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Abdominal Pain

Many diseasescause abdominal pain, and clinical dilemma is to distinguish life-threateningones from those that are mild and self-limited.

Best way to approach diagnosis is toconsider age of child and whether pain is acute or chronic.

Principal Causes of Acute Abdominal Pain

1. Neonates
   1. Common
      1. Colic
      2. Necrotizing enterocolitis
   2. Uncommon
      1. Gastrointestinal obstruction or perforationof any viscus
2. Infants
   1. Common
      1. Colic
      2. Gastroenteritis
      3. Viral illness
      4. Incarcerated inguinal hernia
      5. Intussusception
      6. Trauma including child abuse
   2. Uncommon
      1. Appendicitis
      2. Cow milk protein sensitivity
      3. Lactose intolerance
      4. Gastrointestinal obstruction includingvolvulus with malrotation
      5. Sickle cell pain episodes
      6. Lead poisoning
      7. Neoplasm
3. Preschool children
   1. Common
      1. Constipation
      2. Gastroenteritis
      3. Viral illness
      4. Urinary tract infection
      5. Pneumonia
      6. Trauma
      7. Lactose intolerance
      8. Sickle cell pain episodes
   2. Uncommon
      1. Food poisoning
      2. Diabetic ketoacidosis
      3. Gastrointestinal obstruction
      4. Henoch-Schönlein purpura
      5. Neoplasm
      6. Drugs and toxins
      7. Appendicitis
      8. Intussusception
      9. Hepatitis
4. School-aged children and adolescents
   1. Common
      1. Gastroenteritis
      2. Viral illnesses
      3. Constipation
      4. Trauma
      5. Urinary tract infection
      6. Acute appendicitis
      7. Pneumonia
      8. Lactose intolerance
      9. Sickle cell pain episodes
      10. Functional abdominal pain
   2. Uncommon
      1. Peptic ulcer disease
      2. Biliary tract disease
         1. Acutecholecystitis
         2. Biliary colic
      3. Pancreatitis
      4. Obstructive uropathy
      5. Urolithiasis
      6. Intraabdominal abscess
      7. Primary bacterial peritonitis
      8. Inflammatory bowel disease
      9. Lactose intolerance
      10. Hepatitis
      11. Intestinal obstruction
      12. Diabetic ketoacidosis
      13. Neoplasm
      14. Drugs and toxins
5. Adolescent girls
   1. Common
      1. Primarydysmenorrhea
      2. Mittelschmerz
      3. Pelvic inflammatory disease
   2. Uncommon
      1. Ovarian disorders
      2. Endometriosis
      3. Genital tract malformations with obstruction
      4. Complications of pregnancy

Clinical Features and Diagnosis: Acute Abdominal Pain

Neonates

Colic

Historically thought of as cause of abdominalpain but now conceptualized more broadly. See Chap. 11, Crying and Irritability.

Necrotizing Enterocolitis

Infantsappear ill and usually have abdominal distension and often evidenceof GI bleeding.

Progression of illness commonly resultsin bowel infarction and often perforation.

See Chap.22, Gastrointestinal Bleeding).

Gastrointestinal Obstruction or Perforation of Any Viscus

Reasonableassumption is that neonates with GI tract obstruction or perforationof viscus have abdominal pain, which may be expressed by persistentcrying and irritability.

Vomiting and abdominal distension areprominent findings.

Common causes of obstruction in neonatesare pyloric stenosis, intestinal atresia, volvulus with malrotation,meconium ileus, and congenital aganglionic megacolon.

See Chap.55, Regurgitation and Vomiting.

Infants

Gastroenteritis

Usual presentingfeatures are vomiting, diarrhea, abdominal pain, and fever.

Rotavirus is most common pathogen.Frequent bacterial pathogens include Salmonella, Shigella, and Campylobacterspecies.

Detection of rotavirus antigen in stoolby enzyme immunoassay is diagnostic. Positive stool culture is diagnosticof bacterial infection.

See Chap.14, Diarrhea.

Viral Illness

Many virusescan produce illnesses that may be accompanied by mild nonspecificabdominal pain. Some viruses produce disease in respiratory tractand include rhinoviruses, respiratory syncytial virus, parainfluenzaviruses, influenza viruses, and adenoviruses.

Illness is usually mild and self-limitedand resolves in 3–7 days.

Clinical findings include fever, rhinorrhea,cough, headache, anorexia, vomiting, mild sore throat, and myalgia.

Diagnosis is usually clinical; however,viral culture or polymerase chain reaction of nasal secretions canoften identify specific virus.

Incarcerated Inguinal Hernia

Common causeof intestinal obstruction.

Painful, tender mass is palpable ininguinal area with extension at times into scrotum.

Persistent vomiting, abdominal distension,and inability to reduce hernia suggest intestinal obstruction.

Surgery should be performed immediatelyif hernia cannot be reduced and bowel obstruction is suspected.If hernia can be reduced, surgery is usually planned in severaldays, after edema has diminished.

Intussusception

Clinicalfindings are intermittent abdominal pain, vomiting, abdominal mass,and currant jelly stools.

Not only is air-contrast enema diagnostic,but in many cases it also may be therapeutic.

Trauma, Including Child Abuse

Many abdominalinjuries are mild and cause only abdominal wall musculoskeletal pain.

More serious abdominal injuries includecontusion, laceration, or rupture of spleen, liver, kidney, or intestine.Pancreatic and major vessel injuries are less common.

Splenic injury causes tenderness andoccasionally splenic enlargement secondary to hematoma formation.CT is best method for diagnosing contusion, laceration, or ruptureof spleen.

With significant liver injury, serumaminotransferase levels are usually >3–5 timesnormal level. CT is the best method to determine type and degreeof liver injury.

Hematuria and flank pain may occurwith kidney injury. With history of mild trauma and possibilityof isolated renal injury, excretory urography may be performed.

If more serious injury has occurredwith possible involvement of other abdominal organs, CT is radiologicprocedure of choice. Elevated serum amylase level suggests pancreaticinjury, which can be delineated by CT.

Pelvic trauma may injure pelvis, bladder,urethra, or rectum.

Rectal exam should be performed to determinewhether rectal laceration has occurred.

Pelvic tenderness or pain may indicatepelvic fracture, which can be confirmed by plain radiography.

Bladder and urethral injuries may causesuprapubic pain and hematuria.

If blood is seen at meatus, prostateis higher than normal position, or there is evidence of scrotaltrauma, urethrography should be performed.

Child abuse should be suspected wheneverany unexplained injuries, burns, or fractures occur. Typical skinlesions include bruises in varying stages of healing, especiallyon face, back, chest and abdomen, and different types of scars indicativeof burns or trauma with various implements.

Stabilization of patient with significantabdominal trauma is first priority.

After history and physical exam, thefollowing tests should be performed:

CBC with differential

Analysis of serum electrolytes, glucose,creatinine, amylase, aspartate and alanine aminotransferases, andblood urea nitrogen

Radiography of chest and abdomen

Cervical spine and pelvic radiographyshould be performed if indicated. In serious cases, abdominal CTshould be considered because it is most efficient and effectivemethod to investigate significant abdominal trauma.

Other

Less common causes of abdominal pain in infantsinclude appendicitis, cow milk protein sensitivity, lactose intolerance,GI obstruction, sickle cell pain episodes, lead poisoning, and neoplasms.

Preschool Children

Constipation

Definedas difficult and painful passage of hard stools.

Abdominal pain is usually intermittent,crampy, and generalized.

Stool may be palpable on abdominalor rectal exam.

After bowel movement, pain and palpablestool masses disappear.

See Chap.9, Constipation.

Urinary Tract Infection

Lower abdominal,suprapubic, or flank pain associated with dysuria suggests presenceof urinary tract infection.

Fever and vomiting are common findings.

Pyuria suggests diagnosis, which isconfirmed by positive urine culture.

See Chap.15, Dysuria.

Pneumonia

May producereferred epigastric or periumbilical abdominal pain, especiallyif inflammation occurs in lower lobes of lung.

Fever, cough, tachypnea, and pleuriticpain suggest its presence.

Chest radiography is usually confirmatory.

See Chap.10, Cough.

Lactose Intolerance

Common inpreschool and school-aged children, especially African-Americanand Hispanic children.

Clinical manifestations include diarrheaand recurrent abdominal pain in those individuals who have low lactaseactivity and who ingest large amounts of lactose-containing products.

See Chap.14, Diarrhea.

Sickle Cell Pain Episodes

Vasoocclusiveepisode may cause mild-to-severe abdominal pain. Chest, back, and extremitypain also may occur.

Diagnosis can be confirmed by Hgb electrophoresis.

Food Poisoning

Resultsfrom ingestion of food contaminated with bacteria.

Crampy abdominal pain, diarrhea, andvomiting are typical features.

Recovery usually occurs in 1–2days.

History and physical exam suggest diagnosis.Positive stool culture or culture of suspected contaminated foodconfirms diagnosis.

See Chap.14, Diarrhea.

Diabetic Ketoacidosis

Can be initialpresentation of insulin-dependent diabetes mellitus.

Omission of insulin, acute illness,and emotional stress can be predisposing factors to diabetic ketoacidosis.

History of polyphagia, polydipsia,and polyuria of <1 mo's duration is usually found.Mild nonspecific abdominal pain and vomiting also may occur.

Kussmaul respirations are compensatoryphenomena of severe metabolic acidosis.

Severe illness may produce alterationin mental status that ranges from drowsiness to coma.

Presence of glucosuria, ketonuria,hyperglycemia, and metabolic acidosis confirm diagnosis.

Gastrointestinal Obstruction

Should besuspected with presence of persistent bilious vomiting and abdominal pain.

In this age group, common causes includeincarcerated inguinal hernia and surgical adhesions.

Henoch-Schönlein Purpura

Common causeof vasculitis in childhood.

Characterized by purpuric rash on buttocksand lower legs, abdominal pain, GI bleeding, transient migratoryarthritis of large joints, and hematuria.

Diagnosis is usually clinical.

See Chap.28, Hematuria.

Neoplasm

Wilms tumor,neuroblastoma, and lymphoma usually present with abdominal masses, butabdominal pain also may occur, especially with Wilms tumor.

See Chap.1, Abdominal Masses.

Drugs and Toxins

Acute ingestionof significant amounts of alcohol, iron, lead, or aspirin may produce abdominalpain.

History and measurement of toxic agentin blood are diagnostic.

School-Aged Children and Adolescents

Common causesof abdominal pain in this age group are gastroenteritis, viral illness, constipation,urinary tract infection, pneumonia, trauma, and sickle cell disease,as discussed previously.

Functional abdominal pain, which isusually chronic, is discussed below.

Acute Appendicitis

Occurs mostcommonly between 5 and 15 yrs of age but can occur in children <2 yrs.

First clinical manifestation is usuallycrampy periumbilical pain with shift in pain to right lower quadrantduring next few hours and is due to irritation of parietal peritoneumby small amount of fluid from inflamed appendix.

Location of appendix determines locationof pain.

Retrocecal appendix may irritate psoasmuscle; retrocolic appendix may cause pain in right flank.

Pelvic appendix may produce mild abdominalpain yet distinct tenderness on rectal exam.

Irritation of rectosigmoid colon byinflammatory fluid may cause mild diarrhea; irritation of uretermay cause dysuria.

Low-grade fever usually occurs withnonperforated appendix, whereas perforation usually produces sickerchild with higher fever, more vomiting, and more severe abdominalpain because of peritonitis or a localized abscess. Abdomen is distendedand tender, and signs of septic shock may be present. Children <2yrs are more likely to present with peritonitis and septic shock.

Abdominal findings depend on when childis seen during course of illness. Early in illness, right lowerquadrant tenderness may be found. With progression of illness, involuntaryspasm and rebound tenderness occur.

Child favors right side of abdomenand walks bent over. Climbing up on exam table, coughing, or jumpingup and down aggravate pain and indicate peritoneal inflammation.

Leukocytosis is common.

Results of UA either are normal orshow pyuria because of inflammation of ureter.

Abdominal radiography may occasionallyshow fecalith, edema of lateral abdominal wall, concave lumbar scoliosis,dilated cecum with air-fluid level, or localized ileus in rightlower quadrant.

Diagnosis is usually clinical. Otherstudies are unnecessary if findings are characteristic

In equivocal cases, abdominal U/Sor CT may be helpful.

With suspected appendicitis, surgeryshould be performed, as it is only definitive way to confirm diagnosis.

Appendiceal colic can cause recurrentepisodes of acute right lower quadrant pain. Drinking fluids oreating usually exacerbate the pain within 5–15 mins. Findingof maximum tenderness at McBurney point is evidence for this disorder.No lab tests are diagnostic.

Resolution of pain after removal ofappendix is confirmatory.

Peptic Ulcer Disease

May occurin stomach or duodenum.

Ulcer development is related to gastritiscaused by Helicobacter pylori.

Secondary ulcers usually occur in stomachand may be due to septicemia, burns, head injury, or NSAIDs.

Abdominal pain typically occurs inepigastric area and can awaken individual from sleep.

In many cases, food or antacids relievepain.

Vomiting and GI bleeding (heme-positivestools, hematemesis, melena) also may occur.

Physical exam can be normal or revealepigastric tenderness.

Method of choice to identify ulceris endoscopy.

Biliary Tract Disease

Acute Cholecystitis

Usuallyrelated to presence of gallstones.

Clinical findings include right upperquadrant pain, vomiting, and low-grade fever. Enlarged gallbladdermay be palpable in right upper quadrant.

Abdominal U/S usually showsgallstones and thickened gallbladder wall.

Cholescintigraphy may be performedif individual is obese or has gas-filled loops of bowel.

Biliary Colic

Resultsfrom acute obstruction of cystic or common bile duct, usually by stone.

Pain is in right upper quadrant orepigastric region.

Associated symptoms often include nausea,vomiting, and jaundice.

Plain abdominal radiograph may showstones in some cases; otherwise, abdominal U/S is usuallydiagnostic.

Pancreatitis

Common causesinclude viral infection, blunt trauma, cystic fibrosis, and idiopathic etiologies.

Abdominal pain is usually epigastricand can range from mild to severe. Eating usually aggravates thepain.

Other clinical findings include fever,anorexia, nausea, and vomiting. Epigastric tenderness may be foundon exam. Serum amylase and lipase concentrations are usually increased.

Abdominal U/S and CT are usefulin demonstrating any abnormalities of pancreas.

Obstructive Uropathy

Any typeof obstructive uropathy may produce abdominal pain.

Most common type is ureteropelvic junctionobstruction, which may present with abdominal pain or recurringattacks of flank pain along with nausea and vomiting.

Various tests may be used to evaluateurinary tract obstruction including renal U/S, voiding cystourethrography,intravenous urography, and diuretic renography.

Urolithiasis

Characterizedby acute flank pain and hematuria.

At time of presentation, excretoryurography is useful for diagnosis of radiolucent stones and demonstrationof level of obstruction.

See Chap.28, Hematuria.

Intraabdominal Abscess

May occurwith localization of inflammatory process within abdominal cavity.

Common causes in pediatric populationare appendiceal abscesses.

Tender mass may be palpable on rectalexam with pelvic abscess. Leakage of abscess usually produces seriousillness with associated gram-negative septicemia.

Abdominal U/S or CT is usuallydiagnostic.

Primary Bacterial Peritonitis

May be associatedwith infection of preexisting ascites, which may be associated with nephroticsyndrome or chronic liver disease.

May occur spontaneously without anyprior underlying disease process.

S. pneumoniae, S. pyogenes, and gram-negativeenteric bacteria (e.g., E. coli) are common pathogens.

Usual clinical findings are fever,abdominal pain, and tenderness, especially with movement (coughing,jumping up and down). Vomiting and abdominal distension also mayoccur.

Paracentesis with Gram stain and cultureof fluid may reveal pathogen.

Other

For inflammatorybowel disease, see Chap. 14,Diarrhea.

For hepatitis, see Chap. 36, Jaundice.

Adolescent Girls

Primary Dysmenorrhea

Common problemin adolescence.

Crampy lower abdominal pain usuallybegins 1–3 yrs after onset of menarche.

Occurs with menses or 1–2days before menses and may last a few hours or several days. Nausea,vomiting, headache, lower backache, thigh pain, nervousness, anddizziness also may occur.

Usually diagnosis of exclusion.

Mittelschmerz

Definedas lower abdominal pain that occurs at menstrual mid-cycle and lastsminutes, several hours, or (rarely) 2–3 days.

Pain may be due to spillage of fluidfrom follicular cyst during ovulation, which irritates peritoneum.

Timing of pain provides most importantdiagnostic clue.

Pelvic Inflammatory Disease

N. gonorrhoeaeand C. trachomatis are most common pathogens.

Clinical manifestations include vaginaldischarge, lower abdominal pain, cervical motion tenderness, adnexaltenderness, and fever. Occasionally, mass (abscess) may be palpablein adnexa or cul-de-sac.

Positive cervical culture is diagnostic.Laparoscopy may be necessary to confirm chronic disease.

Ovarian Disorders

Bleedinginto ovarian cyst or rupture of cyst may cause acute lower quadrantpain and tenderness.

Pain usually disappears within a dayafter rupture of physiologic cyst, whereas pain, nausea, vomiting,and fever may persist with other cysts.

Abdominal U/S may be diagnostic;otherwise, diagnosis may be confirmed by laparoscopy or at timeof surgery.

Torsion of ovarian cyst or fallopiantube (less common) may produce unilateral lower abdominal pain andpalpable mass.

In older children and adolescents,torsion is more likely with ovarian tumor. Other findings includenausea, vomiting, and fever.

Abdominal U/S usually demonstratescyst or tumor.

Endometriosis

Definedas presence of endometrial glands and stroma outside normal locationof uterine lining.

Usual presenting feature is pelvicpain, which may be cyclic or acyclic.

Pelvic exam in adolescents usuallyreveals mild-to-moderate tenderness rather than nodules or massesoften found in adult women.

If trial of NSAIDs followed by cyclicoral contraceptives fails to relieve pain, laparoscopy with biopsyshould be performed to confirm diagnosis.

Genital Malformations with Obstruction

Uterineand vaginal malformations that cause obstruction of genital tractmay produce pelvic pain, which is often chronic.

Lesions include imperforate hymen,transverse vaginal septum, vaginal or cervical atresia, and noncommunicatinguterine horn.

Pelvic U/S and MRI are usefulin defining anatomy of these lesions.

Complications of Pregnancy

Crampy abdominalpain and mild uterine bleeding are common findings with threatenedabortion. History usually includes ≥1 missed menstrual cycles.Internal os is closed, and no tissue has been expelled.

With incomplete abortion, uterine bleeding,painful uterine contractions, and passage of tissue fragments areusual findings. Presence of fever and pelvic pain during any stageof spontaneous or induced abortion suggests a septic abortion.

Any female with delayed menstrual period,lower abdominal pain, and abnormal vaginal bleeding should be suspectedof having ectopic pregnancy. There may be no history of missed menstrual periodor abnormal bleeding. Results of hCG urine pregnancy test are usuallypositive.

Pelvic U/S may be helpfulin demonstrating presence of ectopic pregnancy.

Positive culdocentesis with nonclottingblood also suggests ectopic pregnancy.

Laparoscopy or laparotomy confirmsdiagnosis.

Diagnostic Approach: Acute Abdominal Pain

Completehistory and reliable physical exam are far more valuable than anylab test or radiograph in diagnosis.

Ability of physician to make diagnosislargely depends on consideration of all possibilities, knowledgeof how they present, and planned orderly approach.

Age, type of onset, character and locationof pain, and associated findings are useful in diagnosis.

Abdominal pain of sudden onset is mostlikely to occur with intussusception, perforation of viscus, ortorsion of fallopian tube or ovary. Pain of gradual onset usuallyoccurs with appendicitis, pancreatitis, and cholecystitis. Severeintermittent pain may occur with gastrointestinal, genitourinary,or biliary tract obstruction.

Pain of peritonitis is diffuse, constant,and exacerbated by movement.

More recurrent or chronic pain usuallyoccurs with constipation, sickle cell pain episodes, and inflammatorybowel disease.

Lesions of stomach, duodenum, pancreas,and biliary tract commonly cause epigastric pain. Small bowel andproximal colon lesions usually produce umbilical pain. Distal colonlesions may cause hypogastric pain, whereas rectal lesions may producesacral pain.

Irritation of diaphragm may cause shoulderpain, and gallbladder disease may produce pain at right scapula.

Lesions involving ureter or femalegenital tract may produce lower abdominal and pelvic pain.

Most important diagnostic goal is todistinguish abdominal pain that may be life threatening.

2 clinicalcircumstances represent potentially serious disease and requireimmediate investigation: (a) abdominal pain associated with biliousvomiting, persistent vomiting, or abdominal distension, and (b)abdominal pain associated with either localized or diffuse reboundtenderness. Very few clinical problems require such urgent operativeintervention that orderly approach needs to be abandoned. Only exceptionis massive exsanguinating hemorrhage.

Children in whom the diagnosis is uncertainshould be admitted to hospital and observed.

Period of active observation is extremeimportance and is safe.

Most causes can be diagnosed at thebedside by careful and often repeated clinical observations.

Initial lab tests are CBC with differential,UA, urine culture, analysis of stool for blood, ESR, chest and abdominalradiography, and abdominal U/S.

Principal Causes of Chronic or Recurrent Abdominal Pain

Although chronic or recurrent abdominal painis common in pediatric practice, most children have functional abdominalpain and no evidence of organic disease. Besides psychologic (functional)disorders, other causes of chronic or recurrent abdominal pain are

Constipation

Sickle cell pain episodes

Lactose intolerance

Peptic ulcer disease

IBD

Hydronephrosis

Urinary tract infection

Ovarian cyst

Irritable bowel syndrome

Appendiceal colic

Neoplasm

Diagnostic Approach: Chronic or Recurrent Abdominal Pain

Apley (1975)defined recurrent abdominal pain as ≥3 episodes of pain in 3-mo period,severe enough to interrupt normal activity. His studies revealedthat peak incidence in girls was just before puberty and in malesat lower school ages. >90% of children had noevidence of organic disease; emotional disturbance was evident in >50% ofchildren. 4 common features were characteristic:

Family modelfor pain

History of separation, impending divorce,death, or other perceived or threatened losses

Some psychologic gain for the child

Compulsive high-strung child who frequentlyworried in association with overprotective, excessively anxiousfamily preoccupied with child's complaints.

In many children, psychologic basisexists for pain. Typical psychologic problems include feelings ofanxiety and guilt. Parental discord, physical or psychologic illnessof parent, overwhelming financial problems, and learning problemsin school contribute to these feelings, which may manifest themselvesas abdominal pain. Pain is real, whatever the cause, and physiciansmust convey to families that they understand the problems it iscausing and that they plan to explore the problem thoroughly. Bothpsychologic and organic factors should be considered together ratherthan sequentially.

Thorough history and physical examare necessary. Description of the pain and its severity may notbe reliable because more dramatic and emotional children and parentsoften exaggerate the symptoms. Organic causes are more likely ifthe pain is further away from umbilicus and is sharply localized. Presenceof persistent or recurrent fever, vomiting, weight loss, digitalclubbing, perianal disease, abdominal mass, anemia, and increasedESR point toward organic cause. With rare exceptions, organic disease canbe excluded by careful history, complete and thorough physical exam,and minimum of lab investigations, which include CBC with differential,UA, urine culture, stool exam for blood, ESR, and abdominal U/S.

References

1. Altschuler SM, Liacouras CA, eds. Clinicalpediatric gastroenterology. Philadelphia: Churchill Livingstone,1998.
2. Apley J. The child with abdominal pains, 2nd ed. Oxford,U.K.: Blackwell Scientific, 1975.
3. Behrman RE, et al., eds. Nelson textbook of pediatrics,16th ed. Philadelphia: WB Saunders, 2000.
4. Braden B, et al. New immunoassay in stool providesan accurate noninvasive diagnostic method for Helicobacter pyloriscreening in children. Pediatrics 2000;106:115–117.
5. Cassidy JT, Petty RE. Textbook of pediatric rheumatology,4th ed. New York: Churchill Livingstone, 2001.
6. Emans SJH, et al., eds. Pediatric and adolescent gynecology,4th ed. Philadelphia: Lippincott-Raven, 1998.
7. Gartner JC Jr. Recurrent abdominal pain. In: GartnerJC Jr, Zitelli BJ, eds. Common & chronic symptoms in pediatrics.St. Louis: Mosby-Year Book, 1997:365–380.
8. Goldstein DP. Acute and chronic pelvic pain. PediatrClin North Am 1989;36:573–599.
9. Long SS, et al., eds. Principles and practice of pediatricinfectious diseases. New York: Churchill Livingstone, 1997.
10. McAnarney ER, et al., eds. Textbook of adolescent medicine.Philadelphia: WB Saunders, 1992.
11. Ni Y-H, et al. Accurate diagnosis of Helicobacter pyloriinfection by stool antigen test and 6 other currently availabletests in children. J Pediatr 2000;136:823–827.
12. Rowe MI, et al., eds. Essentials of pediatric surgery.St. Louis: Mosby-Year Book, 1995.
13. Ruddy RM. Pain–Abdomen. In: Fleisher GR, LudwigS, eds. Textbook of pediatric emergency medicine, 4th ed. Philadelphia:Lippincott Williams & Wilkins, 2000:421–428.
14. Rudolph, AM, ed. Rudolph's pediatrics, 20thed. Stamford, CT: Appleton & Lange, 1996.
15. Stevenson RJ. Chronic right-lower-quadrant abdominalpain: is there a role for elective appendectomy? J Pediatr Surg1999;34:950–954.
16. Stevenson RJ, Ziegler MM. Abdominal pain unrelatedto trauma. Pediatr Rev 1993;14:302–311.
17. Walker WA, et al., eds. Pediatric gastrointestinaldisease, 3rd ed. Hamilton, Ontario, Canada: BC Decker, 2000.

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Book Source Details

• Book Title: The Diagnostic Approach to Symptoms and Signs in Pediatrics
• Author(s): Paul S. Bellet
• Year of Publication: 2006
• Copyright Details: The Diagnostic Approach to Symptoms and Signs in Pediatrics, Copyright © 2006 Lippincott Williams & Wilkins.

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