1 Why is the evaluation of abdominal pain especially challenging in the pediatric patient?

Infants with abdominal pain may present with nonspecific signs, such as irritability, poor feeding, and lethargy. Toddlers and preschool children may report pain but are unable to provide further details, such as the quality or location of the pain. The physical examination of a child requires time and patience on the part of the examiner. The history and a physical examination of the abdomen may be more difficult to obtain with children. In addition to the more common causes, the differential diagnosis of abdominal pain in children includes a host of disorders unique to the pediatric patient, such as congenital anatomic abnormalities, Henoch-Schönlein purpura, abdominal migraines, or metabolic disorders.

McCollough M, Sharieff GO: Abdominal surgical emergencies in infants and young children. Emerg Med Clin North Am 21:909–935, 2003.

Pollack ES: Pediatric abdominal surgical emergencies. Pediatr Ann 25:448–457, 1996.

2 How can I organize my approach to the patient?

In the unstable patient, the initial approach should begin with an assessment of the patient’s airway, breathing, and circulation. Following stabilization, obtain a complete history and perform a physical examination. The history and physical examination are the essential components of the evaluation. Elicit the nature of the pain, such as its onset, quality, location, and duration, as well as the presence of any associated symptoms. The differential diagnosis of abdominal pain in children is extensive (Table 5-1). The age of the patient and the most likely diagnoses in that age group can be used in concert with the history and physical examination to narrow the differential and guide further diagnostic testing.

3 What are the life-threatening causes of abdominal pain?

4 What are some extraintestinal causes of abdominal pain?

Pain originating at sites distant from the abdomen can be manifest by abdominal pain. In processes such as lower lobe pneumonia, afferent nerves from the parietal pleura share central pathways with those that originate from the abdominal wall. Similarly, scrotal pain may be referred to the abdomen. Other illnesses that are associated with abdominal pain include streptococcal pharyngitis, renal calculi, urinary tract infections, diabetes mellitus, ovarian disease (cyst, torsion, pelvic inflammatory disease), testicular disease, cholecystitis, pancreatitis, sickle cell vaso-occlusive crisis, lead toxicity, and porphyria.

5 How can I maximize the physical examination of the pediatric patient with abdominal pain?

The physical examination of a child requires patience on the part of the examiner, who must take time to establish rapport. Begin with observation, often best accomplished while unseen by the child. Notice the general appearance of the child. Is he lying still on the stretcher, suggesting peritonitis, or writhing with colicky pain? Is she able to climb off or onto the stretcher? Commence further inspection, auscultation, and palpation by examining the least threatening areas first and saving particularly invasive aspects of the examination for last (e.g., otoscopy). Lying the child with his or her knees flexed may facilitate relaxation of the rectus muscles. The child’s “help” can be elicited during the abdominal examination by allowing him to place his hands on top of the examiner’s during palpation. Apply gentle pressure beginning in a location away from the area identified by the child as the most painful. If a surgical consultation is anticipated, the physicians should agree on who will perform the digital r examination, thus minimizing the number of examinations.

McCollough M, Sharieff GO: Abdominal surgical emergencies in infants and young children. Emerg Med Clin North Am 21:909–935, 2003.

6 Does the use of IV analgesia affect the diagnostic accuracy of the physical examination in children with significant abdominal pain of unknown etiology?

It is imperative that health care practitioners caring for children make every effort to safely and effectively treat pain whenever possible. Multiple studies with adults and one with children have shown that giving IV narcotics at adequate doses to decrease pain does not adversely affect the physical examination or diagnostic accuracy in patients with abdominal pain of unknown etiology. In fact, pain control might facilitate localization of the origin of the pain, thereby improving the diagnostic accuracy of the physical examination. Therefore, avoid delaying administration of proper analgesia simply because the diagnosis is unknown or the child is awaiting examination by a consultant.

Kim MK, Strait RT, Sato TT, et al: A randomized clinical trial of analgesia in children with acute abdominal pain. Acad Emerg Med 9:281–287, 2002.

Thomas SH, Silen W, Cheema F, et al: Effects of morphine analgesia on diagnostic accuracy in emergency department patients with abdominal pain: A prospective, randomized trial. J Am Coll Surg 196:18–31, 2003.