Definition (Silen W. Cope’s Early Diagnosis of the Acute Abdomen. 20th ed. New York, NY: Oxford Univ. Press, 2000; Pediatr Rev. 2010;31:135)
• Abd pain 2/2 activation of visceral nerves (innervate hollow viscera & mesentery; poorly localizing), or somatic nerves (innervate parietal peritoneum; focal)
• Parietal inflammation can be 2/2 worsening underlying visceral inflammation; presenting w/ generalized abd pain, which progressively localizes (i.e., appendicitis)
• Pain can be referred to abd from other structures (i.e., pleuritis in lower lobe PNA, Strep. pharyngitis) (Pediatr Clin North Am 2006;53:107)
Clinical Manifestations (BMJ 1969;1:284; Pediatr Rev. 2010;31:135)
• History w/ assoc sx, signs, & physical exam are important to narrow differential
• Concerning sx: Anorexia (appendicitis), bilious emesis (obstruction), rebound or guarding (peritonitis), assoc findings of palpable purpura (HSP) or ecchymosis on abdomen or back (pancreatitis). Fever can be concerning but nonspecific
• Localized pain can be helpful for localization, but is often nonspecific
• RUQ: Gall bladder (GB) or hepatic/perihepatic disease, RLL PNA
• LUQ: Stomach, LLL PNA, splenic dz (often w/ L shoulder pain)
• Epigastrium: Stomach, small bowel, pancreatitis, mesenteric ischemia
• RLQ: Appendicitis (starts periumbilical), ovarian disease in female, ileitis, colitis
• LLQ: Colitis, ovarian disease in female
• Suprapubic: UTI, PID
• Radiating pain: To testicles or labia (nephrolithiasis), to back (pancreatitis, GB)
• Administration of analgesia does not impair clinical exam (Arch Dis Child 2008;93:995)
Etiology (Pediatr Clin North Am 2006;53:107)
• Etiologies and working differential varies based on age. See specific topics for Rx
• Gastroenteritis (viral) & constipation most common benign causes for all ages
• Appendicitis (see ED chapter); dx in 82% of children admitted w/ abd pain
• Higher rates of perforation in children. Often mistaken for gastroenteritis
• Intussusception (see ED chapter); most frequent btw 3 mo and 5 yr, 60% w/i 1st yr
• Peak btw 6 and 11 mo. 60% p/w 2 of 3: Abd pain, vomiting, bloody mucous stool
• Small bowel obstruction: Multi etiologies, most common 2/2 adhesions from prior surgery or incarcerated hernia; p/w abd pain, vomiting (bile), distention
• Incarcerated hernia: 60% inguinal (R side) in 1st yr; p/w groin bulge
• Malrotation w/ midgut volvulus: Highest incidence in 1st mo; often abd pain and bilious vomiting, but can be insidious. Surgical emergency
• Necrotizing enterocolitis: Preterm but in full term as well; present in extremis
• Consider systemic illnesses such as sickle cell disease and DKA
Diagnostic Studies
• Evaluation is dependent on history (associated symptoms & signs) & physical exam
• PMH of abd surgery raises risk of incarcerated hernia or obstruction 2/2 adhesion
• Always consider the possibility of child abuse