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
 (emboli / thrombosis, rupture, occlusion caused
by torsion or tension)
2. 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
 Partial obstruction or total obstruction  intra
lumen pressure   pain
4. 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. Gastroenteritis k. Pyelonephritis
b. Appendicitis l. Colic Ureter
c. Mesenteric lymphadenitis m. Lead intoxication
d. Meckel’s diverticulum n. Torsion of spermatic cord
e. Ileitis regional o. Abdominal epilepsy
f. Colitis ulserativa p. Sickle cell crisis
g. Diabetic acidosis q. Mononucleosis
h. Pneumonia r. Porphiria
i. Torsion of ovarian cord s. Cholecystitis and
j. Constipation cholelytiasis
t. 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. Obstruction
Bowel obstruction caused by fibrosis, volvulus, malrotation
Perforation caused by bowel obstruction
b. Inflammation (appendicitis, primary peritonitis, peritonitis
caused by Meckel’s diverticle perforation, perforation of
duodenal ulcer, perforation caused by typhoid fever, Meckel’s
diverticulitis, cholecystitis with or without gall stone, toxic
mega colon with perforation)
c. Trauma (rupture of spleen, urinary bladder, another visceral
organs, hematoma sub serosa)
d. Bleeding (bleeding intra ovarian cyst)
e. In tropic area (perforation associated with ascariasis,
strongiloidiasis, jejunitis necrotican in New Guinea, perforation
of abscess amoeba)
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)
- Crohn’s disease
- Colitis ulcerative
- Colitis amoeba
- Fecal impaction
- Sickle cell anemia
- Ileus meconeum
- Adenitis mesenterica
b. Liver and billiary tree e. Metabolic
- Hepatitis - Phorphiria
- Cholelytiasis - Hiperlipidemia
- Diabetic keto acidosis
c. Pancreas - Familial Mediterranean
- Pancreatitis fever

d. Kidney f. Gynecologic
- Urinary tract infection - Salphyngitis
- Stone
- Nephritis
Cause of abdominal pain in Indonesia

Neonatal - 3 months 3 months – 2 years

- Cow’s milk allergy - Obstipation

- Pyloric hypertrophy - Gastroenteritis
- Torsion of testis - Bowel duplication
- Obstipation/with - Maldigestion
anal fissure - Gastric mucosal
- Bowel malrotation membrane
- Meckel’s diverticulum
2 years – 5 years > 5 years

- Obstipation - Appendicitis
- Volvulus - Gastritis
- Hepatitis - Ovarian torsion
- Urinary tract - Menstrual cycle
infection - Cholecystitis
- Ascariasis - Functional
- Appendicitis abdominal pain
- Pancreatitis - 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. Anamnesis
2. Physical examination
3. 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. Comprehensive
2. 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 infection
- Hernia
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 Behavior
Organic disorders Response pattern

Environment and
Inducers
Levine and Rappaport
1984
 Etiology of abdominal pain
Gastrointestinal Drugs Liver, spleen
and pancreas
Chronic diarrhea Anti convulsion
Peptic ulcers Antibiotic Cholecyctitis
Bezoar Brochodilator Cholelithiasis
Duplication Pancreatitis
Intermittent volvulus Urinary tract Massive spleenomegali
Meckel’s diverticulum
Appendicitis Hidronephrosis Metabolic
Mesenterical adenitis Pyelonephritis
Abdominal TBc Stone Hypoglycemia
Milk protein intolerance Renal neoplasm Phorphiria
lactose intolerance Ovarian cyst Lead intoxication
Constipatian Dismenorrhea Hyperlipidemia
Ascariasis Endometriosisi Angioneurotic edema
Testis torsion
Testis neoplasm
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. Careful anamnesis, Physical examination,

and further investigation
2. High cost examination and commonly was
not positive
3. 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