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By

Dr IHEJI CHUKWUNONSO

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Abdominal pain in a child is one of the most
common presentations with both trivial and
life threatening etiologies, ranging from
functional pains to serious organic problems
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Diagnosing abdominal pain in children is also
a challenging task
...

volvulus in neonates, intussusception in
toddlers) and trying to thoroughly evaluate a
child in pain can make the process all the
more challenging
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Varying age groups
Gender
Overall stranger anxiety
Caregiver anxiety/idiosyncrasy
Inadequate knowledge of the physician
Ignorance
Poverty
Late presentation

Acute or chronic (Could be recurrent)
 Medical and surgical
 Based on system
 Based on age groups: More relevant to
paediatricians
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Gastrointestinal:
Gastroenteritis
Appendicitis
Mesenteritic
lymphadenitis
Constipation
PUD
IBD
Peritonitis
Abd Trauma
Intussusception
Volvolus
Incarcerated Hernia,
ETC

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GUS
UTI
Calculi
Dysmenorrhea
Mittleschmerz
PID
Threatned abortion
Ectopic Preg
Testicular/ Ovarian
Torsion, etc

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Liver, Spleen,
Pancreas & Biliary
Tract
Hepatitis
Cholecystitis
Cholelithiasis
Splenic infarction
Ruptured spleen
Pancreatitis

Metabolic
 DKA
 Hypoglycaemia
 Acute renal
insufficiency
 Haematological
 SCD
 HUS
 Respiratory System
 Pneumonia
 Diaphragmatic
pleurisy
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 Drugs

and toxins
 Erythromycin
 Salicylates
 Pb poisoning
 Venoms
 Miscellaneous
 Infantile colic
 Pharyngitis
 Angioneurotic
edema

 Tumours
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Neuroblastomas,
??wilms

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<1yr
Infantile colic
Gastroenteritis
Constipation
UTI
Intussusception
Volvolus
Hirschsprung’s dx
Incarcerated hernia
Typhoid enteritis

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>1-5yrs
Gastroenteritis
Appendicitis
Constipation
UTI
Intussusception
Volvolus
Trauma
Pharyngitis
SC crisis
Typhoid enteritis

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>5 – 11yrs
Gastroenteritis
Typhoid fever
Appendicitis
Constipation
UTI
Trauma
Pharyngitis
Pneumonia
SC crisis
Functional pain

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>11 – 18yrs
Appendicitis
Gastroenteritis
Typhoid fever
Constipation
Dysmenorrhea
Mittleschmerz
PID
Threatened abortion
Ectopic pregnancy
Ovarian/testicular
torsion

 Detailed

history
 Thorough examination
 Relevant investigations
 Appropriate treatment

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Note PQRSTAAA

Place/Location: identify the specific location
of the pain, have child use one finger to
locate her pain
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Associated Symptoms

Relevance

Diarrhea

Gastroenteritis, IBD

vomiting

Gastroenteritis, Appendicitis, Pyloric
stenosis,etc

Bloody stool

UGIB/LGIB, Ulcerative colitis, NEC, dysentry,
constipation

Hematemesis

UGIB, PUD, Gastritis

Bilious emesis

Small bowel obstruction

Jaundice

Hepatitis, or biliary tree obstruction, SCD

Joint pain/swelling

IBD, HSP, SCD

Skin lesion

IBD, HSP, liver dx

Testicular pain

Testicular torsion, orchitis

Dysuria,
polyuria/haematuria

UTI, pyelonephritis

Vaginal/Penile Discharge

STI

Dysmenorrhea

Endometriosis

Shortness of breath

Pneumonia, empyema thorascis

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Vitals and Anthropometry (is there evidence
of failure to thrive)
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bruising, swelling), and
abdominal distension
Auscultation: Auscultate before palpation in
the abdominal exam, listen for bowel sounds,
abdominal bruits, pressure of the
stethoscope also tests for tenderness

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Percussion: Assess general tone (tympanic vs
non-tympanic), percuss for liver span and
spleen tip, assess for ascites
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Digital rectal exam: First exam the anus for
fissures and skin tags, then assess for tone,
stool, and blood

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Guided by history and examination findings

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Treat accordingly
NB: Role of analgesics before making
diagnosis controversial??

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Most common gastrointestinal inflammatory
process in children
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Rotavirus diarrhea has a peak incidence
between 4 and 23 months of age
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The best way is to define constipation is not
by the frequency of the stool but by the
difficulty or painful passage of large or hard
stools
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Older children: change in diet, inadequate
fluid intake, hesitance to defeacate, etc

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Telescoping or
invagination of one
portion of intestine
into another

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Male:female – 3:2
Age –
◦ 3 months to 6 years with 80% < age 2
◦ Peak at 6-12 months

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Most common - ileocolic

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Idiopathic –
◦ 75% of ileocolic intussusception
◦ More likely in children < 5

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Leading point
◦ Hyperplasia of Peyer patches in terminal ileum
◦ Structural: small bowel lymphoma, Meckel
diverticulum
◦ Systemic: cystic fibrosis, Henoch-Schönlein, Crohn
disease

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Child usually irritable, but maybe lethergic
May have episodes of crying 1-5minutes
Followed by 3-30minutes of calmness
without pain
Pain episodes related to perstaltic waves and
child may draw the knees upward toward the
chest
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Prevelance – 3/1000
More common in white northern European
descents
Male:female = 4:1 to 6:1
Age – 1 week – 5 months but usually 3 to 6
weeks

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Abdominal pain
Nonbilious vomiting after feeding and with
91% having projectile emesis
◦ Hungry after feeding
◦ Weight loss
◦ Progressive symptoms

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Jaundice
◦ 5% of affected patients
◦ Indirect hyperbilirubinemia due to decreased level
of glucuronyl transferase

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Abdominal distension
Olive mass – RUQ,
after feeding

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Gastric peristaltic
wave from left to
right after feeding

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Plain abdominal x-ray
Ultrasound
Fluroscopic or sonographic UGI series
On chemistry
Decreased chloride
Elevated bicarbonate – metabolic alkalosis
± Hypokalemia
Elevated BUN and creatinine
±Elevated indirect bilirubin

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Shoulder
sign indentation
of pylorus
into the
stomach

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Medical resuscitation first

◦ IVF hydration with potassium
◦ Correction of alkalosis because of
postoperative apnea associated with
general anesthesia

Pyloromyotomy (Ramstedt’s procedure)
Endoscopically-guided balloon dilation –
surgery is contraindicated or incomplete
pyloromyotomy

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Bilious emesis
Abdominal distension
Investigations
UGI- duodenum not crossing the midline
Barium enema – malposition of cecum

Gastric and duodenal bulb distention
Little air in intestine

Cork-screw pattern – barium flowing
through restricted bowel lumen

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Surgery

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Disease of premature neonates

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Breakdown of the mucosal wall of the intestine
which allows bacteria &/or air to enter the bowel
wall

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Believed to be related to some combination of
infection and ischemia

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Presents usually within

1st or 2nd Week

of Life

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SYMPTOMS

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Abdominal Distension

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Feeding Intolerance (Increased Aspirates From
N
...
tube)

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Vomiting

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Other Septic features

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Invx:
FBC, SEUC, Plain Abd Xray, +/- USS

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Treatment

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Rest the bowel ( NPO)

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Antibiotics

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Monitored with serial abdomen films

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FREE INTRAPERITONEAL AIR INDICATES
SURGERY

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PNEUMA intestinalis ( gas in bowel wall)

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TREATMENT

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When NEC is suspected

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Bowel rest ( nothing orally)

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Antibiotics

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Monitored with serial abdomen films

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FREE INTRAPERITONEAL AIR INDICATES
SURGERY

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Most common surgical abdomen
Pain initially visceral: poorly localized, maybe
periumbilical
Within 6-48hrs may become parietal, well
localized, constant on the RIF
Most intense at McBurney’s point
Classical symptoms : RLQ pain with fever,
anorexia, nausea, vomiting +/diarrhea/constipation

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Patient avoids movement, prefers lying by
side
Rebound tenderness, McBurney sign, Rovsing
sign, Psoas sign and obturator sign all
positive
Invx: FBC +/- USS

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Def Rx: Appendicectomy

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Caution: Best not to tell parents child does
NOT have appendicitis

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“My dear physician please don’t send me to
the surgeon” pleads the child silently in her
heart, “Beware- haste not, Listen to my
mother, and then-Examine and again
examine me: This will improve my lot And
assure you accuracy
...
APPROACH TO ACUTE ABDOMINAL PAIN IN CHILDREN
...
[Internet] 2005 [updated 2005 May 1; cited
2010 Mar 6]
...
pediatriconcall
...
asp
Azubuike CA, & Nkaginieme KEO, Paediatrics and Childhealth in
a tropic region, 2nd ed, 2002, African educational services,
Owerri, Nigeria
Kliegman et al, Nelson Textbook of Pediatrics, 18th ed, Saunders
Elsevier, 2010
Neuman MI, Ruddy RM
...
UptoDate
...

Shah SK, Allison ND, Tsao K
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Epocrates Online: BMJ
Group
...

Available from:
https://online
...
com/noFrame/showPage

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