CLINICAL REVIEW

Abdominal Pain in Children With Sickle Cell Disease

Melissa M. Rhodes, MD,*w David Gregory Bates, MD,*w Tina Andrews, RN, BSN,*
Laura Adkins, RN, BSN,* Jennifer Thornton, APN,*w and Jolanda M. Denham, MD*w

Abstract: The dierential diagnosis of abdominal pain is broad in

any child, and further complicated in children with sickle cell disease (SCD). Acute causes of abdominal pain may require emergent
surgery, such as for appendicitis or obstruction caused by a bezoar.
Rapid intervention is necessary and life-saving in children with
SCD and acute splenic or hepatic sequestration. The majority of
children with SCD presenting to the physicians oce or emergency
department will have subacute reasons for their abdominal pain,
including but not limited to constipation, urinary tract infection,
peptic ulcer disease, and cholecystitis. Vaso-occlusive pain often
presents in children as abdominal pain, but is a diagnosis of
exclusion. The case of a 10-year-old girl with intermittent
abdominal pain is used as a starting point to review the
pathophysiology, diagnosis, and treatment of the most acute and
common causes of abdominal pain in children with SCD.
Key Words: sickle cell disease, abdominal pain, splenic sequestration, peptic ulcer disease

(J Clin Gastroenterol 2014;48:99105)

CASE REPORT
A 10-year-old African American girl with homozygous sickle
cell anemia [hemoglobin SS disease (Hb SS disease)] experienced
recurrent episodes of abdominal pain. Her rst episode of abdominal
pain was at 7 years of age, described as burning, with the child
pointing to her epigastric area. She was noted to have belching after
meals. A clinical diagnosis of gastritis was made and she was started
on ranitidine with resolution of her symptoms. Three months later,
despite continuing ranitidine, she had generalized abdominal pain,
particularly after meals. An abdominal ultrasound showed cholelithiasis (Fig. 1). Laparoscopic cholecystectomy was performed and
revealed many pigmented gallstones. One year later, the child was
again complaining of frequent abdominal pain that was peri-umbilical. She was referred to Gastroenterology, where she was diagnosed
with chronic constipation, and started on polyethylene glycol. She did
relatively well for the next 18 months, although she had recurrent
episodes of pain that were treated as vaso-occlusive crisis (VOC) with
ibuprofen and hydrocodone-acetaminophen elixir. Her abdominal
pain became more frequent again and her weight gain was poor, so
she was referred back to Gastroenterology. She was screened for
Helicobacter pylori with stool antigen testing and started on a (PPI)
for suspected peptic ulcer disease (PUD).
One month later, the child was admitted to the hospital for
acute chest syndrome (ACS). As she recovered from ACS, she
began to vomit after every meal. She was noted to have signicant
abdominal distention before vomiting. An upper gastrointestinal
(GI) series demonstrated a markedly enlarged stomach with good
peristalsis, but no emptying of the stomach, consistent with gastric
outlet obstruction (Fig. 2). Upper endoscopy revealed an enlarged
but otherwise normal-appearing stomach with severe pyloric
From the *Nationwide Childrens Hospital; and wDepartment of
Pediatrics, The Ohio State University, Columbus, OH.
The authors declare that they have nothing to disclose.
Reprints: Melissa M. Rhodes, MD, Hematology/Oncology/BMT,
Nationwide Childrens Hospital, 700 Childrens Drive, Columbus,
OH 43235 (e-mail: melissa.rhodes@nationwidechildrens.org).
Copyright r 2013 by Lippincott Williams & Wilkins

J Clin Gastroenterol

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stenosis. Biopsies were unremarkable, without eosinophilic inltration, and immunohistochemical staining for H. pylori was negative. The scope was not able to pass through the pylorus. Computed tomography (CT) scan was reassuring that there was no
extrinsic mass compressing the gastric outlet (Fig. 3). The child was
maintained on total parenteral nutrition and naso-jejunal tube
feedings while she underwent serial balloon dilations of the pylorus
over 2 months (Fig. 4). When a small scope was able to pass
through the pylorus, inammation was visible and thought to be
reactive from healing ulceration. No active ulcer was seen, but the
amount of inammation made resolution with balloon dilation
alone unlikely. She required denitive treatment with surgical
pyloromyotomy, at which time healing peptic ulceration of the
proximal duodenum was noted, and thought to be secondary to
nonsteroidal anti-inammatory drug (NSAID) use. Since surgery,
the child has done well, with no further abdominal pain, steady
weight gain, and improved linear growth.

DIFFERENTIAL DIAGNOSIS OF ABDOMINAL PAIN

IN A CHILD WITH SICKLE CELL DISEASE (SCD)
Abdominal pain can be dicult to gure out in any
child, and sickle cell disease (SCD) adds to the list of possible causes (Table 1). The most urgent cause particular to
SCD that must be evaluated is acute splenic sequestration,
the second leading cause of death in children under 10 years
of age in this population.1 Like other children, those with
SCD can also have appendicitis or other causes of an acute
surgical abdomen. Rarely, bezoars can lead to life-threatening abdominal symptoms. Less emergent, but particular
to children with SCD, are cholelithiasis, hepatic sequestration, renal infarcts, and VOC. Children with SCD have a
higher incidence of urinary tract infection (UTI) and pyelonephritis compared with other children, and are also at risk
for constipation, PUD, and vaso-occlusive abdominal pain.
This article will review pathophysiology, diagnosis, and
treatment of the most urgent and common causes of
abdominal pain in children with SCD: splenic sequestration, hepatic sequestration, bezoar, cholelithiasis, renal
infarction, UTI/pyelonephritis, constipation, PUD, and
vaso-occlusive abdominal pain.

SPLENIC SEQUESTRATION
Splenic sequestration is dened as a decrease in
hemoglobin Z2 g/dL below the patients baseline with an
associated acute increase in spleen size and evidence of
increased erythropoiesis as measured by an elevated reticulocyte count.2,3 Thrombocytopenia may also be present
but is not necessary to make the diagnosis. Splenic
sequestration is caused by intrasplenic trapping of red
blood cells (RBCs), which can result in hypovolemic shock
within a matter of hours due to the majority of the patients
blood volume being trapped in the spleen and not available
in systemic circulation.
Splenic sequestration has been described in all sickle
genotypes but is most commonly reported in individuals with
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FIGURE 1. Cholelithiasis. A longitudinal sonographic view of the

gallbladder demonstrates numerous echogenic foci (arrows)
layering dependently within the gallbladder lumen.

Hb SS disease, among whom it aects 12.6% of children.4

The rst episode of splenic sequestration typically occurs
between 6 months and 6 years of age and is rare past 8 years
of age because of infarction of splenic tissue. Individuals with
Hb SC disease and sickle b-thalassemia maintain a portion of
splenic function past the early school age years. Therefore,
splenic sequestration may be seen in these individuals during

FIGURE 3. Gastric outlet obstruction. A coronal reconstructed

view of the abdomen from an abdominal computed tomography
scan shows a markedly distended fluid-filled stomach occupying
most of the upper abdomen. There is no gastric wall thickening
or space occupying mass at the level of the gastric outlet (arrow).

the older school age and adolescent years and even into
adulthood.5 The rst episode of splenic sequestration is often
associated with a viral or bacterial infection.4 Common
symptoms of splenic sequestration include: abdominal pain,
abdominal fullness, pallor, and lethargy. Physical examination reveals splenomegaly, pallor, tachycardia, and possibly
signs of hypovolemia, which are ominous when present.
Acute transfusion with packed RBCs (PRBCs) should be
performed immediately to stop progression of sequestration
and restore blood volume. Transfusion is usually started with
5 mL/kg PRBCs because this can lead to autotransfusion of
trapped RBCs out of the spleen and back into the circulation,
and a >2 g/dL increase in hemoglobin can be seen.
Approximately 50% to 67% of children who have had 1
episode of splenic sequestration will have subsequent episodes.4 Recurrence of splenic sequestration has been documented in individuals who have been treated conservatively
with observation, as well as those who have been treated
more aggressively with transfusion therapy, once transfusions
are stopped.3 Splenectomy may be necessary to prevent
recurrent and/or life-threatening episodes of splenic sequestration, but increases the risk of sepsis from encapsulated
organisms. Chronic transfusion of 10 to 15 mL/kg PRBCs
monthly is often used in children less than 2 years of age to
prevent recurrence of splenic sequestration until the child can
be immunized adequately against encapsulated organisms.
FIGURE 2. Gastric outlet obstruction. A frontal radiograph of the
abdomen obtained during upper gastrointestinal series shows a
markedly enlarged barium-filled stomach. Despite active peristalsis, no contrast was observed to pass through the region of
the pyloric channel adjacent to the level of the cholecystectomy
surgical clips (arrow).

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HEPATIC SEQUESTRATION
Young adults with SCD have hepatic involvement in
10% of admissions for pain,6 which usually presents with
right upper quadrant pain, tender hepatomegaly, fever,
elevated white blood cells, and mild elevations in
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Abdominal Pain in Children With Sickle Cell Disease

FIGURE 4. Pyloric channel dilation. Two views of the abdomen obtained during fluoroscopic balloon dilation of the pyloric channel.
A, An endoscope is present within the stomach (thick arrow). A balloon catheter is placed at the site of stricture and is partially inflated.
A waist in the balloon identifies the stricture location (white arrow). B, Progressive inflation of the balloon shows disappearance of the
waist indicating successful dilation of the stricture (white arrow).

transaminases and bilirubin. Hepatic sequestration can

occur, and is dierentiated from vaso-occlusive pain by a
signicant drop in hemoglobin (> 2 g/dL from baseline)
with an appropriate increase in reticulocytosis. Sickled
RBCs become trapped in hepatic sinusoids and cause a
process similar to splenic sequestration, with the potential
for severe anemia and hypovolemic shock. This typically
occurs in teenagers or adults rather than young children,
but has been reported in children as young as 5 years of
age.7 A rare but potentially fatal complication of SCD is
intrahepatic cholestasis, the most severe form of hepatic
sequestration. This entity is accompanied by extremely high
bilirubin levels, with over half of the bilirubin conjugated,
and the additional problem of coagulopathy. Patients often
die of fulminant hepatic failure. Treatment with emergent
exchange transfusion and transfusion of plasma may
decrease the high fatality rate of this complication.8

BEZOAR
Children with SCD have an increased incidence of pica,
the mouthing or eating of nonfood items.9 The incidence of
pica decreases with age, but it is as high as 50% in preschoolaged children with SCD.9 Although rare, gastric or intestinal
bezoars resulting from ingestion of hair or foam can be lifethreatening.1012 While taking the history of a child with SCD
and abdominal pain, one must remember to ask about eating
nonfood items. If the response is positive, consider imaging of
the abdomen. Although CT with oral contrast is the most
sensitive imaging technique, plain lms and ultrasound can
also be diagnostic.10 If present, gastric or intestinal bezoars
may require emergency surgery, but may be ameliorated by
endoscopy.
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CHOLELITHIASIS
A hallmark of SCD is hemolytic anemia, which is
more severe in patients with Hb SS/Hb S b0 thalassemia
than in those with Hb SC disease or Hb S b + thalassemia.
Hemolyzed RBCs leak bilirubin, which remains unconjugated, and can form pigmented gallstones. As part of
normal physiology, the gallbladder contracts after a fatty
meal. If gallstones are present, the stones are forced up
against the cystic duct, leading to pressure and to pain. The
pain typically localizes to the right upper quadrant, or it
can radiate to the right shoulder blade or to the chest.
Patients often report the pain as dull but constant for 1 to 2
hours at a time. Although typical symptoms present 1 to 2
hours after a fatty meal, patients do not always report such
an association. Patients with SCD reporting episodic
abdominal pain should be investigated for cholelithiasis,
which is present in 50% by 18 years of age.1315 Abdominal
ultrasound can usually diagnose cholelithiasis in patients
with SCD, with nuclear hepatobiliary scans rarely being
necessary. Children with symptomatic cholelithiasis should
have scheduled cholecystectomy, both to prevent further
pain episodes and to eliminate the risk for acute cholecystitis or associated pancreatitis. Scheduled cholecystectomy is typically laparoscopic rather than open,
which has been shown to reduce the length of hospitalization without increasing intraoperative risks.16 Therapeutic management of children with SCD incidentally
found to have cholelithiasis by ultrasound for another
reason, but who are asymptomatic, remains unclear. Some
advocate cholecystectomy before complications,17 but others would wait, as complications from asymptomatic
cholelithiasis are rare.18 Common bile duct obstruction can
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TABLE 1. Causes of Abdominal Pain in Children With Sickle Cell

Disease
Common, Emergent
Splenic sequestration
Hepatic sequestration
Cholecystitis
Pyelonephritis
Renal infarction
Common, nonemergent
Constipation
Vaso-occlusive pain
Gastroenteritis
Urinary tract infection
Cholelithiasis/choledocholithiasis
Peptic ulcer disease
Functional abdominal pain
Uncommon, emergent
Appendicitis
Gut malrotation/intussusceptions
Bezoar
Pancreatitis
Pelvic inammatory disease
Bowel necrosis
Obstruction
Incarcerated hernia
Tumor (renal medullary carcinoma)
Uncommon, nonemergent
Inammatory bowel disease
Lactose intolerance
Nephrolithiasis
Celiac disease

occur at the time of initial presentation, or years after

cholecystectomy, and has a higher incidence in patients
with SCD than the general population (30% to 50% vs.
10% to 15%).19 Clinicians should have a low threshold for
performing endoscopic retrograde cholangiopancreatography in children with symptoms of biliary disease, even
after cholecystectomy.19,20

RENAL INFARCTION
The pathophysiology of renal injury is mostly from the
process of chronic sickling of the erythrocytes in the renal
microvasculature. The arterial side of the renal microvasculature normally has low oxygen tension, hypertonicity, and a low pH. In the renal medulla, these factors
promote further formation of sickled hemoglobin polymers
in the RBCs. This event results in an increase of blood
viscosity, functional venous engorgement, and interstitial
edema, predisposing the renal microcirculation to ischemia
and infarction. Obliteration of the medullary vasculature
initially results in segmental scarring and interstitial brosis, and progresses to infarction and necrosis, such as
papillary necrosis. It is thought that, because of the
destruction in the medulla, renal cortical blood ow and
glomerular ltration rate are increased by the secretion of
vasodilator prostaglandins.21 The most common glomerular changes, namely glomerulomegaly with hypercellularity, and focal and segmental glomerulosclerosis,
occur in more than half of individuals with SCD but are not
associated with pain.22 Papillary necrosis often presents as
painful gross hematuria, whereas the glomerular lesion
presents with various degrees of painless hematuria and
proteinuria.
Hematuria is a common problem in SCD and can
develop at any age. It is thought to be caused by infarction

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of the microvessels of the medulla and renal papillae.

Patients with sickle cell trait are prone to episodes of
painless gross hematuria as well. Treatment consists of bed
rest and hydration, but transfusions may be necessary for
excessive blood loss. Other causes of hematuria need to
be excluded, such as nephrolithiasis, coagulopathy, and
tumors involving the bladder, ureter, or kidneys. Renal
medullary carcinoma is a highly aggressive kidney tumor
predominantly aecting patients with sickle cell trait or Hb
SC disease, occurring both in children and adults. Patients
usually present with ank pain and hematuria, which can
be a common complex in SCD, posing a delay in diagnosis
of this highly malignant tumor.23 Ultrasound of the kidneys
and bladder can identify the location of bleeding either
from a stone or a tumor. Increased echogenicity of the renal
pyramids or calcyceal clubbing by urography may suggest
sickle cell nephropathy.21

UTI/PYELONEPHRITIS
Children with SCD are more susceptible to UTI and
pyelonephritis. Splenic infarcts lead to a reduced humoral
immune response, which predisposes patients with SCD to
encapsulated bacterial infections, including UTI.24 As in
children without SCD, there is a greater prevalence for UTI
among girls and predominance in gram-negative organisms.22 There is also an association between symptomatic
UTI and sickle cell pain episodes, bacteremia, and pneumonia.25 Consideration for UTI should be taken when a
child with SCD presents with abdominal pain. Diagnosis is
completed by obtaining a clean catch urinalysis with a
reex culture, which is a relatively simple and inexpensive
test, followed by treatment with the appropriate antibiotic.

CONSTIPATION
Constipation is one of the most common gastrointestinal problems in children of all ages, but reports of the
exact prevalence are highly variable. A systematic review in
2006 found a prevalence ranging from 0.7% to 29.6%, with
a median of 8.9% of all children.26 Constipation is the most
common cause of abdominal pain in children presenting
both to the emergency department and to primary care.2729
The pathophysiology of constipation is complex, with
genetic predisposition, low ber intake, poor uid intake,
sedentary lifestyle, and a history of painful stooling leading
to a cycle of stool retention all playing a part in the problem.26,30 Diagnosis of constipation is made mostly by
history taking, using Rome III criteria from 2006.31
Constipation is best treated with education and judicious
use of polyethylene glycol for initial bowel cleanout, followed by a maintenance regimen of polyethylene glycol
and/or other osmotic or stimulant laxatives for 6 to 24
months.30,32 Of particular importance to children with SCD
is to remember that opioid medications all have in common
the side eect of constipation. Children who do not normally suer from constipation should be placed on stool
softeners at a minimum, and potentially on osmotic or
stimulant laxatives, with the use of opioids.33

PUD
An adult population-based study estimated the prevalence of PUD at 5% to 15%.34 On the basis of 353 adult
SCD patients, a Jamaican study estimated the prevalence of
duodenal ulcer (DU) at 7.7%.35 Despite the lack of large
population-based pediatric studies, rates of PUD in
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childhood appear to be low. Large pediatric centers anecdotally report an incidence of 5 to 7 children with gastric or
DUs per 2500 hospital admissions each year.36 A few case
reports of PUD in pediatric SCD patients exist,37,38 but
population-based prevalence studies of PUD in pediatric
SCD patients are absent. In a 2009 adult study, the
majority of 154 Hb SS and Hb SC patients localized
abdominal pain to the epigastrium (36% and 50%,
respectively).39 In the same study, PUD/gastritis occurred
more frequently than abdominal VOC, hepatopathy,
enteritis, and cholelithiasis among all patients.39
The pathogenesis of peptic ulcers in the general population includes acid hypersecretion, decreased mucosal
resistance, or a combination of the 2. Rao et al37 and Julka
et al40 proposed sickling-induced arterial occlusion resulting in a primary mucosal infarctive lesion, ultimately
causing duodenal ulceration (DU). This hypothesis is supported by work from Serjeant et al,35 who reported that
DU was more common in individuals with elevated irreversible sickle cell counts, and Lee et al,41 who reported that
total and fetal hemoglobin levels were signicantly lower
in SCD-DU patients. Rao et al37 suggest a common
pathophysiology of arterial occlusion with compromised
blood supply in both leg and DU formation, and that
suppression of sickle hemoglobin production with RBC
transfusions may promote DU healing, similar to the
healing observed with leg ulcers.42 Owing to the minimal
role of acid hypersecretion and the substantial eects of
sickling-induced mucosal damage in the creation of DU in
SCD patients, acid blockade should be considered adjunctive therapy. Denitive endoscopic and surgical interventions should be considered early to minimize the risk of
morbidity, including intestinal perforation, GI bleeds, and
gastric outlet obstruction.
Contrast radiography of the upper GI tract, also referred to as a barium meal or an upper GI series, can often
demonstrate peptic ulcer, as well as ulcer-related gastric
outlet obstruction (as in this case patient).43 Air contrast, also
known as double-contrast studies, more accurately identies
DUs compared with single-contrast studies.44 The accuracy
of upper GI series, however, may be limited by poor visualization of shallow or small (< 0.5 cm) ulcers, very large ulcers,
and the performing radiologists lack of experience or
expertise.45 Capsule endoscopy can detect ulcers when used in
evaluation of obscure GI bleeding.46,47 Although it is more
invasive and may require anesthesia, routine upper endoscopy more accurately diagnoses ulcers compared with singlecontrast and double-contrast studies.48 In addition, upper
endoscopy is preferable over other techniques as biopsies can
be obtained to make denitive diagnoses and to evaluate for
malignancy. Endoscopy allows for better assessment of
impending medical emergencies (eg, deep ulcers with adherent clots, active bleeding) and performing of therapeutic
maneuvers, if warranted.49 Stool occult blood may be helpful
in assessing bleeding from a peptic ulcer. Elevated serum
gastrin and subnormal gastric pH levels suggest gastrinomas
and Zollinger-Ellison syndrome.
H. pylori are gram-negative bacteria that, owing to their
ability to produce urease, can withstand the acidic environment of gastric mucosa.50 H. pylori infection is a common
cause of DUs and gastritis in both adults and children.51
H. pylori infection does not appear to be more common in
SCD patients as supported by a recent study of 72 SCD
patients with recurrent abdominal pain, in which 70% were
H. pylori IgG positive, similar to the rates among the nonr

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Abdominal Pain in Children With Sickle Cell Disease

SCD cohort.52 As H. pylori may require iron for growth, the

authors also propose that iron overload may contribute to
the high prevalence of H. pylori infection among SCD
patients, younger than 5 years of age in particular.52 H. pylori
infection may also increase the risk of NSAID-induced
ulcers.53 In children, stool antigen assays are more sensitive,
whereas serum IgG and polymerase chain reaction from oral
mucosa have higher specicity for H. pylori infection.54 In a
meta-analysis of pediatric studies of H. pylori therapies in
developed nations, 2 to 6 weeks of nitroimidazole and
amoxicillin, 1 to 2 weeks of clarithromycin, amoxicillin, and a
PPI, and 2 weeks of a macrolide, a nitroimidazole, and a PPI
or bismuth, amoxicillin, and metronidazole were the most
ecacious therapeutic regimens.55
There are 2 additional risk factors for PUD particular
to children with SCD about which providers should be
aware. Children with SCD who have received multiple
blood transfusions may be treated with iron chelators.
Deferasirox is an oral iron chelator that has gastric ulcer
listed in its product information as an infrequent adverse
event. Gastric protection is not routinely recommended
with deferasirox, but PUD should be considered in children
who experience abdominal pain with this medication.56
Secondly, like the child described in our case, many children with SCD take frequent NSAIDs as part of their
treatment for vaso-occlusive pain. Gastric protection with
oral NSAIDs is not routinely recommended in children,
although the literature supports high-dose histamine 2
receptor antagonists or PPIs for patients at high risk for
PUD.5759 Further, various NSAIDs have dierent safety
proles related to PUD, with selective Cox-2 inhibitors
being safer than ibuprofen, which is generally safer than
ketorolac or naproxen.60,61 Our program, like many others,
uses ibuprofen alone in most patients, and either ibuprofen
or a selective Cox-2 inhibitor along with a PPI in patients
with known or suspected PUD.

VASO-OCCLUSIVE PAIN
Vaso-occlusive pain in SCD can be obvious when
there is visible swelling, no history of injury or fever, and no
overlying erythema, such as in dactylitis. Although more
often than not, it is a clinical diagnosis based on patient
history of severe pain in a typical location for that patient,
precipitated by change in the weather, dehydration, stress,
overuse, or exposure to cold, and improved with hydration,
rest, and pain medications. It is caused by irreversible
sickling leading to sickled polymers that obstruct blood
ow and prevent oxygenation to tissues.2 Abdominal vasoocclusive pain is dicult to dierentiate from other organic
causes of abdominal pain, including many of those described above, as well as functional abdominal pain of childhood, in which no pathologic mechanism can be found to
explain the pain. Thorough history of the onset, location,
type of pain, exacerbating and relieving factors including
food, defecation, and acid reducers can be helpful. Physical
examination should rule out an acute surgical abdomen,
splenomegaly, hepatomegaly, or mass. Lack of bowel
sounds or metabolic acidosis should be considered signs
concerning for ischemic colitis. The child should have
complete bowel rest and imaging performed with ultrasound or CT scan. Only once other causes have been considered and eectively ruled out, we advocate treating for
vaso-occlusive pain with both an NSAID and opioid
scheduled around the clock for 24 to 48 hours, increasing
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oral hydration, and adding medications for constipation. If

there is any concern for gastritis or NSAID use is prolonged, a high-dose acid blocker should also be used.

RECOMMENDATIONS FOR EVALUATION

Each child with SCD presenting with abdominal pain
obviously requires a careful history taking and physical
examination. While history taking, attention should be given
to eating habits, including whether or not the child eats nonfood items (pica), hydration, and ber content that would raise
suspicion for constipation, and whether or not pain is associated with dairy products. Timing of pain in relation to eating
is helpful in raising or lowering suspicion of cholelithiasis. A
thorough history of bowel habits is essential to determine the
role of constipation in the childs pain, and bathroom hygiene
for possibility of UTI. Blood in the urine or changes in the
appearance or odor of the urine may lead to concerns for
pyelonephritis or renal infarction. Vomiting without diarrhea
raises concern for appendicitis or for obstruction, whereas
vomiting and diarrhea together are more typical of gastroenteritis. Medication used, including dosages and frequency,
may give clues for opioid-induced constipation or risk for
PUD from NSAIDs. If pain is relieved by oral analgesics, this
pain is typical of a childs VOC, and no other red ags are
raised, further VOC management is in order. Of course,
location and characterization of the pain may point to PUD,
appendicitis, splenic sequestration, or hepatic sequestration.
Physical examination should focus on any peritoneal signs that
may indicate an acute surgical abdomen, splenomegaly, hepatomegaly, or mass. Simple lab tests include a CBC and
reticulocyte count (decreased hemoglobin and platelets in
either splenic or hepatic sequestration), transaminases and
bilirubin (very high in hepatic sequestration, hyperbilirubinemia alone in choledocholithiasis), lipase and amylase
if pancreatitis is suspected, and urinalysis for UTI (leukocyte
esterase, nitrates) or renal infarct (RBCs in the urine).
Abdominal ultrasound is helpful for suspected cholelithiasis,
appendicitis, pyelonephritis, or mass.

THE CASE
In returning to our patient, by 10 years of age she
experienced a signicant amount of abdominal pain, from
various pathologic causes described above. She was treated
clinically for gastritis, constipation, and vaso-occlusive
pain, and surgically for symptomatic cholelithiasis. She has
not had any evidence of renal disease, other than hyposthenuria. She has not had splenic or hepatic sequestration
and does not have pica. Before developing gastric outlet
obstruction, she had been treated for pain on and o for
months, with episodic use of ibuprofen. This NSAID use,
along with severe SCD as manifested by ACS and low
baseline hemoglobin, may have contributed to development
of peptic ulceration of her duodenum, complicated by
formation of a stricture, and pyloric outlet obstruction.
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