhea or tenesmus dysentery (mucus and blood) Esophageal reflux Recurrent, after Substernal Chest Burning Sour taste in mouth, Sandifer meals, bedtime syndrome Duodenal ulcer Recurrent, before Epigastric Back Severe burning, gnawing Relieved by food, milk, antacids; meals, at night family history Pancreatitis Acute Epigastric/hypogastric Back Constant, sharp, boring Nausea, emesis, marked tenderness Intestinal Acute or gradual Periumbilical–lower Back Alternating cramping (colic) Distention, obstipation, bilious obstruction abdomen and painless periods emesis, increased bowel sounds Appendicitis Acute or gradual Initially periumbilical or Back or pelvis Sharp, steady Nausea, emesis, local (1-2 days) epigastric; later localized if retrocecal tenderness with/without fever; to the right lower quadrant patient is motionless Meckel diverticulitis Recurrent or Generalized diffuse with None Sharp Hematochezia: painless unless (mimics constant perforation: periumbilical– intussusception, diverticulitis, appendicitis) lower abdomen or perforation Inflammatory bowel Recurrent Depends on site of Dull cramping, tenesmus Fever, weight loss, with/without disease involvement hematochezia Intussusception Acute Periumbilical–lower None Cramping, with painless Guarded position with knees abdomen periods pulled up, “currant jelly” stools Lactose intolerance Recurrent with Lower abdomen None Cramping Distention, gaseousness, milk products diarrhea Urolithiasis Acute, sudden Back Groin Severe colicky pain Hematuria; calcification on KUB x-ray study, CT scan Pyelonephritis Acute, sudden Back None Dull to sharp Fever, costochondral tenderness, dysuria, pyuria, urinary frequency Cholecystitis/ Acute Right upper quadrant Right shoulder, Severe colicky pain Hemolysis with/without jaundice cholelithiasis scapula CT, computed tomography; KUB, kidney, ureter, and bladder. Data from Andreoli TE, Carpenter CJ, Plum F, et al. Cecil Essential of Medicine. Philadelphia: WB Saunders; 1994:326; Behrman R, Kliegman R. Nelson Essentials of Pediatrics. 2nd ed. Philadelphia: WB Saunders; 1994:396. Location of pain. The location of the pain at its onset and any unknown in the toddler and infant, although the parent can determine change in location are very important (Table 10.5; see also Table 10.1). whether the discomfort is constant, cramping, or intermittent. If the Most intraperitoneal visceral pain is a response to the stimulation of child intermittently draws the legs up in a flexed position and cries, the stretch fibers in the bowel wall and is mediated through the spinal clinician can assume that intermittent pain is present. nerves. This pain is sensed as a deep, aching periumbilical pain. Pain Child’s activity level. The effect of the pain on the child’s activities caused by inflammation of the parietal peritoneum (acute appendici- is an important indicator of the severity of the underlying disease. If tis) is localized to the area of the inflamed organ or is diffuse if the the pain is sufficiently severe to awaken the child from a sound sleep, inflammation is extensive and involves more of the peritoneal cavity. it is of much more significance than pain that occurs only at school Pain
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