Abdominal pain in children

2. Abdominal pain
ACUTE
CHRONIC
Abdominal pain is one of the most common reason for
which parents take the child to a doctor.

4. 4
Let us see what
different kinds of
abdominal pains
this Beautiful child
could have……
Acute
oOrganic
oInorganic/ Idiopathic/ functional
Chronic
Organic
Inorganic/ Idiopathic/ functional
Here again there may be many
variations

5. Abdominal Pain
• Abdominal pain can result from:
• injury to the intra-abdominal organs,
• injury to overlying somatic structures in the
abdominal wall, or
• extra-abdominal diseases.

6. Visceral pain
• Visceral pain results when nerves within the gut detect
injury.
• The nerve fibers responsible for visceral sensation are
nonmyelinated and mediate pain sensation, which is
vague, dull, slow in onset, and poorly localized.
• A variety of stimuli, including normal peristalsis and various
chemical and osmotic states, activate these fibers to some
degree, allowing some sensation of normal activity.
• Regardless of the stimulus, visceral pain is perceived when
a threshold of intensity or duration is crossed.
• Lower degrees of activation may result in perception of
nonpainful or perhaps vaguely uncomfortable sensations,
whereas more intensive stimulation of these fibers results
in pain.
• Overactive sensation may be the basis of some kinds of
abdominal pain, such as functional abdominal pain.

7. Somatic Pain
• In contrast to visceral pain, somatic pain results when overlying
body structures are injured.
• Somatic structures include the parietal peritoneum, fascia, muscles,
and skin of the abdominal wall.
• In contrast to the vague, poorly localized pain emanating from
visceral injury, somatic nociceptive fibers are myelinated and are
capable of rapid transmission of well-localized painful stimuli.
• When intra-abdominal processes extend to cause inflammation or
injury to the parietal peritoneum or other somatic structures, poorly
localized visceral pain becomes well-localized somatic pain.
• In acute appendicitis, visceral nociceptive fibers are activated
initially by the early phases of the infection. When the inflammatory
process extends to involve the overlying parietal peritoneum, the
pain becomes more acute and localizes generally to the right lower
quadrant. This is called somatoparietal pain.

8. Referred pain
• Referred pain is a painful sensation in a body region distant from
the true source of pain.
• The physiologic cause is the activation of spinal cord somatic
sensory cell bodies by intense signaling from visceral afferent
nerves, located at the same level of the spinal cord.
• The location of referred pain is predictable based on the locus of
visceral injury.
• Cardiac visceral pain is referred to left-sided T1-5 somatic
segments, causing left shoulder and arm pain.
• Stomach pain is referred to the epigastric and retrosternal regions,
• and liver and pancreas pain is referred to the epigastric region.
• Gall-bladder pain often is referred to the region below the right
scapula.
• Somatic pathways stimulated by small bowel visceral afferents
affect the periumbilical area, and a noxious event in the colon
results in infraumbilical referred pain.

9. Acute Abdominal Pain
• Distinguishing Features.
• Acute abdominal pain can signal the presence of a
dangerous intra-abdominal process, such as appendicitis or
bowel obstruction, or may originate from extraintestinal
sources, such as lower lobe pneumonia or urinary tract
stone.
• Not all episodes of acute abdominal pain require
emergency intervention.
• Appendicitis must be ruled out as quickly as possible; the
evaluation must be efficient, properly focused, and rapid.
• Only a few children presenting with acute abdominal pain
actually have a surgical emergency.
• These surgical cases must be separated from cases that can
be managed conservatively.

10. Initial Diagnostic Evaluation.
• Important clues to the diagnosis can be
determined by History and physical examination.
• The onset of pain can provide some clues.
• Events that occur with a discrete, abrupt onset,
such as passage of a stone, perforation of a
viscus, or infarction, result in a sudden onset.
• Gradual onset of pain is common with infectious
or inflammatory causes, such as appendicitis and
IBD.

11. • A standard group of laboratory tests usually is
performed for abdominal pain.
• An abdominal x-ray series also is usually
obtained.
• Further imaging studies may be warranted to
identify specific causes.
• CT can visualize the appendix if the examination
and laboratory findings suggest a possibility of
appendicitis but the diagnosis remains in doubt.
• If the history and other features suggest
intussusception, a barium or pneumatic (air)
enema may be the first choice to diagnose and
treat this condition with hydrostatic reduction

12. Diagnostic Approach to Acute
Abdominal Pain
History
Onset
Sudden or gradual, prior episodes, association with
meals, history of injury
Nature Sharp versus dull, colicky or constant, burning
Location
Epigastric, periumbilical, generalized, right or left
lower quadrant, change in location over time
Fever Presence suggests appendicitis or other infection
Extraintestinal
symptoms
Cough, dyspnea, dysuria, urinary frequency, flank
pain
Course of symptoms
Worsening or improving, change in nature or
location of pain

13. Physical Examination
General Growth and nutrition, general
appearance, hydration, degree of
discomfort, body position
Abdominal Tenderness, distention, bowel sounds,
rigidity, guarding, mass
Genitalia Testicular torsion, hernia, pelvic
inflammatory disease, ectopic pregnancy
Surrounding structures Breath sounds, rales, rhonchi, wheezing,
flank tenderness, tenderness of
abdominal wall structures, ribs,
costochondral joints
Rectal examination Perianal lesions, stricture, tenderness,
fecal impaction, blood
Diagnostic Approach to
Acute Abdominal Pain

14. Laboratory
CBC, C-reactive protein, ESR Evidence of infection or inflammation
AST, ALT, GGT, bilirubin Biliary or liver disease
Amylase, lipase Pancreatitis
Urinalysis Urinary tract infection, bleeding due to stone,
trauma, or obstruction
Pregnancy test (older
females)
Ectopic pregnancy
Radiology
Plain flat and upright
abdominal films
Bowel obstruction, appendiceal fecalith, free
intraperitoneal air, kidney stones
CT scan Rule out abscess, appendicitis, Crohn disease,
pancreatitis, gallstones, kidney stones
Barium enema Intussusception, malrotation
Ultrasound Gallstones, appendicitis, intussusception,
pancreatitis, kidney stones
Endoscopy
Upper endoscopy Suspected peptic ulcer or esophagitis
Diagnostic Approach to
Acute Abdominal Pain

15. Differential Diagnosis.
• With acute pain, the urgent task of the clinician is
to rule out surgical emergencies.
• In young children, malrotation, incarcerated
hernia, congenital anomalies, and
intussusception are common concerns.
• In older children and teenagers, appendicitis is
more common.
• An acute surgical abdomen is characterized by
signs of peritonitis, including tenderness,
abdominal wall rigidity, guarding, and absent or
diminished bowel sounds.

16. Differential Diagnosis of Acute Abdominal Pain
Traumatic
Duodenal hematoma
Ruptured spleen
Perforated viscus
Functional
Constipation*
Irritable bowel syndrome*
Dysmenorrhea*
Mittelschmerz (ovulation)*
Infantile colic*
Infectious
Appendicitis*
Viral or bacterial gastroenteritis/adenitis*
Abscess
Spontaneous bacterial peritonitis
Pelvic inflammatory disease
Cholecystitis
Urinary tract infection*
Pneumonia
Bacterial typhlitis
Hepatitis
Genital
Testicular torsion
Ovarian torsion
Ectopic pregnancy
Genetic
Sickle cell crisis*
Familial Mediterranean fever
Porphyria
Metabolic
Diabetic ketoacidosis
Inflammatory
Inflammatory bowel disease
Vasculitis
Henoch-Schönlein purpura*
Pancreatitis
Obstructive
Intussusception*
Malrotation with volvulus
Ileus*
Incarcerated hernia
Postoperative adhesion
Meconium ileus equivalent (cystic
fibrosis)
Duplication cyst, congenital
stricture
Biliary
Gallstone
Gallbladder hydrops
Biliary dyskinesia
Peptic
Gastric or duodenal ulcer
Gastritis*
Esophagitis
Renal
Kidney stone
Hydronephrosis

17. Distinguishing Features of Abdominal Pain in Children
Disease Onset Location Referral Quality Comments
Functional: irritable
bowel syndrome
Recurrent Periumbilical,
splenic and
hepatic
flexures
None Dull, crampy,
intermittent;
duration 2 hr
Family stress, school
phobia, diarrhea and
constipation;
hypersensitive to pain
from distention
Esophageal reflux Recurrent,
after meals,
at bedtime
Substernal Chest Burning Sour taste in mouth;
Sandifer syndrome
Duodenal ulcer Recurrent,
before
meals, at
night
Epigastric Back Severe burning,
gnawing
Relieved by food, milk,
antacids; family
history important; GI
bleeding
Pancreatitis Acute Epigastric-
hypogastric
Back Constant, sharp,
boring
Nausea, emesis,
marked tenderness

18. Distinguishing Features of Abdominal Pain in Children
Disease Onset Location Referral Quality Comments
Intestinal obstruction Acute or
gradual
Periumbilical-lower
abdomen
Back Alternating
cramping (colic)
and painless
periods
Distention,
obstipation, bilious
emesis, increased
bowel sounds
Appendicitis Acute Periumbilical or
epigastric; localizes
to right lower
quadrant
Back or
pelvis if
retrocecal
Sharp, steady Nausea, emesis,
local tenderness, ±
fever, avoids
motion
Meckel diverticulum Recurrent Periumbilical-lower
abdomen
None Sharp Hematochezia;
painless unless
intussusception,
diverticulitis, or
perforation
Inflammatory bowel
disease
Recurrent Depends on site of
involvement
Dull cramping,
tenesmus
Fever, weight loss,
± hematochezia
Intussusception Acute Periumbilical-lower
abdomen
None Cramping, with
painless periods
Guarded position
with knees pulled
up, currant jelly
stools, lethargy

19. Distinguishing Features of Abdominal Pain in Children
Disease Onset Location Referral Quality Comments
Lactose intolerance Recurrent with
milk products
Lower
abdomen
None Cramping Distention, gaseousness,
diarrhea
Urolithiasis Acute, sudden Back Groin Severe,
colicky pain
Hematuria
Pyelonephritis Acute, sudden Back None Dull to sharp Fever, costochondral
tenderness, dysuria, urinary
frequency, emesis
Cholecystitis and
cholelithiasis
Acute Right upper
quadrant
Right
shoulder
Severe,
colicky pain
Hemolysis ± jaundice, nausea,
emesis

20. Recurrent (Chronic) Abdominal Pain
• Recurrent abdominal pain is defined as the occurrence of
multiple episodes of abdominal pain over at least 3 months
that are severe enough to cause some limitation of activity.
• Recurrent abdominal pain is a common problem in
children, affecting more than 10% of children at some time
during childhood.
• The peak incidence occurs between ages 7 and 12 years.
• Although the differential diagnosis of recurrent abdominal
pain is fairly extensive , most children with this condition
are not found to have a serious (or even identifiable)
underlying illness causing the pain.

21. Differential Diagnosis of Recurrent Abdominal Pain
Functional abdominal pain*
Irritable bowel syndrome*
Chronic pancreatitis
Gallstones
Peptic disease
Duodenal ulcer
Gastric ulcer
Esophagitis
Lactose intolerance*
Fructose malabsorption
Inflammatory bowel disease*
Crohn disease
Ulcerative colitis
Constipation*
Obstructive uropathy
Congenital intestinal malformation
Malrotation
Duplication cyst
Stricture or web
Celiac disease*

22. Differential Diagnosis
• The most common disorder to consider is functional
abdominal pain.
• Children with functional pain have pain that
characteristically occurs daily or nearly every day, is not
associated with or relieved by eating or defecation, and is
associated with significant loss of the ability to function
normally.
• These children typically have personality traits that include
a tendency toward anxiety and perfectionism, which result
in stress at school and in novel social situations.
• The parents typically state that the child enjoys going to
school, but the pain often is worst at the start of the school
day and before returning to school after vacations.
• A child with suspected functional pain must be evaluated
carefully to exclude other causes of discomfort.

23. • Functional abdominal pain differs from irritable
bowel syndrome (IBS) in minor ways.
• Children with IBS have pain beginning with a
change in stool frequency or consistency, a stool
pattern fluctuating between diarrhea and
constipation, and relief of pain with defecation.
• Symptoms in IBS are linked to gut motility.
• Pain is commonly accompanied in both groups of
children by school avoidance, secondary gains,
anxiety about imagined causes, lack of coping
skills, and disordered peer relationships.

24. Distinguishing Features.
• One needs to distinguish between functional pain
and IBS and more serious underlying disorders.
• When taking the history, the pediatrician should
ask about the warning signs for underlying
illness.
• If any warning signs are present, further
investigation is necessary.
• Even if the warning signs are absent, some
laboratory evaluation is warranted.

25. Warning Signs of Underlying Illness in
Recurrent Abdominal Pain
Vomiting
Abnormal screening laboratory study
Fever
Bilious emesis
Growth failure
Pain awakening child from sleep
Weight loss
Location away from periumbilical region
Blood in stools or emesis
Delayed puberty

26. • The physician and the parents must feel assured that
no serious illness is being missed; a judicious
laboratory evaluation after a careful history and
complete physical examination can accomplish this.
• One mistake that must be avoided in treating recurrent
pain is performing too many tests.
• When the physician responds to each normal test with
an order for another one, the parents and child may
think that there is a serious illness that is being missed.
• Instead of being reassured by normal tests, the child's
parents are made to believe that the mystery is
deepening with every subsequent normal test result.
• The initial evaluation recommended in avoids these
problems.

27. • While waiting for laboratory and ultrasound results, a 3-day trial of
a lactose-free diet should be instituted to rule out lactose
intolerance.
• If tests are normal and no warning signs are present, testing should
be stopped.
• If there are warning signs, worrisome symptoms, progression of
symptoms, or laboratory abnormalities that suggest a specific
diagnosis, additional investigation may be necessary.
• If antacids consistently relieve pain, an upper GI endoscopy is
indicated.
• If the child is losing weight, a barium upper GI series with a small
bowel follow-through or contrast CT is a good idea to look for
evidence of CD.
• Celiac disease also should be considered.

28. Suggested Evaluation of Recurrent Abdominal Pain
Initial Evaluation Follow-up Evaluation*
Complete history and physical
examination
CT scan of the abdomen and pelvis with
oral, rectal, and intravenous contrast
Ask about "warning signs" Celiac disease serology-endomysial
antibody or tissue transglutaminase
antibody
Determine degree of functional
impairment (e.g., missing school)
Barium upper GI series with small bowel
follow-through Endoscopy of the
esophagus, stomach, and duodenum
CBC Colonoscopy
ESR
Amylase, lipase
Urinalysis
Abdominal ultrasound-examine liver,
bile ducts, gallbladder, pancreas,
kidneys, ureters
Trial of 3-day lactose-free diet

29. Treatment of Recurrent Abdominal Pain
• A child who is kept home or sent home from school
because of pain receives a lot of attention for the
symptoms, is excused from responsibilities, and
withdraws from full social functioning.
• This situation rewards complaints and increases the
child's anxiety about health.
• When the child observes that the adults are worried,
the child worries too.
• To break this cycle of pain and disability, the child must
return to normal activities immediately, even before
all test results are available.

30. Treatment of Recurrent Abdominal Pain
• The child should not be sent home from school with
stomachaches; rather, the child may be allowed to take a
short break from class in the nurse's office until the
cramping abates.
• It is useful to inform the child and the parents that the pain
is likely to be worse on the day the child returns to school.
• Anxiety worsens dysmotility and pain perception.
• Sometimes, medications can be helpful.
• Fiber supplements are useful to manage symptoms of IBS.
• In difficult and persistent cases, amitriptyline or a selective
serotonin reuptake inhibitor may be beneficial.

31. Outcome
After 5 years,
 1/3 of children with RAP will have resolution of
their pain,
 1/3 continue to complain of the same
symptoms, and
 1/3 will have a different recurrent pain
complaint.
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