Abdominal Pain
Marina Catallozzi
Approach to the Patient with Abdominal Pain
I. Definition of the Complaint
Abdominal pain is a common complaint in pediatrics and has a long list of
possible causes, not all of which are gastrointestinal (GI). Abdominal pain is
usually stimulated by one of three pathways: visceral pain, somatic pain, or
referred pain. Visceral pain is caused by a distended viscus, which activates a
local nerve, sending an impulse that travels through autonomic afferent fibers
to the spinal tract and central nervous system. Localization of pain is often
difficult and frustrating, because there are very few afferent nerves traveling
from the viscera, and the nerve fibers overlap. Visceral pain is usually felt
in the epigastric region, the periumbilical region, or the suprapubic area.
Somatic pain, because it is carried by somatic nerves in the parietal
peritoneum, muscle, or skin, is usually well localized and sharp. Referred
pain, defined as abdominal pain perceived at a site remote from the actual
affected viscera, can be sharp and localized or diffuse. There is a great deal
of individual variability with regard to the experience of pain, so that
neuroanatomic, neurophysiologic, pathophysiologic, environmental, and
psychosocial factors all play a part. The frequency of this chief complaint
necessitates categorizing the presentation of abdominal pain as acute, chronic,
or recurrent.
With acute abdominal pain, the patient or a parent is usually able to pinpoint
the onset of the pain to an event or time of day. Although the pain may be mild
initially, it often becomes progressively worse and interferes with sleep and
normal activities. Other than intussusception, acute abdominal pain that
requires surgical intervention does not recur and is not relieved without
intervention. Nausea, vomiting, diarrhea, fever, and anorexia often accompany
acute abdominal pain. Patients often appear acutely ill and attempt to protect
the abdomen from further examination by their positioning. Chronic abdominal
pain is defined as pain that lasts 2 weeks or longer; it usually does not
require surgery. Recurrent abdominal pain has several definitions and is
frequently referred to as a description rather than a diagnosis. Although
formal definitions and guidelines exist, the definition basically includes any
recurrent abdominal pain in a child for which the family seeks medical
attention. Because of the frustration for the family and child, as well as the
extensive differential diagnosis for this problem, a consistent approach is
vital. The approach must include a thorough history (arguably the most
important component), physical examination, laboratory testing, imaging
studies, and empiric interventions.
II. Complaint by Cause and Frequency
Although abdominal pain is a frequent complaint, it is not in itself a
diagnosis, and a thorough evaluation of this symptom is required to determine
the causative pathology. The causes of abdominal pain in childhood vary by age
and can be classified based on whether the abdominal pain is acute, chronic, or
recurrent in nature (Table 7-1). They also can be grouped by etiologic
category: infectious, toxicologic, metabolic, tumor/oncologic, traumatic,
congenital/anatomic, allergic/inflammatory, and functional/other (Table 7-2).
III. Clarifying Questions
Accurate diagnosis in a child with abdominal pain requires a thorough history
and physical examination. There must be consideration of the type and location
of pain in order to create a working differential and approach to the
individual patient with abdominal pain. The following questions may be helpful
in arriving at a diagnosis.
• When did the pain begin, and how long has it lasted?
— The determination of acute, chronic, or recurrent pain is vital in considering
possible causes, in identifying conditions that require surgical intervention
and in determining any other life-threatening causes of abdominal pain that do
not require surgical intervention. Although gastroenteritis and constipation
are considered the most common causes of acute and chronic pain, respectively,
other causes must be ruled out.
Whereas an infant frequently displays pain as a behavior change (e.g., poor oral
intake, irritability, inconsolable crying), older children can verbalize the
character of the pain. For diagnoses such as irritable bowel syndrome, in which
the chronicity of the pain is an important feature of the diagnosis, the
duration of pain is vital information. Additionally, with chronic or recurrent
pain, the timing of the pain is key. For example, pain that awakens a child
from sleep suggests peptic disease, whereas pain that occurs during dinner is
often associated with constipation. Paroxysms of pain, in which the child has
20-minute intervals of being well between periods of inconsolability, is
classically seen with intussusception.
• What is the location of the pain?
— Even if abdominal pain seems localized, a thorough examination must be
performed to rule out other, non-GI causes of the pain. Certain locations
herald specific disease processes. Perhaps the most important of these is the
association of appendicitis with acute pain in the right lower quadrant (even
more specifically, tenderness over McBurney
's point). Although appendicitis is the most common cause for emergency surgery
(apart from trauma) in children, the rate of initial misdiagnosis has been
found to be between 28% and 57%. (Acute appendicitis often does not result in
pain as the first symptom, but other surgical emergencies that are potentially
life-threatening and catastrophic do, including malrotation with volvulus,
intussusception, and ovarian torsion.) The classic pattern associated with
acute appendicitis
—periumbilical visceral pain that travels to the right lower quadrant with
subsequent nausea, vomiting, and anorexia
—is found in only 50% of adults and is far less common in children younger than
12 years of age. For infants, vomiting, pain, diarrhea, fever, irritability,
grunting, and refusal to walk or limp are just a few of the nonlocalizing
symptoms of acute appendicitis that lead to misdiagnosis and high perforation
rates. In children 2 to 5 years of age, the rate of appendicitis is low (less
than 5%) but the more classic signs and symptoms are more common. The incidence
of appendicitis increases in school-aged children and adolescents, and when the
incidence peaks, so do the more common symptoms of vomiting, anorexia, and
right lower quadrant pain.
Right lower quadrant pain can also be associated with Crohn's disease, mesenteric adenitis associated with group A streptococcal
pharyngitis, bacterial enterocolitis (particularly
Yersinia enterocolitica and Campylobacter jejuni), Meckel diverticulitis, and intussusception. Right upper quadrant pain should
prompt investigation of cholecystitis, cholelithiasis, Fitz-Hugh
–Curtis syndrome, and right lower lobe pneumonia. Left upper quadrant pain often
indicates splenomegaly, hemolytic crisis, or splenic trauma. Epigastric pain
may indicate peptic disease (e.g., peptic ulcer disease, esophagitis secondary
to gastroesophageal reflux disease, gastritis), or pancreatitis. Suprapubic
pain can suggest a urinary tract infection (UTI), menstrual disorders, or
pelvic inflammatory disease. Some disorders commonly cause radiation of pain
and should always be investigated: back pain may be observed with pancreatitis
or UTI, and gallstones frequently are associated with shoulder pain.
• Has there been a change in stool pattern, has there been blood in the stool, or
is the pain relieved with defecation?
— Questions regarding stool pattern and consistency are important in both acute
and chronic abdominal pain. In the acute setting, diarrhea early in the history
can point toward an infectious etiology such as viral or bacterial
gastroenteritis. Additionally, rectal examination and examination of the stool
gives important diagnostic information. Whereas bloody mucoid or currant-jelly
stools are seen late in the course of intussusception, hemoccult positivity can
be seen earlier. For more chronic etiologies, such as constipation, irritable
bowel syndrome, and inflammatory bowel disease, these questions can also
clarify the diagnosis.
• Is there associated emesis?
— Although vomiting can occur with abdominal pain of various causes, vomiting in
the absence of abdominal pain often indicates upper intestinal tract disease.
Bilious emesis heralds obstruction.
• Can the examination reveal the cause of the abdominal pain?
— If the diagnosis is unclear and surgical intervention remains a possibility,
reassessment and reexamination by the same clinician is an important part of
the evaluation. This is particularly important with diagnoses such as
appendicitis, for which there is no definitive piece of historical,
examination, or laboratory data that will make the diagnosis.
Certain physical examination findings suggest the diagnosis. These include the
Cullen sign (discoloration of the umbilicus) or Grey Turner sign (discoloration
of the flank) in hemorrhagic pancreatitis, Murphy
's sign (pain with deep palpation of the right upper quadrant) in gallbladder
disease, and Rovsing
's sign (pain in the right lower quadrant with palpation of the contralateral
side) in appendicitis.
• Has there been an ingestion or toxin exposure?
— Ingestion of certain medications or heavy metals (e.g., lead) can lead to
chronic abdominal pain.
• Has there been a preceding illness or recent travel?
— An upper respiratory tract infection frequently precedes intussusception; a
mesenteric lymph node is thought to act as the lead point.
• Is there any significant family history?
— The family history can be key in diseases such as inflammatory bowel disease
and familial Mediterranean fever, as well as genetic disorders such as cystic
fibrosis.
• What is the child's weight and height?
— Failure to thrive indicates a more chronic disease, such as inflammatory bowel
disease.
IV. References
1. Ruddy RM. Pain—Abdomen. In: Fleisher GR, Ludwig S, eds. Textbook of pediatric emergency medicine, 4th ed. Philadelphia: Lippincott Williams & Wilkins, 2000.
2. Kalloo AN. Overview of differential diagnoses of abdominal pain. Gastrointes Endosc 2002:56;255–257.
3. Ashcraft KW. Consultation with the specialist: acute abdominal pain. Pediatr Rev 2000:21;363–367.
4. Lake AM. Chronic abdominal pain in childhood: Diagnosis and management. Am Fam Physician 1999:59;1823–1830.
5. Thiessen PN. Recurrent abdominal pain. Pediatr Rev 2002:23;39–46.
6. Zeiter DK, Hyams JS. Recurrent abdominal pain in children. Pediatr Clin N Am 2002:49;53–71.
7. Brown KA. Abdominal Pain. In: Schwartz MW, ed. The 5-minute pediatric consult. Philadelphia: Lippincott Williams & Wilkins, 2000.
8. D'Agostino J. Common abdominal emergencies in children. Emerg Med Clin North Am 2002:20;139–153.
9. Douglas DA, et al. Irritable bowel syndrome: A technical review for practice
guideline development.
Gastroenterol 1997:112.
10. Okada PJ, Hicks B. Pediatric surgical emergencies: Neonatal surgical
emergencies.
Clin Pediatr Emerg Med 2002:3.
11. Tunnessen WW. Abdominal Pain. In: Tunnessen WW, ed. Signs and symptoms in pediatrics, 3rd ed. Philadelphia: Lippincott Williams & Wilkins, 1999.
The following cases represent less common causes of abdominal pain in childhood.
Pictures
Book Source Details
- Book Title: Pediatric Complaints and Diagnostic Dilemmas
- Author(s): Samir S Shah MD; Stephen Ludwig MD
- Year of Publication: 2003
- Copyright Details: Pediatric Complaints and Diagnostic Dilemmas, Copyright © 2003 Lippincott Williams & Wilkins.
Other Book Chapters Related to Lower abdominal pain
Read excerpts from these other book chapters related to Lower abdominal pain:
Medical Books Excerpts
- FLANK PAIN
- "Algorithmic Diagnosis of Symptoms and Signs" (2003)
- [ read ]
- Dyspepsia
- "Handbook of Signs & Symptoms (Third Edition)" (2006)
- [ read ]
- Flank pain
- "Handbook of Signs & Symptoms (Third Edition)" (2006)
- [ read ]
- Dyspepsia
- "Professional Guide to Signs & Symptoms (Fifth Edition)" (2006)
- [ read ]
- Flank pain
- "Professional Guide to Signs & Symptoms (Fifth Edition)" (2006)
- [ read ]
- Abdominal Pain
- "The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter" (2000)
- [ read ]
- Abdominal pain
- "Alarming Signs and Symptoms: Lippincott Manual of Nursing Practice Series" (2007)
- [ read ]
- Flank pain
- "Alarming Signs and Symptoms: Lippincott Manual of Nursing Practice Series" (2007)
- [ read ]
- Dyspepsia
- "Signs & Symptoms: A 2-in-1 Reference for Nurses" (2007)
- [ read ]
- Flank pain
- "Signs & Symptoms: A 2-in-1 Reference for Nurses" (2007)
- [ read ]
- Abdominal Pain
- "The Diagnostic Approach to Symptoms and Signs in Pediatrics" (2006)
- [ read ]
- Dyspepsia
- "Nursing: Interpreting Signs and Symptoms" (2007)
- [ read ]
Copyright Details: Pediatric Complaints and Diagnostic Dilemmas, Copyright © 2008 Williams & Wilkins.
More About Causes of Lower abdominal pain
» Next page: Abdominal Pain - Case 7-1: 13-Year-Old Boy (Pediatric Complaints and Diagnostic Dilemmas)
Rate This Website
What do you think about the features of this website?
Take our user survey and have your say:
Website User Survey
Medical Tools & Articles:
Next articles:
Tools & Services:
Medical Articles:
Forums & Message Boards
- Ask or answer a question at the Boards:
