ABDOMINAL PAIN IN CHILDREN

Aswitha Boediarso

Child Health Department

Faculty of Medicine
University of Indonesia, Jakarta

Abdominal pain :

Common symptom

Lesion: - intra abdomen

- extra abdomen

For early diagnosis: - careful anamnesis

- physical examination
- further investigation

Surgical case or not?

Source of abdominal pain :

Viscera abdomen

Others organ outside of abdomen

Lesion of Medulla Spinalis

Metabolic disturbance

Psychosomatic

Pathogenesis
1.

Vascular disorders

2.

(emboli / thrombosis, rupture, occlusion

caused by torsion or tension)

Inflammation

Pain if the inflammation process are in

peritoneum parietalis somatic inervation
Local pain or general pain.
Type of pain : stabile, increase with
movement of inflammatory peritoneum

3.

Passage disorders/obstruction of
luminal organ in peritoneal or
retroperitoneal cavity

4.

Partial obstruction or total obstruction

intra lumen pressure pain

Traction, inflammation and stretching

of peritoneum visceralis

Type of pain and source of pain

Fore gut pain in upper abdomen

Mid gut pain in middle abdomen
Hind gut pain in lower abdomen
Muscle spasm colic which difficult to
investigate the localization, not
influenced with cough or abdominal
pressure
Peritoneal irritation pain in the field of
irritation, stable, influenced by cough and
abdominal pressure

Referred pain
Disorders of extra abdominal organ
(i.e. thorax) sensory inervation
(N. Vagus) abdominal pain

Cause of abdominal pain by age groups

(Chamberlain and Recee, 1978)
Infant commonly caused by
obstruction
a. Colic
b. Constipation
c. Volvulus
d. Intussusceptions/invagination
e. Strangulated hernia
f.
Pyloric stenosis
g. Perforation of gastrointestinal tract
h. Appendicitis
i.
Acute hydrops of gallbladder

Older child commonly caused by

infection
a.
b.
c.

d.
e.
f.
g.
h.
i.

Gastroenteritis
Appendicitis
Mesenteric
lymphadenitis
Meckels diverticulum
Ileitis regional
Colitis ulserativa
Diabetic acidosis
Pneumonia
Torsion of ovarian
cord

k.
l.
m.
n.
o.
p.
q.
r.
s.

t.

Pyelonephritis
Colic Ureter
Lead intoxication
Torsion of spermatic cord
Abdominal epilepsy
Sickle cell crisis
Mononucleosis
Porphiria
Cholecystitis and
cholelytiasis
Pancreatitis

Cause of acute abdominal pain by age

groups, that requirring surgical
intervention
(Walker-Smith et al, 1983)
Infant / age < 2 years old
Abdomen :
Perforation of gastric ulcers
Bowel obstruction : - intusussception
- volvulus and malrotation
Appendicitis and enterocolitis necroticans
Extra abdomen :
Inguinal hernia with strangulation and
incarceration

Age > 2 years old

Abdomen:
a.

b.

c.

d.
e.

Obstruction
Bowel obstruction caused by fibrosis, volvulus,
malrotation
Perforation caused by bowel obstruction
Inflammation (appendicitis, primary peritonitis,
peritonitis caused by Meckels diverticle perforation,
perforation of duodenal ulcer, perforation caused by
typhoid fever, Meckels diverticulitis, cholecystitis with
or without gall stone, toxic mega colon with
perforation)
Trauma (rupture of spleen, urinary bladder, another
visceral organs, hematoma sub serosa)
Bleeding (bleeding intra ovarian cyst)
In tropic area (perforation associated with ascariasis,
strongiloidiasis, jejunitis necrotican in New Guinea,

Extra abdomen:
a. Torsion of testis
b. Inguinal hernia with strangulation and
incarceration

Cause of non surgical abdominal pain

(Walker and Smith, 1983)
Infant / age < 2 years old

Abdomen :
- Intestinal infection

Extra abdomen :
- Pneumonia
- Urinary tract infection

Infant / age > 2 years old

Abdomen :
a. Intestinal
- Infection (Salmonella, Shigella,
Campylobacter,
Yersinia enterocolitica)
- Food intoxication (Toxin of Staphylococcus,
etc)
- Purpura Henoch Schonlein (purpura
anaphylactoid)
- Crohns disease
- Colitis ulcerative
- Colitis amoeba
- Fecal impaction
- Sickle cell anemia
- Ileus meconeum

b. Liver and billiary

tree
- Hepatitis
- Cholelytiasis
c. Pancreas
- Pancreatitis
d. Kidney
- Urinary tract infection
- Stone
- Nephritis

e. Metabolic
- Phorphiria
- Hiperlipidemia
- Diabetic keto acidosis
- Familial Mediterranean
fever
f. Gynecologic
- Salphyngitis

Cause of abdominal pain in

Indonesia
Neonatal
-3
3 months 2 years
months
- Obstipation
- Cows milk
- Gastroenteritis
allergy
- Bowel duplication
- Pyloric
- Maldigestion
hypertrophy
- Gastric mucosal
- Torsion of testis
membrane
- Obstipation/with
- Meckels
anal
fissure
diverticulum
- Bowel
malrotation

2 years 5 years
-

Obstipation
Volvulus
Hepatitis
Urinary tract
infection
- Ascariasis
- Appendicitis
- Pancreatitis

> 5 years
-

Appendicitis
Gastritis
Ovarian torsion
Menstrual cycle
Cholecystitis
Functional
abdominal pain
- Urinary tract
stone
- Varicocele testis

Clinical manifestation by age group

( Halimun 1980 )

0 - 3 months : vomiting
3 months 2 years : vomiting,
pitching/crying, trauma(-)
2 5 years : can tell the pain, localization
not true
> 5 years : can tell the type and
localization of the pain

Diagnostic approach
1.
2.
3.

Anamnesis
Physical examination
Laboratories and further investigation

Anamnesis

Age
Pain (localization , type, time, frequency, other
symptom)
Defecation pattern
Urination pattern
Menstrual cycle
Skeletal muscle disorders
Growth and development disorders
Psychosocial aspect
Trauma
History of family disease

Physical examination
1.
2.

Comprehensive
In abdomen and extra abdomen

Physical examination

Especially in abdomen
- Inspection: Asymmetry,
meteorismus,
bowel
contour
- Palpation: Stretching, pain, tumor
- Percussion: Fluid?
- Auscultation: Bowel sound
- Rectal touchier
Extra abdomen examination
- Pneumonia/Acute respiratory

Laboratory and further investigation

Routine ( urine, blood, feces)

Culture
3 positions of abdominal plan photo
Thorax photo (severe disease)
Barium meal/follow through
Barium enema
Intravenous pyelography
Ultrasound
Endoscopies

Therapy

Require surgical intervention?

Depend on etiology

Surgical abdominal pain

Abdominal pain that require surgical

intervention

Symptoms
- Severe pain, stable, onset 3-4 hours
- Vomiting : green or fecal
- Increase temperature

Surgical abdominal pain

Obstruction
- Invagination, bolus ascariasis,
volvulus/rotation of gaster

Inflammation
- Acute appendicitis, acute cholecystitis,
peritonitis

Blood flow disturbance

- Invagination, malrotation, volvulus,
ovarian cyst torsion

Physical examination

Localized or generalized peritoneal

sign
Sign of obstruction
- Abdominal distention
- Bowel contraction and peristaltic

Tumor mass
Anorectal bleeding

Abdominal emergency

Rigidity of abdominal wall

Tenderness
Rebound tenderness
Defense muscular

Further investigation

Abdominal plain photo

Barium meal/follow through
Barium enema
Intravenous pyelography if
suspected urinary tract disorders
Ultrasound
Endoscopy

Therapy

Exploration/operation
laparotomy

Recurrent abdominal pain

Definition (Apley, 1975)
Recurrent abdominal pain is
intermittent abdominal pain at least 3
times which persists for longer than 3
months and affects normal activity

Prevalence

Age 3 14 years old

mostly 5 10 years old
5% of pediatric outpatient
Organic cause 5-10%

Etiology

Organic 5-15,6% cases

Functional 80%

Cipto Mangunkusumo Hospital

(1988)
17 cases

47% spasmophylia

11.8% gastritis

5.9% colitis

29.4% worms infection

11,8% psychological/psychiatric
disorders

Recurrent abdominal pain concept

1.

Classical (2 groups)
Organic
Functional

2.

Barr
Organic
Disfunctional
Psychogenic

3.

Levine & Rappaport

Life style

Somatic predisposition
Disfunction
Organic disorders

Behavior
Response pattern

Environment and
Inducers
Levine and Rappaport
1984

Etiology of abdominal pain

Gastrointestinal

Drugs

Chronic diarrhea
Peptic ulcers
Bezoar
Duplication
Intermittent volvulus
Meckels diverticulum
Appendicitis
Mesenterical adenitis
Abdominal TBc
Milk protein intolerance
lactose intolerance
Constipatian
Ascariasis

Anti convulsion
Antibiotic
Brochodilator

Urinary tract
Hidronephrosis
Pyelonephritis
Stone
Renal neoplasm
Ovarian cyst
Dismenorrhea
Endometriosisi
Testis torsion
Testis neoplasm

Liver, spleen
and pancreas

Cholecyctitis
Cholelithiasis
Pancreatitis
Massive spleenomega

Metabolic
Hypoglycemia
Phorphiria
Lead intoxication
Hyperlipidemia
Angioneurotic edema

Symptoms suggested organic

disorders

Persistent fever

Growth and development disturbance

Weight loss

Anemia

Hematemesis

Melena

Hematochezia

Pain away from midline

Perianal disease

Diagnostic approach
1.

2.

3.

Careful anamnesis, Physical

examination, and further
investigation
High cost examination and commonly
was not positive
Endoscopy greater probability to
find the etiology

Anamnesis

Age
Pain (localization , type, time, frequency, other
symptom)
Defecation pattern
Urination pattern
Menstrual cycle
Skeletal muscle disorders
Growth and development disorders
Psychosocial aspect
Trauma
History of family disease

Laboratory and further investigation

Routine ( urine, blood, feces)

Ureum, creatinine

Culture

3 positions of abdominal plan photo

Thorax photo (severe disease)

Barium meal/follow through

Barium enema

Intravenous pyelography

Ultrasound

Endoscopy

Therapy

Depend on etiology
Sedative and analgesic