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COMMON ABDOMINAL
EMERGENCIES IN CHILDREN
James D’Agostino, MD

Pediatric abdominal complaints are common presentations in emer-

gency departments (EDs), and emergency physicians are challenged
every day with a vast array of gastrointestinal disorders. Because young
children with abdominal disorders cannot fully describe their pain or
how they feel, the emergency physician must use clinical experience,
accurate history taking, diligent physical examinations, and diagnostic
studies to help differentiate well children from children with significant
illness. This article facilitates the emergency physician’s understanding
of common abdominal emergencies in children.

GENERAL APPROACH TO CHILDREN WITH

ABDOMINAL EMERGENCIES

Pain is probably the most common reason that patients visit EDs to
seek medical advice.18 Abdominal pain is a common complaint in chil-
dren and is associated with a large number of gastrointestinal disorders.
Nearly one third of children presenting to an ED with abdominal pain
did not receive a specific diagnosis.41 Determining exact causes can be
difficult. The emergency physician must be aware of stoic children who
deny pain in fear of further medical intervention, and histrionic children
who demonstrate exaggerated pain.
Infants demonstrate pain reaction as a change in behavior: persistent
crying, irritability, inability to be consoled, fussiness,45, 55 sleeplessness,

From the Department of Emergency Medicine, State University of New York Upstate
Medical University, Syracuse, New York

EMERGENCY MEDICINE CLINICS OF NORTH AMERICA

VOLUME 20 • NUMBER 1 • FEBRUARY 2002 139

140 D’AGOSTINO

and poor feeding. Older children, adolescents and even toddlers describe
pain with words such as aching, awful, or horrible.59 It is interesting to
note that many children with the same pathophysiology can have diver-
gent pain severity and medication requirements.26 The child writhing in
pain from a benign condition such as intestinal colic from constipation
can appear similar to the child in pain from a potentially life-threatening
condition such as intestinal obstruction from intussusception. Anxiety,
which is most likely experienced by nearly all pediatric emergency
patients,46 has a tendency to increase the painful stimuli,16 and, like pain,
it also should be addressed and controlled.
Differentiating the child with a benign abdominal process from the
child with a more serious condition can be difficult. The emergency
physician must obtain a thorough history of the present illness and use
patience in examining young patients; often, waiting for the right mo-
ment to examine anxious patients and even repeating their examinations.
Coupled with specific laboratory and radiologic studies, a thoughtful,
thorough evaluation can allow the emergency physician to diagnose
abdominal disorders more accurately.

APPENDICITIS

Appendicitis is the most common nontraumatic surgical emergency

in children.15 There is a slight male predominance, with a peak incidence
of 9 to 12 years of age.35 Although uncommon in infants and children
under 2 years, neonatal cases have been reported.32 Diagnosis is particu-
larly challenging in this younger age group.

Clinical Presentation

The classic signs and symptoms of appendicitis are periumbilical

visceral pain (after obstruction of the appendix), followed by nausea,
vomiting, and anorexia, with the development of right lower quadrant
abdominal parietal pain. This progression can be noted in up to 50% of
adults but is less common in children younger than 12 years of age43
and can account for the initial misdiagnosis in this age group of 28%
to 57%.13
For ages 2 years and younger, the most common symptoms are
vomiting (85%–90%), pain (35%–77%), diarrhea (18%–46%), and fever
(40%–60%).3, 22 Misleading clinical signs in this age group have included
irritability (34%–40%), grunting respirations (8%–23%), cough or rhinitis
(40%), and right hip complaints, such as refusal to walk or limping
(3%–23%).3, 22, 37, 50 Localized right lower abdominal tenderness is noted
in fewer than 50% of infants3, 22 and the inability of this age group to
verbalize their complaints, coupled with misleading clinical signs, have
led to perforation rates of 82% to 92%.23, 35
In children ages 2 to 5 years, the incidence of appendicitis is still
 COMMON ABDOMINAL EMERGENCIES IN CHILDREN 141

low (fewer than 5% of all pediatric appendicitis cases20) and in contrast

to infants, right lower abdominal tenderness is more common (58%–85%)
than diffuse tenderness (19%–28%).60 Abdominal pain (89%–100%), vom-
iting (66%–100%), fever (80%–87%), and anorexia (53%–60%) predomi-
nate in this age group.22, 60 Vomiting is often the first symptom preceding
pain that is noted by the parent.43
The incidence of appendicitis increases in school-aged children and
peaks in adolescence and the late teenage years. In children 6 to 12 years
of age vomiting occurs in 68% to 95% of children with appendicitis
(with up to 18% preceding or concurrent with pain). Anorexia (47%–
75%), diarrhea (9%–16%), constipation (5%–28%), and dysuria (4%–20%)
are also seen in children with appendicitis.42 Fevers above 103F (39.5C)
are uncommon,35 although temperatures up to 102F (38.9C) to 103F
(39.5C) can occur after perforation.23 One study found that temperatures
above 100.4F (38.0C) were found in 4% of school-aged children with
symptom duration less than 24 hours, 64% with symptoms lasting 24 to
48 hours, and 63% with symptoms lasting over 48 hours.14 Nearly all
the children in this age group have right lower quadrant tenderness,
although the entire abdomen can be tender or diffusely tender in 15%
of children without perforation, and up to 83% with perforation.39

Diagnostic Studies

Although no single laboratory test is diagnostic for appendicitis,

patients in whom the physician is considering this diagnosis should
have a complete blood count (CBC), urinalysis, and in menstruating
adolescents a ␤-human chorionic gonadotropin level performed. The
white blood cell (WBC) count is insensitive and nonspecific for appendi-
citis, and, with the advent of ultrasonography (US) and focused abdomi-
nal computed tomography (CT) scan, less reliance should be placed on
this test for decision making.42 WBC counts greater than 10,000 occur in
62% of normal patients, 89% of patients with appendicitis, and 93% of
patients with perforated appendicitis.35 Abnormal urinalyses (⬎ 5 WBC/
hpf or RBCs) can be found in 7% to 25% of children with appendicitis.43
Although abdominal radiographs frequently are ordered on nearly
all patients with a differential diagnosis of appendicitis, their true value
in the diagnostic work-up is questionable.31 Some advocate the use of
abdominal radiographs in children to evaluate selectively for intra-
abdominal free air, intestinal obstruction, fecalith, lower lobe pneumonia,
intussusception, and renal and biliary calculi.58 The finding of small
bowel obstruction on the abdominal radiograph in children younger
than 3 years of age should alert one to the high possibility of a perforated
appendix.17
Where the diagnosis of appendicitis is not secured with history and
physical alone, US is used increasingly. There is a reported sensitivity of
80% to 92% and specificity of 86% to 98%.10, 12, 21, 27 The use of abdominal
CT scans for the diagnosis of appendicitis has been thought not to be
142 D’AGOSTINO

cost effective,23 although its accuracy has been prospectively studied and
the sensitivities and specificities range from 87% to 100% and 83% to
97%, respectively.38 The abdominal CT scan can reveal the distended
appendix, fecaliths, focal thickening of the cecal wall, and fluid collec-
tions in cases of appendiceal rupture. In some institutions, CT scan of
the right lower quadrant is used if US findings are equivocal or if an
abscess is suspected.58
Garcia-Peňa and her colleagues have shown improved diagnosis, as
well as a high degree of diagnostic accuracy and cost-effectiveness with
a protocol using both US and CT scans.19 Patients with equivocal clinical
findings have an US. If the US findings are positive, they are taken
directly to the operating room (OR). If the US findings are negative or
equivocal, a CT scan with rectal contrast is performed. If the CT scan is
positive the patient is taken to the OR. More than 60% of children in
this series had a beneficial change in management, and there was a
projected cost savings of $565 per patient.19

Differential Diagnosis

The most common diagnoses confused with appendicitis are acute

bacterial enterocolitis (particularly Yersinia enterocolitica and Campylo-
bacter jejuni, both of which can present with focal right lower quadrant
pain, fever, diarrhea, and visible rectal blood), mesenteric lymphadenitis
(although the pain is less severe, and peritoneal signs are usually not
present), pelvic inflammatory disease (and other gynecologic disorders),
urinary tract infections, Meckel’s diverticulitis, intussusception, and
right lower lobe pneumonia.

Management

If an acute abdomen is considered, the emergency physician must

act appropriately to stabilize the patients with intravenous fluid support
and immediate surgical consultation. Patients should receive nothing by
mouth and broad-spectrum intravenous antibiotics are administered if
obvious perforation is suspected (e.g., febrile, diffuse tenderness, rigid
abdomen, or ill-appearing patients). There is controversy over adminis-
tering intravenous antibiotics in uncomplicated pediatric appendicitis.51
In equivocal cases, admission is sometimes warranted to observe pa-
tients for progression of signs and symptoms.

HYPERTROPHIC PYLORIC STENOSIS

Pyloric stenosis, an idiopathic hypertrophy of the pyloric muscle, is

the most common pediatric surgical condition that causes emesis.23 The
etiology is unknown. Pyloric stenosis occurs in about 1 in 250 births;
 COMMON ABDOMINAL EMERGENCIES IN CHILDREN 143

first-born boys are at increased risk.25 There is a male-to-female ratio

of 4 : 1.

Clinical Presentation

The infant with pyloric stenosis usually presents in the third week
of life with a range of 1 to 10 weeks.23 It is uncommon in the first few
days of life.4 Vomiting is the primary complaint and after several days
lethargy and dehydration occur. The vomiting occurs near the end of or
within 30 minutes of a feeding, is always nonbilious, and is projectile.
Projectile emesis is a common complaint. The physician often must
clarify what the parent is describing. Patients with pyloric stenosis
usually have true, forceful projectile emesis.
The physical examination usually reveals a hungry infant who eats
again after vomiting. The infant should be evaluated for signs of dehy-
dration by examining the anterior fontanelle in the sitting position and
assessing the rate and intensity of the distal pulses. The infant’s level of
consciousness, perfusion of the extremities, and condition of the mucous
membranes also can aid in determining hydration status. The abdomen
is generally soft and nondistended. Gentle examination of the midepig-
astrium while the infant is eating can allow the examiner to palpate
deeply and feel an olive-like mass; however, in the author’s experience,
this mass is palpated infrequently, and a similar experience is reported
in the literature.4 The emergency physician must observe the infant
during and after feeding. Assessment of the sucking mechanisms, the
infants eagerness to eat, and the nature of vomiting can be made.
Early in the course of this disorder, patients are often well hydrated,
with an excellent sucking mechanism, and make vigorous attempts to
eat. As dehydration ensues, the patient becomes increasingly lethargic,
and feeding activity and tone are diminished. Late in the course of the
illness, the patient can experience periods of apnea because of severe
metabolic alkalosis.

Diagnostic Studies

Serum electrolyte levels should be taken and can reveal the hypoka-
lemic, hypochloremic metabolic alkalosis commonly found in advanced
cases of this disorder. If an olive-like mass is palpated, the diagnosis is
most ensured, but if not, further studies are warranted. An abdominal
radiograph can reveal a large gastric bubble, suggesting a gastric outlet
obstruction; however, US of the pylorus is the preferred study in most
institutions and is highly sensitive and specific.1, 58 Pyloric stenosis is
present if the pylorus muscle thickness is equal to or exceeds 4 mm.6 In
cases in which US is inconclusive, an upper gastrointestinal series is
done to evaluate for possible gastroesophageal reflux, duodenal atresia,
or malrotation.23 Pyloric stenosis can appear as a filling defect in the
144 D’AGOSTINO

distal stomach and duodenal bulb, or as a string of contrast through the

stenotic pyloric channel.

Differential Diagnosis

A common disorder confused with pyloric stenosis is gastroesopha-

geal reflux disease (GERD), which generally causes nonforceful, nonpro-
jectile regurgitation. Again, the examiner should observe the infant dur-
ing and after feedings. An upper gastrointestinal (UGI) series can
sometimes but not always demonstrate gastroesophageal reflux. UGI
has a low specificity for GERD. Many normal patients demonstrate
reflux with a barium meal. Admission for pH probe testing can further
confirm GERD. US usually does demonstrate pyloric stenosis if it is
present. Other diagnoses to consider are gastroenteritis, intestinal malro-
tation with obstruction, duodenal atresia, and an annular pancreas.

Management

Pyloric stenosis is not a surgical emergency but can be a medical

emergency because of electrolyte disturbances and significant dehydra-
tion. The key to management of these infants is rapid volume replace-
ment and judicial electrolyte correction. A surgical consult should be
obtained once the diagnosis is suspected, further oral intake withheld, a
nasogastric tube placed to decompress the stomach, and the patient
should be admitted. Restoration of circulating blood volume with intra-
venous fluids is warranted.
Isotonic fluids should be given. Initially, 0.9% normal saline solution
should be given as a 20 mL/kg bolus infusion if dehydration or signs
of poor perfusion are present. Lactated Ringer’s solution is not indicated
because the patient is already alkalotic and the alkalosis can precipitate
apnea. The infant’s serum glucose level should be checked and moni-
tored closely. Continued fluid therapy is usually with solutions con-
taining 5% dextrose and 0.9% sodium chloride. Potassium chloride (3–5
mEq/kg/day) should be added when urine output is established. Ade-
quate rehydration and stabilization is associated with decreased surgical,
anesthetic, and postoperative complications. Surgery is often delayed for
1 to 2 days while rehydration and normalization of electrolytes is
achieved. Pyloromyotomy (e.g., Ramstedt procedure) is curative.

INTUSSUSCEPTION

Intussusception, an invagination of the proximal portion of the bowel

into an adjacent distal bowel segment, is a common cause of intestinal
obstruction in infants,24 second only to an incarcerated inguinal hernia
as the cause of intestinal obstruction in infants.51 The peak incidence of
 COMMON ABDOMINAL EMERGENCIES IN CHILDREN 145

intussusception is at 10 months of age, with a range of 3 months to 2

years. Pathologic lead points are commonly noted in older children,
with Meckel’s diverticulum being the most common.29 In children
younger than 2 years of age, a pathologic lead point is found in less
than 5% to 10% of cases. Other causes of lead points are submucosal
hemorrhage from Henoch-Schölein purpura, lymphomas, and intestinal
polyps.23

Clinical Presentation

The classic triad of intermittent colicky abdominal pain, vomiting,

and bloody stools full of mucus (‘‘currant jelly’’ stools) is seen infre-
quently (about 20%). More infants present with only two symptoms.9 It
is common for these infants to have a history of severe intermittent
abdominal pain every 20 to 30 minutes, with periods of relief lasting 10
to 20 minutes, during which they can appear calm and healthy.23 Other
patients become extremely lethargic and pale.29 In those infants without
bloody stools, occult blood is present in up to 75% of cases.28 Therefore,
the emergency physician should Hemoccult test the stool in all infants
with altered mental status.
Although the finding of a sausage-like mass in the right upper
quadrant with absence of bowel in the right lower quadrant (Dance’s
sign) is pathognomonic of intussusception, this finding is present in only
85% of cases and might not be palpated in crying infants, who can have
tense abdominal muscles. The physician should try to examine the
abdomen with the infant asleep (not uncommon after paroxysmal at-
tacks), which gives a softer and more revealing abdominal examination.

Diagnostic Studies

Plain abdominal radiographs, including flat plate, upright, and

cross-table lateral films, are the initial studies in children with possible
intussusception. These films can be normal particularly in infants who
present early in their disease,23 and therefore normal plain films of the
abdomen should not be used to exclude the diagnosis.48 Radiographic
findings suggestive of intussusception include a paucity of intestinal
gas, little or no stool in the colon,58 and small bowel obstruction. Intra-
peritoneal air should be ruled out with upright or decubitus films. A
soft tissue mass can be seen in the right upper quadrant in up to 50%
of cases5 and at times in the rectum. The barium enema is the gold
standard study for the diagnosis of and therapy for intussusception. Air-
contrast enemas have been used for many years in some countries and
have been shown to be as effective as barium enemas in the diagnosis
and treatment of intussesception.47 Air contrast decreases the risks asso-
ciated with perforation during barium enemas in this disease. US has
been used increasingly in diagnosis of this condition.
146 D’AGOSTINO

Differential Diagnosis

Disorders that cause intestinal obstruction, abdominal pain, and

blood in the stool should be considered, such as malrotation with midgut
volvulus, Meckel’s diverticulum (although this classically causes pain-
less bleeding), and incarcerated inguinal hernia (although the inguinal
mass should help differentiate from intussusception). Henoch-Schönlein
purpura can coincide with (ie, and be the cause for the intussusception)
and despite the purpuric rash and joint involvement, a barium or air-
contrast enema can be unavoidable.

Management

Once intussusception is suspected, a surgical consultation should

be obtained, oral intake withheld, and intravenous fluid resuscitation
provided prior to attempts at barium or air-contrast reduction. One can
place a nasogastric tube into the stomach if obstruction is present. The
air-contrast enema has been shown to be as effective as barium in
reducing the intussusceptum.34, 47 And has replaced the barium enema
as the study of choice at most major centers in the United States.
Successful reduction of intussusception occurs in 60% to 80% of cases.58

MALROTATION AND MIDGUT VOLVULUS

Volvulus results from an incomplete rotation and an abnormal fixa-

tion of the bowel during embryonic development. This malrotation
predisposes the bowel to twist on itself, leading to bowel obstruction
and vascular compromise. Volvulus occurs in 68% to 71% of neonatal
malrotation cases.56 Patients with malrotation may have obstructing fi-
brous bands (Ladd’s bands) that can cause proximal intestinal obstruc-
tion. Unfortunately, complete volvulus can lead to bowel necrosis in 1 to
2 hours,15 and therefore clinical and radiographic evaluation of suspected
volvulus cases must be done promptly.
The incidence of malrotation is 1 in 500 births.23 Nearly two thirds
of midgut volvulus cases present in the first month of life, 75% by 1
year23, 58 and the remaining cases any time later in life.58

Clinical Presentation

Midgut volvulus has a sudden onset of vomiting, abdominal pain,

and feeding intolerance in the otherwise healthy young infant. Bilious
emesis, the hallmark, is present in 77% to 100% of cases.44, 56 Symptoms
are more vague in the older child and malrotation without volvulus can
occur even in adulthood. The older child can display symptoms of
chronic, intermittent vomiting, crampy abdominal pain, failure to thrive,
 COMMON ABDOMINAL EMERGENCIES IN CHILDREN 147

constipation, bloody diarrhea, and hematemesis.30 The frequency of vol-

vulus complicating malrotation in the older child ranges from 14%
to 65%.44, 56
Unfortunately for the emergency physician, malrotation and even
early volvulus have few, if any, abnormal physical findings.7, 44 In a
review of 22 patients undergoing surgery for malrotation, Torres found
that 50% of patients had normal abdominal examinations and 32% had
abnormal distension without tenderness.56 The obstruction in midgut
volvulus is usually high, and proximal and abdominal distention might
not be present. A high index of suspicion is therefore necessary to
diagnose this disease especially early in its course. With midgut volvu-
lus, intestinal ischemia progresses to gangrene, and virtually all patients
develop abdominal pain and peritoneal signs. At this stage, tachycardia
and hypovolemia are present40 and, as infarction ensues peritonitis,
abdominal distention, profound dehydration and shock occur.23 When
the diagnosis is delayed, the patients may be pale and grunting.37

Diagnostic Studies

CBC, electrolytes, blood-urea-nitrogen (BUN), and creatinine levels,

as well as blood type and cross match are performed in these patients
but should not be used in the diagnostic evaluation of infants with
malrotation and midgut volvulus. Radiographs vary in patients with
midgut volvulus. The upright, flat-plate and cross-table lateral abdomi-
nal films can demonstrate small bowel obstruction, abdominal paucity
of gas distally, and a markedly dilated duodenum and stomach.54 At
times, a normal bowel gas pattern can be seen because the obstruction
is usually in the proximal bowel.58
In patients suspected of having malrotation and midgut volvulus,
particularly when the abdominal radiographs are equivocal, the diagnos-
tic study of choice is the upper gastrointestinal study.23, 58 Malrotation
with midgut volvulus is suspected when the duodenojejunal junction is
in an abnormal location (ie, not to the left of the vertebral column), and
the contrast material either ends abruptly or tapers like a corkscrew,
indicating abdominal proximal intestinal obstruction.23 If US is used for
the vomiting infant (as in pyloric stenosis), any abnormal relationship
between the superior mesenteric artery and vein warrants an upper
gastrointestinal study.58

Differential Diagnosis

Duodenal webs, duodenal stenosis, and duodenal atresia can result

in a clinical picture similar to that of midgut volvulus. Lower intestinal
obstruction usually causes abdominal distention. Adynamic ileus can
result in bilious vomiting; however, unexplained bilious vomiting in a
young infant is malrotation and midgut volvulus until proved otherwise.
148 D’AGOSTINO

Management

When midgut volvulus is suspected, surgical consultation for imme-

diate laparotomy is required to decrease morbidity and mortality. Intra-
venous fluids are begun, and, if vascular collapse is present, rapid
normal saline boluses are given until adequate perfusion is attained. A
nasogastric tube should be inserted into the stomach and intravenous
antibiotics started.

MECKEL’S DIVERTICULUM

Meckel’s diverticulum, a vestige of the omphalomesenteric duct, oc-

curs in 2% of the population. Two percent of patients with a Meckel’s
diverticulum manifest symptoms. The diverticulum is usually 2 feet
proximal to the terminal ileum. Forty-five percent of symptomatic pa-
tients are younger than 2 years old.2 This finding is known as ‘‘Meckel’s
rule of twos.’’

Clinical Presentation

Meckel’s diverticuli are the most common cause of significant lower

gastrointestinal bleeding in children.2, 36 Most patients with bleeding
have peptic ulceration within the diverticulum or adjacent ileum. The
bleeding can be intermittent or massive. It is classically painless,36 al-
though some patients do experience pain.8 The stools appear bright red
or tarry, depending on the briskness of the bleeding and the location of
the diverticulum.2
In a total of 830 cases of Meckel’s diverticulum of all ages, Amoury
found intestinal obstruction and intussusception in 35% of patients,
bleeding in 32%, diverticulitis in 22%, and umbilical fistula in 10%.2
Although bleeding occurs in young patients, diverticulitis occurs more
frequently in older patients.2, 8

Diagnostic Studies

In addition to CBC, electrolytes, BUN, and creatinine levels, if one

suspects Meckel’s diverticulum, a blood type and cross match should be
done. Abdominal radiographs are usually normal, although they can
demonstrate obstruction or perforation. The Meckel’s scan, using intra-
venous technetium 99m, is 75% to 85% sensitive for identifying hetero-
topic gastric tissue when bleeding is present.11
 COMMON ABDOMINAL EMERGENCIES IN CHILDREN 149

Differential Diagnosis

Other causes for lower GI bleeding include intestinal polyps, intus-

susception, anal fissures, midgut volvulus, bacterial enteritis, and peri-
anal streptococcal disease.

Management

Patients should be given adequate intravenous fluid support, and

oral intake should be withheld. With massive bleeding, a blood transfu-
sion is sometimes necessary. In stable but bleeding patients, a Meckel’s
scan can be done, and, if positive, a surgical consultation obtained. In
unstable patients, or if peritoneal signs are present, surgery should not
be delayed.

INCARCERATED INGUINAL HERNIA

Inguinal hernia repair is the most common surgical procedure in

children. One to two percent of children have an inguinal hernia (ap-
proaching 30% in premature infants) and 10% of inguinal hernias even-
tually are complicated by incarceration.33 Seventy percent of incarcera-
tions occur in infants younger than 1 year of age,57 with the greatest risk
occurring during the first 6 months of life.49 If left undiagnosed and
untreated, incarcerated inguinal hernias can have serious and even life-
threatening consequences.23 The prevalence of inguinal hernias occurs in
a male-to-female ratio of 6 : 1.

Clinical Presentation

Many parents bring children to the ED after noting a bulge or

swelling in the groin area. These masses can be noted during diaper
changing, or during crying or other Valsalva maneuvers. Gradual swell-
ing of the bowel in boys and bowel or ovary in girls causes incarceration.
Signs and symptoms of vomiting, lack of bowel movements, abdominal
distention, and poor feeding can indicate the presence of intestinal
obstruction. Prolonged incarceration manifests itself as an erythematous,
firm, immobile, tender mass.

Diagnostic Studies

Transillumination of the scrotum, using an otoscope, can help to

differentiate a hydrocele from an incarcerated inguinal hernia. Abdomi-
nal radiographs should not be necessary to diagnose an incarcerated
inguinal hernia, although signs of intestinal obstruction can be present.
150 D’AGOSTINO

With an inguinal hernia, the neck of the groin mass should emanate
from the distal ring of the inguinal canal.

Differential Diagnosis

Hydroceles can be confused with inguinal hernias, particularly com-

municating hydroceles, in which the size changes with Valsalva maneu-
vers or with recumbence. Lymphadenopathy can be palpated in the
inguinal area; however, a swollen lymph node is usually smaller than
an inguinal hernial mass, is not mobile, and does not involve the ingui-
nal canal. Undescended or retracted testicles can appear to be inguinal
hernias. The emergency physician should be sure to palpate both testi-
cles in the scrotum prior to diagnosing an inguinal hernia.

Management

If intestinal obstruction is present (e.g., bilious vomiting, abdominal

tenderness and distention, bloody stools, and a hypovolemic state), one
should resuscitate with intravenous fluids, place a nasogastric tube
into the stomach, and obtain laboratory studies and emergent surgical
consultation.
If an incarcerated inguinal hernia is present without obstruction or
shock, one should attempt a manual reduction. Nearly 95% of inguinal
hernias can be reduced by gentle constant upward pressure on the
hernia sac.52 With more resistant incarcerated inguinal hernias, sedation
and a Trendelenburg position are helpful. Once the patient is sedated,
one should apply firm, constant upward pressure on the hernia sac with
one hand while ‘‘milking’’ the neck of the hernial mass into the distal
ring of the inguinal canal with the other hand.
If the inguinal hernia is reduced successfully, one should consult
with a pediatric surgeon for outpatient follow-up. Depending on the
duration of the incarceration and the difficulty in reduction, some pediat-
ric surgeons do admit these patients for observation. If reduction is
unsuccessful, then immediate surgical consultation is warranted. En-
trapped ovaries can be difficult to reduce. Some pediatric surgeons delay
surgery if the ovary appears normal, nonerythematous, and nontender.33
All patients with inguinal hernias eventually require surgery, and follow-
up consultation with a pediatric surgeon must be arranged prior to ED
discharge.

SUMMARY

Because young children often present to EDs with abdominal com-

plaints, emergency physicians must have a high index of suspicion for
the common abdominal emergencies that have serious sequelae. At the
 COMMON ABDOMINAL EMERGENCIES IN CHILDREN 151

same time, they must realize that less serious causes of abdominal
symptoms (e.g., constipation or gastroenteritis) are also seen. A gentle
yet thorough and complete history and physical examination are the
most important diagnostic tools for the emergency physician. Repeated
examinations and observation are useful tools. Physicians should listen
carefully to parents and their children, respect their concerns, and honor
their complaints.
Ancillary tests are inconsistent in their value in assessing these
complaints. Abdominal radiographs can be normal in children with
intussusception and even malrotation and early volvulus. Unlike the
classic symptoms seen in adults, young children can display only leth-
argy or poor feeding in cases of appendicitis or can appear happy and
playful between paroxysmal bouts of intussusception. The emergency
physician therefore, must maintain a high index of suspicion for serious
pathology in pediatric patients with abdominal complaints. Eventually,
all significant abdominal emergencies reveal their true nature, and if one
can be patient with the child and repeat the examinations when the
child is quiet, one will be rewarded with the correct diagnosis.

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4. Benson CD: Infantile hypertrophic pyloric stenosis. In Welch KJ, Randolph JG, Ravitch
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Address reprint requests to

James D’Agostino, MD
Department of Emergency Medicine
State University of New York Upstate Medical University
750 East Adams Street
Syracuse, NY 13210

e-mail: dagostinj@upstate.edu