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Problems in Family Practice Acute Abdominal Pain in Children

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Problems in Family Practice Acute Abdominal Pain in Children dysuria. The older child may start bed­ wetting with or without dysuria. A problems in Family Practice drop of fresh, clean unspun urine will usually reveal pyuria, but in the early case relatively few white blood cells may be seen compared to gross bacillu- Acute Abdominal Pain ria. The infection may have underlying urinary tract abnormality, stone, in Children hydronephrosis, polycystic kidney or renal neoplasms. The IVP is important Hyman Shrand, M D in detecting these underlying prob­ lems. Cambridge, M assachusetts 4. Viral Hepatitis. Malaise, anorexia, abdominal pain, and tenderness over Acute abdominal pain in children is a common and challenging prob­ the liver occur with hepatitis A or B. lem for the family physician. The many causes of this problem require Later, patients who become jaundiced a systematic approach to making the diagnosis and planning specific have dark urine and pale stools. In therapy. A careful history and physical examination, together with a teenagers, “needle tracks” suggest sy­ ringe transmitted Type B (H.A.A.) small number of selected laboratory studies, provide a rational basis hepatitis. Youngsters with infectious for effective management in most cases. This paper reviews the more mononucleosis may present as hepati­ common causes of acute abdominal pain in children with special em­ tis. phasis on their clinical differentiation. 5. Upper Respiratory Tract. Strepto­ coccal pharyngitis, a common cause of Abdominal pain in a child is always followed by vomiting is more likely an vomiting and abdominal pain, can be an emergency. The primary physician intra-abdominal disorder. recognized by looking at the throat must identify a “medical” cause in or­ with confirmatory throat culture. An Common Medical Causes der to prevent unnecessary interfer­ infant with otitis media draws up the ence and yet be on the alert for any One cannot stress enough that the legs and cries, which may be misinter­ condition requiring surgery. This can child with abdominal pain must be ful­ preted by the mother and physician as be done by a detailed history, a full ly examined. “colic.” Pain referred to the abdomen physical examination, and a few sim­ 1. Gastroenteritis. This is frequently by pleural irritation, pneumonia, or ple laboratory tests — never forgetting confused with acute appendicitis. Ta­ pleurodynia can easily mimic a surgical the urine. This article will review the ble 3 demonstrates the similarities and catastrophe. Yet, gentle palpation will more common causes of acute abdomi­ differences. The most important single usually distinguish the unyielding nal pain in children and suggest a prob­ sign favoring appendicitis is increasing guarding of peritoneal involvement lem-solving approach whereby the localized tenderness. from the softer, more yielding abdom­ family physician can make the diagno­ 2. Mesenteric Lymphadenitis. After inal wall of referred pain. Pneumonia is sis as the basis for effective therapy. certain viral or bacterial infections, associated with high fever, cough, pain The causes of acute abdominal pain there may develop a syndrome of ab­ aggravated by breathing, and crackles may be either extra or intra-abdominal dominal pain with nausea, vomiting, in the chest. It may be confirmed by (Table 1). Almost one third of cases and tenderness with enlarged lymph x-ray. admitted to the hospital remain undi­ nodes in the right iliac fossa. This 6. Henoch-Schonlein Purpura is a dif­ agnosed (Table 2). The main actors in syndrome is completely benign and is fuse vasculitis with pain in the abdo­ the dram a of the acute abdomen are often confused with appendicitis. As a men or joints. A characteristic anaphy­ pain, vomiting, localized tenderness, general rule the child feels hungry, and lactoid purpura involves the buttocks, swelling in the abdomen, and changes abdominal tenderness, unaccompanied legs, and arms but avoids the trunk. in the stools. The diagnosis' can be by the rigidity of appendicitis, de­ Stools may contain blood, as may the made by their order of appearance. creases as the hours pass. The W.B.C. urine. Henoch-Schonlein may either Extra-abdominal causes are either sec­ count is usually low. simulate an intussusception or actually ondary to vomiting or to pain referred Every physician has seen the doubt­ provoke one. Hemophilia often causes to the abdomen from irritated pleura, ful appendicitis resolve spontaneously painful retroperitoneal bleeding. pericardium, spine, or diaphragm. As a and called it mesenteric lymphadenitis, 7. Acute Rheumatic Fever may pre­ general rule, vomiting followed by while every surgeon has at times oper­ sent with abdominal pain and tender­ pain is extra-abdominal whereas pain ated on an “acute appendix” and ness in the right iliac fossa. A preced­ found only “mesenteric lymphadeni­ ing history of sore throat and fever with raised ASO titer and sedimenta­ From the Division of Pediatrics and Adoles tis.” cent M edicine, M o u n t A u b u r n H o s p ita l 3. Urinary Tract Infection with right­ tion rate is suggestive. The presence of Cambridge, Massachusetts. Requests for re sided renal colic is easily confused other criteria of rheumatic fever will Sh'r'ItL Sh^u.d be addressed to Dr. Hymar ... ' Chief of Division of Pediatrics ant with appendicitis. The young child has clinch the diagnosis. Medicine. Mount Auburn Hospi high fever, vomiting, and abdominal 8. Pancreatitis. Severe, constant abdo­ MasS 02138°Unt AUbUm Str6et' Cambridge pain and is less likely to complain of minal pain in the upper abdomen radi- THE JOURNAL OF FAMILY PRACTICE, VOL. 2, NO. 2, 1975 131 Table 1. Causes of Abdominal Pain Table 1 Continued Medical More Common Surgical Causes of Acute Abdomen Extra-Abdominal Review of Systems Clue Appendicitis H ead M ig ra in e Scintillating aura, Hernia strangulation h e m ic ra n ia I ntussusception Raised intracranial pressure Meckel's diverticulum ( tu m o r ) F u n d i V o lv u lu s Lead poisoning Pica A d h e s io n s M e n in g itis Neck stiffness Gallbladder, Kidney E p ile p s y History, EEG Trauma — blunt or penetrating Perforations E ar O titis media Bulging, red ear drums Psychological - These are the most T h r o a t Pharyngitis Sore throat com m on causes of recurrent abdomi­ Streptococcal nal pain over a period of more than three m onths in children overagesix Chest (referred pain) P le u ris y Cough, tachypnea, and often called 'spastic colon.' pain worse on breathing P n e u m o n ia Symptoms & signs, x-ray chest ating through to the back may be asso­ Pericarditis Epidemic myalgia E p id e m ic ciated with nausea, vomiting, diarrhea, distension, and shock in acute pancrea­ J o in ts Rheumatic fever Symptoms and signs Rheumatoid disease titis. The serum amylase is raised fora Henoch-Schonleins P u rp u ra few hours, while the amylase in the S k in H e p a titis J a u n d ic e urine is raised for a few days. Mumps Herpes zoster S h in g le s Henoch-Schonleins Purpura pancreatitis is now rare. The more common causes include: (1) prolonged U rin e Diabetes m ellitis Glycosuria, ketonuria Urinary tract infection P y u ria steroid therapy, (2) trauma-blunt in­ N e p h ritis Casts, album inuria, jury, (3) hyperlipidemia, (4) ascaris h e m a tu ria Renal colic Hematuria, crystalluria obstruction of the bile or pancreatic P o rp h y ria Burgundy red urine duct, (5) idiopathic, and (6) azathio- B lo o d Hemophilia, Purpura History, bleeding elsewhere prine.3 Sickle cell disease Negro Hem olytic crisis H is to ry 9. Sickle Cell. A routine sickle cell pre­ Electrolyte disturbances Vom iting, diarrhea, paration is indicated for black children dehydration Familial mediterranean fever with abdominal pain. During a hemo­ lytic crisis the splanchnic circulation is Intra-abdominal impaired. Pallor and listlessness with L iv e r H e p a titis Jaundice, dark urine pale stools, abnormal liver, abdominal pain, tenderness, disten­ enzymes and tests sion, and decreased borborygmi ac­ Pancreas Pancreatitis Serum and urine amylase company an enlarged spleen. The physician should suspect a surgical S p le e n Infectious mononucleosis Abnormal mononuclears Monospot test problem if the pain persists after ad­ ministration of intravenous fluids. N od e s Mesenteric lymphadenitis Tender right iliac fossa 10. Primary Peritonitis. Nowadays this K id n e y Urinary tract infection History, urine, abdomen exam. is usually found in children with idio­ Hydronephrosis IVP pathic nephrosis. A known nephrotic S to n e s loses appetite and develops severe ab­ T e s tis Torsion, epididymitis Swollen testis dominal pain with high fever. Paracen­ Ovary Mittelschmerz History tesis reveals purulent fluid with pneu­ Ovarian cyst or tumor Pelvic exam mococcus or streptococcus which usu­ Fallopian tubes Salpingitis, ectopic Adenexal tenderness, ally responds to penicillin. missed period 11. Lead Poisoning. Abdominal pain, Gallbladder Cholecystitis History, physical constipation and vomiting may follow examination S to n e Cholecystogram w ith pica for lead-containing sub­ stances. X-rays may reveal radiopaque Gastrointestinal Overeating, overdrinking, History, rectal constipation lead paint in the abdomen or lead lines Gastroenteritis, dysentery Vomiting, diarrhea in the long bones. A high blood lead Poisonings I ngestion Regional enteritis History, diarrhea level is confirmatory. Ulcerative colitis History, diarrhea 12. Poisoning. An abrupt onset of gen­ Peptic ulcer W o rm s Stools, ova, parasite eralized illness in the high-risk group M ilk allergy History, eczema Typhoid fever History aged one to four years with a history Necrotizing enterocolitis Bloody diarrhea, of ingestion followed by vomiting, ab­ exchange transfusion dominal pain, and diarrhea should sug­ gest poisoning.
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