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Home , Appendicitis, Cholecystitis, Fecalith

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- Abdominal ria. The may have underlying urinary tract abnormality, stone, in Children hydronephrosis, polycystic kidney or renal . The IVP is important

Hyman Shrand, M D in detecting these underlying prob­ lems. Cambridge, M assachusetts 4. Viral . Malaise, , , 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 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 . 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 physical examination, and a few sim­ 1. . This is frequently by pleural irritation, , or ple laboratory tests — never forgetting confused with acute . Ta­ pleurodynia can easily mimic a surgical the urine. This article will review the ble 3 demonstrates the similarities and catastrophe. Yet, gentle 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 . Pneumonia is sis as the basis for effective therapy. certain viral or bacterial , associated with high , 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 , 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 with pain in the abdo­ the dram a of the 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 has at times oper­ sent with abdominal pain and tender­ pain is extra-abdominal whereas pain ated on an “acute ” 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. with right­ tion rate is suggestive. The presence of Cambridge, Massachusetts. Requests for re sided 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. . 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 Clue Appendicitis H ead M ig ra in e Scintillating aura, strangulation h e m ic ra n ia I ntussusception Raised intracranial pressure Meckel's ( tu m o r ) F u n d i V o lv u lu s Pica A d h e s io n s M e n in g itis Neck stiffness , 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, , distension, and 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 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 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 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 , 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 . 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 History tesis reveals purulent fluid with pneu­ Ovarian cyst or tumor Pelvic exam mococcus or which usu­ Fallopian tubes Salpingitis, ectopic Adenexal tenderness, ally responds to penicillin. missed period 11. Lead Poisoning. Abdominal pain, Gallbladder History, physical 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, Vomiting, diarrhea in the long bones. A high blood lead Poisonings I ngestion Regional History, diarrhea level is confirmatory. Ulcerative 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 History aged one to four years with a history Necrotizing Bloody diarrhea, of ingestion followed by vomiting, ab­ exchange transfusion dominal pain, and diarrhea should sug­ gest poisoning. Some of the more com­ mon poisons are: salicylates, arseni- cals, aminophylline, bacterial food poi-

1 3 2 THE JOURNAL OF FAM ILY PRACTICE, VOL. 2, NO. 2, 19?5 of diagnosis compounded by the mis­ lowing complications may occur: rec­ Table 2. Children with Acute Ab­ use of purges, paregoric, or antiemetic tal bleeding (either bright red or mele- lead to a perforation rate of about 80 dominal Pain Admitted to Hospital1 na), intestinal obstruction, intussus­ percent. The classical sequence found ception, or (with perfor­ in the older child of crampy periumbil­ ation which mimics an acute appen­ Num ber ical pain (which later moves to the Group dicitis). A Meckel’s diverticulum is fre­ right iliac fossa), followed by vom­ quently suspected, often looked for, iting, followed by localized tenderness but seldom found. Barium studies are I. Appendicitis in the right iliac fossa is acute appendi­ confirmed histology 114 usually useless. More recently, techne­ citis until proven otherwise. Whenever tium scanning has located the hetero­ II. Preoperative the inflamed appendix is located in appendicitis topic gastric mucosa.6 other parts of the abdomen or pelvis Mesenteric 11 4. Trauma. After an automobile acci­ Appendix with there will be corresponding sites of dent or fall from a height or bicycle, threadworm 2 tenderness. Practically all these chil­ abdominal pain should suggest an in­ 1 Ovarian cyst dren lose their appetite. The white tra-abdominal catastrophe and all such Leukemia 1 blood count and temperature usually No cause 5 children should be hospitalized until remain near normal for the first 24 asymptomatic.7 The spleen, liver, kid­ Total 21 hours, but after perforation both will ney, pancreas, gastrointestinal or geni­ III. Medical disorder rise and the vomiting becomes more tourinary tract may be injured or rup­ no operation frequent. The physician should be tured. Suggestive signs are pallor, tach­ Urinary tract infection 17 wary of the “treacherous lull” which Pneumonia 10 ycardia, tenderness, distension, a frac­ may precede perforation. Such a child Dysentery 6 tured rib or pelvis, and hematuria. The Paratyphoid 2 usually lies quietly in bed with legs girth of the abdomen should be mea­ Tonsillitis 2 drawn up and is reluctant to move. If sured. A plain x-ray of the abdomen Diabetes 1 the appendix is retrocecal, the child may reveal free intraperitoneal air. The Inguinal adenitis __ 1_ walks with a stoop and complains of serum amylase may be raised and the Total 43 pain when the thigh is extended. A hematocrit may fall. A child with a IV. No diagnosis 119 gentle may reveal head showing signs of “shock” V. Other surgical tenderness or a mass. In about 50 per­ usually is bleeding in the abdomen. emergencies cent a diagnostic is revealed by Ringer’s lactate should be started, the Obstructions 11 x-ray. __ 7 If the appendicitis irritates the blad­ Total 18 der, confusing pyuria and hematuria Table 3. Comparison of Appendicitis Grand Total 315 may be found. Often the symptoms and Gastroenteritis2 and signs are highly suggestive but not absolute. Repeated evaluation will usu­ soning, phenol, corrosives, various ally determine whether the process is Percent in Percent in Symptoms appendicitis enteritis houseplants, and mushrooms.4 progressing or decreasing. If in serious 13. Diabetes. Diabetic keto-acidosis is doubt, a is better than the notoriously associated with abdominal risk of a perforated appendix. Abdom inal pain, vomiting, and tenderness. A pre­ 2. Intussusception. A common cause pain 95.2 96.9 ceding polyuria and polydipsia is usu­ of intestinal obstruction reaches a Vom iting 56.1 44.3 ally found with glycosuria, ketonuria, peak incidence at age six months. The Nausea 22.0 11.6 and hyperglycemia. A child should classical triad of intermittent abdo­ never be taken to surgery before the minal pain, vomiting, and blood in Diarrhea 8.4 9.7 urine is examined for sugar, blood, al­ stools occurs in all but a small minori­ Constipation 1.1 2.8 bumin, bile, and cells. ty. Intermittent abdominal pain will Localized pain 14. Allergy. Allergy to milk occasion­ be found in over 90 percent, vomiting on pressure 96.2 16.7 ally causes “colic” and bleeding. Sub­ in 60 percent, blood in stools in 16 Diffuse pain stituting a soybean formula for cow’s percent and a palpable mass in 24 per­ on pressure 58.5 milk can bring dramatic improvement cent.5 The infant who intermittently Rebound and confirms the diagnosis. draws up the leg, cries out in pain, be­ tenderness 65.4 comes pale, and vomits probably has Muscle Intra-abdominal Surgical Causes an intussusception. An immediate bari­ guarding 61.3 11.3 1. The Acute Appendix. The narrow um is both diagnostic and ther­ Pain in Douglas' lumen of the appendix is easily ob­ apeutic.5 Delay in diagnosis is disas­ cul-de-sac 18.6 structed. Removal before perforation trous. Evident entails little morbidity; after per­ 3. Meckel’s Diverticulum. A Meckel’s intestinal foration the peritonitis or sounds diverticulum occurs in only two per­ (borborygmi) 25.2 leads to significant morbidity and, cent of the population, about 50 per­ even in the best centers, a mortality of cent containing heterotopic gastric Tympanism 6.6 two percent. In the young, difficulties mucosa. In about 30 percent, the fol­

'HE JOURNAL OF FAMILY PRACTICE, VOL. 2, NO. 2, 1975 1 3 3 blood typed and cross-matched, and a hernial orifices and request radio­ Discussion catheter passed if the child cannot graphy for signs of obstruction or in­ After a detailed history, the child void. Call the surgeon at once. tussusception. with abdominal pain must be fully ex 5. Foreign Bodies in the G.I. Tract. A Obstruction in the Newborn may amined, looking for infections of the variety of objects are swallowed by be due to a meconium plug, atresia of respiratory, gastrointestinal, and J children but most of them pass the , , or , me­ nary tract. Exclude raised intracranial through. If they stop in the conium of fibrocystic disease or pressure and remember that constipa­ (chicken bones are notorious offen­ with Hirschsprung’s disease. The classi­ tion commonly causes cramps. Ex- ders), they can be removed by endo­ cal signs are bilious vomiting, abdom­ amine for strangulated hernia and note scopy. A pin in the bowel should be inal distension, and failure to pass presence of abdominal scars which watched radiographically, and if it meconium. Suspect an obstruction if may indicate an obstruction secondary stays in one place for more than five the mother has hydramnios, especially to adhesions. Careful palpation and days it has probably pierced the gut if the amniotic fluid is green and the rectal examination will usually identi­ and should be removed. In certain ar­ newborn has not passed meconium. fy a mass or inflamed appendix which eas obstruction by round worms is still X-rays of the abdomen will usually re­ at times will be confused with a mes­ common. veal the site of obstruction. Early diag­ enteric lymphadenitis. If an intussus­ 6. . If an abdominal nosis before aspiration or dehydration ception is suspected, immediate bari­ mass is found, the common retroperi­ is mandatory since the ideal time for um enema will be both diagnostic and toneal causes are either a neuroblasto­ surgery is in the first 24 hours. therapeutic. The urine must always be ma, hydronephrosis, multicystic kid­ examined for red and white blood ney or a Wilms’ tumor. An IVP is es­ Gastrointestinal Bleeding cells, sugar, and bile. A sickle cell prep- sential in the workup. The common in- Bleeding from above the ileocecal aration should be ordered for black traperitoneal causes are enlargement of valve produces black, tarry stools. children. When the diagnosis is in liver, spleen or uterus, an ovarian cyst, Bleeding from the small bowel or co­ doubt after initial examination, the hydrometrocolpos, intussusception, lon colors the stools brick red. Bright evaluation is repeated after an hour, red blood on the outside of the stool, and an appendix abscess. Constipation consultation arranged, or the child ad­ is common in childhood because of on paper, or in the toilet bowl usually mitted to the hospital. The anxious the unfortunate popularity of refined comes from the lower colon or anorec­ child resisting examination can be re­ foods and sugar-coated cereals. Fecal tal area. The most common cause of laxed by a rapidly acting barbiturate impaction is a frequent cause of ab­ bleeding by far is the fissure in ano capsule inserted into the rectum. The dominal pain and the mass in the belly with its history of constipation, pain­ child should never be given a purga­ can be remarkable. Occasionally the ful defecation, and a streak of blood tive, antiemetic, powerful analgesic, or cause of the constipation might be on the hard stool. before the diagnosis is defi­ Hirschsprung’s disease. One should always test with guaiac nite. These will mask symptoms and 7. Stones. Stones in the gallbladder or or hematest to verify that blood is pre­ signs, delay diagnosis, and expedite the urinary tract can cause severe colic. sent and look for signs of bleeding pathological process. A careful history may be suspected when elsewhere. If gastrointestinal bleeding and physical examination, together there is tenderness in the right upper is diagnosed and significant, a nasogas­ with laboratory studies, provide a ra­ quadrant, signs of obstructive jaun­ tric tube will determine if there is tional basis for effective management dice, and a history of a hemolytic dis­ blood in the stomach. Other investiga­ in most cases. ease. X-rays or cholecystograms will tions include barium studies, endos­ confirm their presence. Urinary tract copy, and selective celiac and superior stones are suggested by abdominal mesenteric arteriography. The follow­ pain, fever, pyuria, hematuria, family ing are the more common causes of history of cystinuria, or other meta­ gastrointestinal bleeding in children: bolic defects. Most calculi are radio­ A. Sw allow ed blood, especially paque but uric acid and xanthine from a nose bleed References stones are radiolucent. 1. Winsey AS, Jones PF: Abdom inal 8. Surgical Problems in Infancy and pain in childhood. Br Med J 1:653-659, Peptic ulcer 1 9 6 7 Newborn. In one series of 87 infants8 Intussusception 2. Richter H, et a I: Differential diagno sis of acute appendix in children. Annales from birth to one year, the following Meckel’s diverticulum Nestle 18:45-47, 1968 surgical disorders were found: strangu­ Blind gut 3. Raffensperger JG, et al: The Acute Abdomen in Infancy and Childhood. Phila­ lated hernia 36 percent; malformations Tumors and polyps delphia, JB Lippincott, 1970 20 percent; intussusception 16 per­ Peutz-Jegher’s syndrome 4. Scherz RG, et al: Management of ac­ cidental childhood poisoning. Pediatrics cent; perforation nine percent; ob­ 54:323-356, 1974 struction and eight percent; 5. Gierup J, et al: Management of intus­ B. Dysentery susception. Pediatrics 50:535-546, 1972 ascaris one percent and acute appendi­ Henoch-Schonlein 6. Kilpatrick ZM: Scanning in diagnosis citis one percent. Bilious vomiting oc­ of Meckel's diverticulum. Hospital Practice Regional enteritis 9:131-134, 1974 curs if the obstruction is below the 7. Hood JM, Smyth BT: Non-penetra­ ting intra-. J Pediatr Surg ampulla of vater or with peritonitis. 9:69-77, 1974 Distension is common but rigidity un­ 8 . DeLima AJ, Araujo BS: Acute Abdo men in children. Annales Nestle 17:27 usual. One should always examine the C. Generalized bleeding disorder 1 9 6 8

1 3 4 THE JOURNAL OF FAM ILY PRACTICE, VOL. 2, NO. 2, 19,s