Dr.Azad A Haleem AL.MezoriUniversity Of Duhok

Faculty of Medical ScienceSchool Of Medicine

Pediatrics Department2015

Abdominal Pain in children

Abdominal pain

ACUTECHRONIC

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

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Let us see what different kinds of abdominal pains this Beautiful child could have……

Acute

oOrganicoInorganic/ Idiopathic/ functional

Chronic

OrganicInorganic/ Idiopathic/ functional

Here again there may be many variations

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.

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.

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.

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.

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.

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.

• 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

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 infectionExtraintestinal

symptoms Cough, dyspnea, dysuria, urinary frequency, flank pain

Course of symptoms Worsening or improving, change in nature or location of pain

Physical ExaminationGeneral 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

LaboratoryCBC, C-reactive protein, ESR Evidence of infection or inflammationAST, ALT, GGT, bilirubin Biliary or liver diseaseAmylase, lipase PancreatitisUrinalysis Urinary tract infection, bleeding due to stone,

trauma, or obstructionPregnancy test (older females)

Ectopic pregnancy

RadiologyPlain 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, malrotationUltrasound Gallstones, appendicitis, intussusception,

pancreatitis, kidney stonesEndoscopyUpper endoscopy Suspected peptic ulcer or esophagitis

Diagnostic Approach to Acute Abdominal Pain

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.

Differential Diagnosis of Acute Abdominal Pain

TraumaticDuodenal hematomaRuptured spleenPerforated viscusFunctionalConstipation*Irritable bowel syndrome*Dysmenorrhea*Mittelschmerz (ovulation)*Infantile colic*InfectiousAppendicitis*Viral or bacterial gastroenteritis/adenitis*AbscessSpontaneous bacterial peritonitisPelvic inflammatory diseaseCholecystitisUrinary tract infection*PneumoniaBacterial typhlitisHepatitis

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

ObstructiveIntussusception*Malrotation with volvulusIleus*Incarcerated herniaPostoperative adhesionMeconium ileus equivalent (cystic fibrosis)Duplication cyst, congenital strictureBiliaryGallstoneGallbladder hydropsBiliary dyskinesiaPepticGastric or duodenal ulcerGastritis*EsophagitisRenalKidney stoneHydronephrosis

Distinguishing Features of Abdominal Pain in Children

Disease Onset Location Referral Quality CommentsFunctional: 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

Distinguishing Features of Abdominal Pain in Children

Disease Onset Location Referral Quality CommentsIntestinal obstruction Acute or

gradualPeriumbilical-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

Distinguishing Features of Abdominal Pain in Children

Disease Onset Location Referral Quality CommentsLactose intolerance Recurrent with

milk productsLower 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

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.

Differential Diagnosis of Recurrent Abdominal Pain

Functional abdominal pain*Irritable bowel syndrome*Chronic pancreatitisGallstonesPeptic disease Duodenal ulcer Gastric ulcer EsophagitisLactose intolerance*Fructose malabsorptionInflammatory bowel disease* Crohn disease Ulcerative colitisConstipation*Obstructive uropathyCongenital intestinal malformation Malrotation Duplication cyst Stricture or webCeliac disease*

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.

• 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.

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.

Warning Signs of Underlying Illness in Recurrent Abdominal Pain

VomitingAbnormal screening laboratory studyFeverBilious emesisGrowth failurePain awakening child from sleepWeight lossLocation away from periumbilical regionBlood in stools or emesisDelayed puberty

• 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.

• 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.

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 ColonoscopyESR Amylase, lipase Urinalysis Abdominal ultrasound-examine liver, bile ducts, gallbladder, pancreas, kidneys, ureters

Trial of 3-day lactose-free diet

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.

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.

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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