Abdominal pain
Background
Abdominal pain is a frequent presentation in children of all ages. There are endless possible causes for abdominal pain, most of which are not life-threatening. Often, the pathology is not even in the abdomen. Younger children in particular have a tendency to complain of abdominal pain when completely unrelated parts of their body are suffering the true insult. Middle ear infections are one such common reason for a toddler to say that their tummy hurts. In many cases the cause is never found and the pain disappears as mysteriously as it came.
Assessing the child with abdominal pain can be a very rewarding experience. Most of the time, the child will be brought to you by puzzled, anxious parents. Usually, you will be able to offer an explanation, reassurance and possibly even a treatment. So consider these children a challenge which you expect to conquer.
How to assess
Much of this is the same as assessing adults with the same problem. You take a history and then examine the child and possibly do some tests. At the end of this process you will have an idea as to whether or not there is a surgical problem and whether you know what the cause of the abdominal pain is. If you have no definite diagnosis, do not be surprised. The decision is now whether to send the child home or refer them (and to whom you will refer).
Since you will probably want to test a urine specimen, it is worthwhile making this a priority from the start. Otherwise, when you do ask, the child will just have passed urine and then seems to lose all ability to do so for the next few hours. Then, starting with the history, it is important to ask the following questions:
•When did the pain first appear? Has it been constant since then or does it come and go?
•Does anything make the pain better? If analgesia has been given, find out exactly what, how often and how much.
•Does anything make it worse?
•What is the pain like? Where is the pain felt? Has the pain moved?
•How bad is the pain? Some children will use words to describe the severity, and some can give it a score out of ten. A smiley/sad face chart is a useful tool for assessing severity.
•Has the child been eating and drinking? When was the last time they had anything? If you suspect a surgical problem, advise that the child should not have anything else to eat or drink for the time being.
•Has the child been opening their bowels? If not then have they passed wind? This question gets some great responses!
•Has there been any diarrhoea, blood or mucous in the stools?
•Has the child been passing urine? Is it less or more often than usual? Are there symptoms such as dysuria or eneuresis?
•Has anyone in the family had a similar problem either recently or in their own childhood?
When examining the child, be aware that the best information comes from standing back and looking at the child, preferably without them being aware that you are doing so. It is therefore very useful to casually pay attention to any observations that you can make while taking the history.
•Look at the whole child. How are they behaving? Are they subdued and still, or have you seen them move comfortably?
•Does the abdomen move with breathing? The younger the child, the more their abdomen will normally move while they breathe. When peritoneal discomfort sets in, this abdominal movement ceases.
•Assess skin colour, warmth of peripheries, pulse and central capillary refill.
•Listen to the chest and heart and look for signs of respiratory distress. Have you noticed a cough?
•Look at the skin of the abdomen for scars and bruises.
•Tell the child that you are about to feel their tummy. Tell them that you will be gentle and that you will stop if they want you to. Do not use the word ‘hurt’, even to say ‘I won’t hurt you.’
•While looking at the child’s response, gently feel the child’s abdominal wall. If the child is anxious then use their hand under yours. You will be able to assess tenderness, though not masses.
•If possible, now palpate deeply in the way that would find masses or organomegaly.
•Percuss gently, more to assess whether there is tenderness on percussion (which is a sign of peritonism) than to assess the percussion note.
•Auscultate for bowel sounds.
•Inspect the inguinal regions for hernias and in boys, inspect and palpate the scrotum.
•Now go back and examine the ears and throat. It is important to do this, since many of these children will have an upper respiratory tract infection (URTI) as the cause of their abdominal pain. To do it before examining the abdomen risks upsetting the child and will make the abdominal assessment impossible.
•Test a urine specimen and if in doubt check a blood sugar. Other tests may be helpful, but these are two tests that are relatively harmless and if not done will occasionally lead to missed diagnoses.
The ‘must do’s
If dealing with a newborn, consider an atresia as a possibility. Even if a baby has passed meconium, there may be a congenital defect in their bowel.
Always examine the throat and ears.
Always check a urine specimen.
Always examine the genitalia of a male patient.
Always consider gynaecological causes in a pubertal female patient.
Remember to consider child abuse at any age.
If referring to a surgeon, remember to advise that the child should not eat or drink until they have been seen and told that they can drink again.
Pitfalls to avoid
There is essentially no role for rectal examination in children. It should really only ever be performed in exceptional circumstances. It is not needed to assess peritonism, as that can be assessed adequately per abdomen.
Do not avoid asking questions for fear of embarrassing the patient or parents. Better to embarrass them than suffer humiliation yourself. Do not shy away from issues of sexual activity, sexual maturity and possible abuse.
Do not hesitate to give adequate analgesia. Giving a reasonable amount of painkiller will not mask significant intra-abdominal pathology and it is cruel to leave a child with untreated pain. The quantities of syrup required to give a child analgesia will not jeopardise their induction of anaesthesia should this be needed later.
Figure 6.1 Causes of abdominal pain in children
A guide to the initial management of abdominal pain
The information gathered will allow you to make a diagnosis in most cases. The following table lists the most common and most important diagnoses:
Diagnosis | Age group, common symptoms, etc |
Colic | This condition affects babies from soon after birth to the age of several months old. It is very common, to the extent that you could call it a normal variant. The colicky child is essentially the one who is experiencing more extreme abdominal spasms as their bowel gets used to moving food from the stomach to the rectum. It is essential to demonstrate normal growth as they present as thriving children, though the parents’ may be at their wit’s end. Typically they describe episodes of crying associated with drawing up of legs. This can go on for hours at a time and often nothing will settle the child. Colic can be diagnosed based on a typical history and a well child. No tests are needed, provided the child has no concerning features in the history, on examination or on the growth chart, and no treatment is effective. The management consists of reassurance and explanation. |
Pyloric stenosis | This classically affects babies around the age of four weeks old. It is more common in first born males and especially where there is a family history of pyloric stenosis. The classic history is of a progressively more severe vomiting. The child is hungry for feeds, vomits minutes after a feed and then cries. True projectile vomiting should raise suspicion of pyloric stenosis. However, children with pyloric stenosis may not have projectile vomiting and vice versa. Surgical management is needed for this condition but usually after fluid resuscitation. |
Intussusception | This dangerous condition can occur at any age. One peak of incidence occurs around 6 to 12 months of age. This is thought to be due to the child having more severe viral infections as maternal antibodies dwindle. As a result, the Peyer’s patches in the gut swell in response to infection providing a lead point for the bowel to get stuck inside itself. These children present with episodes of severe abdominal pain, or floppy and pale episodes, or both. Vomiting is often associated. The ‘textbook’ sign of redcurrant jelly occurs when bowel is ischaemic and thus is a late sign. All children with suspected intussusception need urgent surgical assessment. |
Constipation | The build up of faeces usually results in the symptoms of colic in children under one year old. However constipation can occur at any age and has many forms of presentation. Constipation is a very common cause of abdominal pain in children at all ages and is frequently missed. Because diagnosis and management of constipation is such an art form, this deserves a chapter of its very own (see Chapter 7). |
Urinary tract infection (UTI) | UTI actually doesn’t always present with abdominal pain in children, but it is an important differential whenever the problem is apparently abdominal. Assessment and management of UTI is covered in Chapter 5. |
Mesenteric adenitis | This phenomenon occurs mainly in children under five years old. It is abdominal pain caused by intra-abdominal lymph node inflammation and can only truly be diagnosed at laparoscopy. In reality, it is sometimes diagnosed in a child who has an obvious viral infection and associated abdominal pain. Such children are usually given analgesia and managed at home. Mesenteric adenitis can be severe however and mimic a surgical abdomen. In patients where this diagnosis is suspected but the child is more unwell, or has signs of a possible surgical abdomen, surgical assessment is compulsory even if there is a rampant upper respiratory tract infection. |
Gastroenteritis | Whenever a child develops diarrhoea and vomiting due to gastroenteritis, abdominal pain can be a prominent feature. There can be colicky pains due to bowel spasms as the gut becomes inflamed. However it is the pain that follows vomiting which can lead doctors to suspect a surgical abdomen because the abdominal wall may be tender to palpation. The factors that should lead away from a diagnosis of eg appendicitis are the presence of diarrhoea, and the onset of vomiting before the pain started. Although not all abdominal tenderness is surgical, getting enough information to be sure can be difficult in children. If in doubt, observe or refer. The management of diarrhoea and vomiting is covered in Chapter 8. |
Appendicitis | Appendicitis, probably the most hunted for diagnosis in the child with abdominal pain, is thankfully uncommon. It does start to occur more often in the older child and when missed can cause devastating infection. The child with mild or early appendicitis may not be easy to spot, so, when unsure, a careful assessment and repeated examination (after about an hour) are both essential. Classic appendicitis results in an unwell and usually very subdued child. The feature that distinguishes appendicitis from some of the causes of abdominal pain that might mimic it is the presence of abdominal pain that precedes vomiting. It is unusual to have acute appendicitis without a fever. In the older child the progression of pain from around the umbilicus towards the right lower quadrant may help to make the diagnosis. However, a textbook history is rare, and so the reality is that surgical opinions should be sought whenever a child has significant abdominal tenderness or other signs of a surgical abdomen. |
Pneumonia | A lower lobe pneumonia is one of the lesser known causes of abdominal pain. The pneumonia is often missed initially, partly because pneumonia is sometimes difficult to pick up and partly because the chest is away from the area of focal symptoms in these patients. To avoid getting caught out, think of it as a possibility and do justice to examining the respiratory system. The management of lower respiratory tract infection is covered in Chapter 5. |
Testicular torsion | About a quarter of boys who have torsion of the testes present with abdominal pain. It may also present in preverbal children who will simply be upset and inconsolable. The diagnosis is usually apparent when the scrotum is examined. The scrotum may be swollen or the testis may be tender. The important factor is to always examine the genitalia of a boy presenting with upset or abdominal pain. Prompt surgical intervention increases the chance that the testis will be salvageable. If the boy has the torsion corrected within four hours of onset, usually the testis will be |
Testicular torsion | viable. However, by 12 hours from the onset, this number has dropped below half being salvageable. |
Pregnancy, ovarian torsion and pelvic inflammatory disease | I find that GPs and emergency medicine doctors are usually better than paediatricians at considering gynaecological causes for abdominal pain. About 30% of children in the UK have their first act of sexual intercourse before the age of 16. Every year approximately one in every hundred girls under the age of 16 becomes pregnant. Of course, gynaecological problems such as torsion of an ovary can occur even if not sexually active. The important thing is to realise that this is an important possibility to consider in pubertal girls. The only way to adequately assess the possibility of a gynaecological cause is to politely ask to speak to the child alone or with a nurse only. (It is important to be adequately chaperoned when discussing or examining for sexual health matters with anyone, but even more so with a child.) Most parents will see the value in your desire to explore confidential issues and if you are denied this opportunity, this raises the concern of possible child abuse. When you are able to discuss sexual health in a suitable environment, ask a full gynaecological history in an age-appropriate way. |
Non-specific abdominal pain | This diagnosis of exclusion is made frequently in children but is poorly understood. It is usually less acute than other forms of abdominal pain in its onset. Often, it is the random and recurrent nature of the pain which causes much anxiety to the family. In order to diagnose non-specific abdominal pain, a child must be well and thriving in between episodes and other possible diagnoses must be excluded. (The most common cause of mysterious abdominal pains is most definitely constipation. I would even consider an empirical trial of macrogol treatment for a few weeks before saying with certainty that constipation has been ruled out.) Therefore the nature of the diagnosis usually requires outpatient referral to a paediatrician before it can be said that all causes have been excluded. |
Non-IgE food allergy | While we tend to think of allergy as presenting with rashes and wheeze, this is not always the case. Non-IgE food allergy in children presents mostly with GI symptoms. Babies may vomit, cry and have poor weight gain. Older children may have intermittent abdominal pains. Gluten and cow’s milk protein are both probable allergens if a non-IgE food allergy is suspected. |
Inflammatory bowel disease | Crohn’s disease and ulcerative colitis do occur, though uncommonly, in childhood. As well as abdominal pain, the children with inflammatory bowel disease usually present with bloody or mucousy diarrhoea. The features which set the children with inflammatory bowel disease apart from the more acute causes of bloody diarrhoea are the chronic signs and symptoms in the assessment. If a child has features suspicious for inflammatory bowel disease, they should be referred to the paediatric medical team. |
Diabetic ketoacidosis | Especially when a child presents for the first time as a diabetic, this life-threatening condition can be easily missed in the hunt for a cause of abdominal pain. The child can be mistakenly diagnosed as having a surgical abdomen because there is abdominal pain and vomiting without diarrhoea in a patient who is significantly unwell. Because early recognition of this condition is essential to prevent the associated morbidity and mortality, it is worth including a blood sugar test in the initial assessment of any child with abdominal pain and vomiting. A urine dipstick will also point you towards the diagnosis but may not be immediately forthcoming. This condition should be managed according to local or national guidelines initially with cautious but adequate fluid resuscitation. |
Non accidental injury (NAI) | Child abuse can cause abdominal pain for physical or psychological reasons. When fever is absent and no other diagnosis is apparent, it is important to not just consider but also to exclude this possibility. This can only really be done by explaining that this is part of your job and ensuring that you have asked the child about physical and sexual abuse in a place and a way that would allow them to respond. This is a complicated but important subject which also has its own chapter (see Chapter 10). |
Table 6.1 Diagnoses for abdominal pain
How to be a know-it-all
Abdominal migraine is a cause of acute and recurrent abdominal pain which is probably under-diagnosed. If the specific questions are asked, there may be a history of headache, visual disturbance or nausea associated with the abdominal pains. A first degree relative with migraine also makes the diagnosis more likely. Identifying the diagnosis will often end months of wondering why the tummy pains are occurring. Treatment is the same as for migraine headaches, and both lack much evidence to support the standard treatments given.
De-mystifying the role of the paediatrician: what the paediatrician might do
One dilemma frequently faced by a referring doctor is ‘who do I refer to?’ If the provisional diagnosis is surgical, then surgeons who are skilled in managing the age group of child you are dealing with should be happy to take a direct referral.
Children with abdominal pain will frequently be admitted under the sole care or with the joint care of the paediatric medical team, especially in district general hospitals. The paediatrician is a good person to assess the child who has an uncertain diagnosis. They are also good at managing pain and fluid balance.
Ultimately if a child needs referring it is important to get them to the most appropriate specialist as quickly as possible. For example, a child with intussusception should be seen by a surgeon urgently, and if the doctor you speak to is unwilling, ask to speak to the consultant. However any doctor used to making referrals will know that sometimes surgeons are sceptical about our assessment. Although it may be frustrating for the paediatrician to be landed with a possible surgical problem it is in the best interest of the child that a willing doctor will admit the child to observe while managing their pain and fluid balance. If the paediatrician also assesses and feels that the problem is surgical then they can re-refer.
FAQs
Is it ok to give non-steroidal anti-inflammatory drugs (NSAIDs) to children who already have abdominal pain?
NSAIDs are useful analgesics for children but have well known side effects. There is a lack of evidence regarding the safety of NSAIDs when given to children who either have abdominal pain or an empty stomach. In practice, children seem to tolerate NSAIDs much better than adults do. I would advise a preference for giving paracetamol to any child who needed analgesia in any case. If this is not adequate then a NSAID may well improve pain control, so I use them cautiously.
If used on an ‘as required’ basis for no more than a couple of days then gastritis is unusual. In fact, there can be a beneficial effect, since children who are febrile or have abdominal pain tend not to want to eat. If a NSAID can help to resolve these symptoms then they are more likely to feel like eating.
The notable exception to the rule is that it is unwise to allow a child who is dehydrated to have NSAIDs. Renal complications are also thankfully rare, but children with poor urine output are at greater risk and so should not take NSAIDs.
What do I tell the parents?
When I think that their child has colic:
‘From what you have told me and having examined your baby, it seems most likely to me that the problem is colic. What we call colic is just the fact that the baby is feeling uncomfortable moving food around their bowels. No one really knows why some babies get this and others don’t. The good news is that colic is completely harmless to your baby. The bad news is that nothing helps colic to go away.’
‘Colic does go away on its own after a few weeks, however in the meantime I understand how upsetting it is. Studies show that none of the medicines that you can buy for colic are any better than a placebo, so I do not use them. I understand that some parents feel that they work and I certainly have nothing against parents using them if that is the case. The most important thing to understand is that the colic will come and go as it pleases, so you should not exhaust yourself trying to make it go away. If you have made sure that your child is fed, warm, and in a clean nappy, then if they cry despite a cuddle, you are not doing anything wrong if you put them down in their cot. Sometimes a baby that cries constantly can be very frustrating and it is better to let them cry than to get upset with your baby.’
When I think that the abdominal pain is most likely related to a viral illness and the child does not need to be referred to a surgeon:
‘The tummy pain that your child has is probably due to the cold virus which they are suffering with at the moment. Everyone has glands inside their tummy just like the ones in the neck that get swollen when we are poorly. Children seem to be prone to getting painful swollen glands in their tummies when they are ill with any viral infection. Because that fits with what your child has at the moment and they are not worryingly unwell, I am happy for them to go home. They should respond well to medicines like paracetamol and they can have that at home just as easily. The tummy pain should start to go away as the cold/sore throat gets better, which might take a few days.’
‘I am always careful about tummy pain though, because it can be a little tricky sometimes. I don’t think that your child has a problem like appendicitis, otherwise I would not think about suggesting that you take them home. However, if the pain gets worse despite medicines, or your child starts vomiting, stops drinking or seems more unwell, it is best to get them seen again. At any point, if you think that something has changed and you are worried, I want you to bring your child back.’
Flowchart for assessing the child with abdominal pain
Figure 6.1 Flowchart for assessing the child with abdominal pain
Summary for abdominal pain
•The causes of abdominal pain in children are multiple. Most are not harmful, however, abdominal pain can be a symptom of serious illness.
•The diagnosis is usually apparent from the history, and should be supported by careful examination.
•A urine specimen should usually be tested.
•In most cases a cause is suspected and the child is well enough to be allowed home, but appropriate advice is essential to ensure that the child returns if more unwell.
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