Acute Abdominal Pain

Acute abdominal pain i n c h i l d h o o d may range from a m i n o r self limiting

non-specific illness to a life threatening surgical emergency. I t may be the
first attack or i t may occur i n a c h i l d who gives a history o f recurrent
abdominal pain. Age is i m p o r t a n t when treating c h i l d h o o d abdominal
p a i n because the type o f illness, p r e s e n t a t i o n , a n d p a t h o l o g i c a l
conditions differ at various ages. I t is also necessary to differentiate
conditions that require an operation from those that can be managed
medically.

HISTORY
T h e presenting symptoms i n infants are irritability and crying which may
progress to lethargy and even coma as the illness progresses. O t h e r
symptoms which may be present i n c l u d e severe episodic screaming
attacks with drawing up o f legs due to colic or intussusception (Figs. 1.1
and 1.2), vomiting, diarrhoea, b l o o d and mucus i n stools, abdominal
distension and features o f systemic disease such as fever and rashes.
Toddlers (besides presenting with any o f the above symptoms) can
indicate that they have abdominal pain. However, they are unable to
localise the site o f the pain pardy due to their inability to communicate
a n d pardy due to the nature o f the pathological processes i n this age
g r o u p which do not localise the disease process.
In older children, i t is possible to determine the location o f the pain, its
nature, its r e l a t i o n to feeding, its severity and radiation, time and
frequency o f occurrence a n d d u r a t i o n ; the presence or absence o f
associated symptoms such as weight loss, fever, v o m i t i n g , b l o a t i n g ,
diarrhoea, or urinary symptoms; and whether any intermittent illness

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2 A Practical Approach lo Clinical Paediatrics

Fig. 1.2 Barium enema shows tup-shaped filling defect from the head of
int.ussusceptum.
Acute Abdominal Pain 3

(past a b d o m i n a l operations, cystic Fibrosis, haemolytic anaemias) or

recent trauma has occurred.
In adolescent girls a menstrual history should be obtained in order to
diagnose conditions such as ectopic pregnancy and dysmenorrhoea. I n
all cases, i n f o r m a t i o n about bowel habit should be obtained.

EXAMINATION
A general physical examination i n c l u d i n g pulse, respiratory rate, blood
pressure, temperature and hydration will be helpful i n identifying the ill
c h i l d and recognising the many systemic conditions which present with
acute abdominal pain. Examination o f the chest should be carried out
carefully, as p n e u m o n i a a n d asthma may occasionally present as
abdominal pain. Examination o f the scrotum for strangulated hernias
and torsion o f the testis is mandatory.
I n a l l cases, a careful a b d o m i n a l e x a m i n a t i o n is necessary. O l d
operation scars should be noted. Particular attention should be paid to
the recognition o f the presence o f lumps, e.g. sausage^ shaped lumps in
intussusception, "renal lumps" i n kidney disease. A loaded colon is often
found in patients with constipation. Areas o f tenderness should be clearly
i d e n t i f i e d , e.g. tenderness may be localised to the right itiac fossa
(in c h i l d r e n above the age o f 8 years) in appendicitis, salpingitis and
mesenteric lymphadenitis; tenderness i n the flank and suprapubic region
in renal disease; and tenderness i n the right hypochondrium in acute
cholecystitis.

DIAGNOSIS
T h e r e are a n u m b e r o f traps in the diagnosis o f acute abdominal pain.
Patients with chest infections and asthma with or without respiratory
symptoms can present with acute abdominal pain. Children with torsion
of the testis may present with acute pain i n the right iliac fossa besides
the testicular swelling (which the patient may forget to m e n t i o n ) . Pain
may be the p r e s e n t i n g s y m p t o m o f c o n s t i p a t i o n , worms, diabetic
ketoacidosis, lead poisoning (Fig. 1.3), malignant disease, sickle cell
4 A Practical Approach to Clinical Paediatrics

anaemia, p o r p h y r i a a n d m i g r a i n e . Unless a c a r e f u l h i s t o r y a n d
examination are carried out, the diagnosis may be missed.
Infants suspected o f having intussusception will require a b a r i u m o r
air enema w h i c h w i l l c o n f i r m the diagnosis a n d may r e d u c e the
intussusception.
Acute a b d o m i n a l pain due to a p p e n d i c i t i s may be d i f f i c u l t to
distinguish from mesenteric adenitis, as i n both conditions the pain may
be generalised or localised to the right iliac fossa. History o f an acute
viral illness with generalised lymphadenitis may help i n the diagnosis.
Yersinia and Campylobacter infection may be confused w i t h regional
ileitis; however, a history o f weight loss will support the latter diagnosis.
Pain due to renal disease (acute pyelonephritis, pelvi-ureteric j u n c t i o n
obstruction) usually starts i n the flank before it becomes generalised and
may be intermittendy colicky. I n older girls, the differentia] diagnosis
also includes ectopic pregnancy and salpingitis which can occur w i t h o u t
sexual contact and can be confused with appendicitis, ovarian cysts and
dysmenorrhoea.
Acute cholecystitis, although u n c o m m o n , occurs i n children with a
history o f cystic fibrosis and haemolytic disorders. The pain is usually
localised to the right upper quadrant. The pain i n acute pancreatitis is
Acute Abdominal Pain 5

severe, central or epigastric and radiates to the back. I n these patients,

v o m i t i n g is a p r o m i n e n t symptom and the patient is often very sick.

MANAGEMENT
The management o f infants with acute abdominal pain is complex and
r e q u i r e s e x p e r t p a e d i a t r i c care. T h e causes are many a n d the
presentation confusing. They often require urgent resuscitation. Expert
advice should be sought early (including by phone) and intravenous
fluids should be commenced.
In older c h i l d r e n , the diagnosis may be obvious from the history and
physical examination but often it is obscure and early involvement o f a
paediatric specialist is helpful i n directing tests and management. Often
the only decision that needs to be made is whether the child needs to
have an o p e r a t i o n o r not, w i t h the exact diagnosis unclear u n t i l
laparotomy or further tests are performed. It is more i m p o r t a n t to
recognise and resuscitate the c h i l d and to obtain expert advice early than
i t is to pursue an exact diagnosis with multiple investigations.