Abdominal Pain in Children
Section snippets
General approach to the child who has abdominal pain
Important information often can be elicited even before speaking to the parents or laying hands on a child. Infants and young toddlers are usually afraid of strangers. Older children may associate a clinic environment or a “man in a white coat” with immunizations and pain. The difficulty of physical examination increases when the physician enters the examination room and the child bursts into tears. Observing the child's behavior before any interaction may reveal the reassuring signs of a young
Epidemiology
Acute gastroenteritis (AGE) is the most common gastrointestinal inflammatory process in children. The cause is usually viral, and rotavirus is the most common virus. In the United States, 200,000 children are hospitalized every year, and 300 to 400 deaths are caused by diarrheal disease. Costs to health care are estimated at $2 billion per year. Rotavirus is the most significant cause of severe diarrhea in childhood, with a peak incidence between 4 and 23 months of age. A rotavirus vaccine was
Constipation
Parents often worry that their infant or child is constipated, particularly because it is common for infants to strain and turn red in the face during bowel movements. Unfortunately, a uniform definition of constipation has yet to be determined. 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. Newborns typically have a meconium stool in the first 48 hours of life and then can range from zero to 12
Causes
Appendicitis is the abdominal pain most commonly treated surgically in childhood, affecting four of every 1000 children. Appendicitis is the cause of pain in 2.3% of all the children with abdominal pain seen in ambulatory clinics or EDs. Of all the children admitted to the hospital with abdominal pain, 82% are diagnosed with appendicitis [15]. Because of the difficulty in evaluating young children with abdominal pain, perforation rates for appendicitis are higher than in the general adult
Pathophysiology
Intussusception was first described over 300 years ago. It is the prolapse of one part of the intestine into the lumen of an immediately distal adjoining part. The most common type is ileocolic invagination. During the invagination, the mesentery is dragged along into the distal lumen, and venous return is obstructed. This leads to edema, bleeding of the mucosa, increased pressure in the area, and eventually obstruction to arterial flow. Gangrene and perforation result.
Causes
Intussusception is seen
Pathophysiology
Small bowel obstruction may result from intrinsic, extrinsic, or intraluminal disease. Although the most common causes of small bowel obstruction are adhesions from previous abdominal surgery and incarceration of a hernia [70], intussusception, appendicitis, Meckel's diverticulum, malrotation with midgut volvulus, and tumors also should be considered as possible causes. In addition to inguinal hernias, umbilical, obturator, and femoral canal hernias may also lead to small bowel obstruction [56].
Causes
Inguinal hernias occur in 1% to 4% of the population, more often in males (6:1), and more often on the right side (2:1). Premature infants are at a higher risk for hernias (30%), and 60% of incarcerated inguinal hernias occur during the first year of life. Umbilical hernias are also commonly seen in the infant population. Unlike inguinal hernias, umbilical hernias will rarely become incarcerated and usually will close without surgery by 1 year of age. Other disorders place patients at an
Pathophysiology and causes
Meckel's diverticulum is the most common congenital abnormality of the small intestine. Meckel's diverticulum is a remnant of the omphalomesenteric (vitelline) duct that disappears normally by the seventh week of gestation. It is a true diverticulum, containing all layers of the bowel wall. Up to 60% of these diverticuli containing heterotopic gastric tissue and heterotopic pancreatic, endometrial, and duodenal mucosa have also been reported [72], [73]. The features of Meckel's diverticulum are
Very young infants
Very young infants, those less than a few months old, also have unique gastrointestinal conditions. Colic should be considered a diagnosis of exclusion. Hypertrophic pyloric stenosis is a common presentation, and surgical correction does not need to be immediate. Volvulus caused by congenital malrotation is a true surgical emergency, and consultation with a pediatric surgeon should be immediate once the diagnosis is considered. Fortunately, necrotizing enterocolitis, another gastrointestinal
Colic
Colic affects 1 in 6 families and is more likely to be reported by older mothers with longer full-time education and nonmanual occupations. To this day, the cause of colic remains unclear but is believed to be related to increased gas production in the infant's intestines and, possibly, to neurologic or psychologic reasons. Other experts consider colic to be part of the normal distribution of crying.
Pathophysiology
Hypertrophic pyloric stenosis (HPS) is a narrowing of the pyloric canal caused by hypertrophy of the musculature. The cause of this condition remains unclear, but some experts theorize that HPS is caused by Helicobacter pylori, the same bacteria associated with peptic ulcer disease. This theory is based on nonspecific evidence, such as the temporal distribution, seasonality, and familial clustering of HPS, along with the pathologic finding of leukocytic infiltrates, and the increased incidence
Pathophysiology
Congenital malrotation of the midgut portion of the intestine is often the cause of volvulus in the neonatal period. Malrotation occurs during the fifth to eighth week in embryonic life when the intestine projects out of the abdominal cavity, rotates 270°, and then returns into the abdomen. If the rotation is not correct, the intestine will not be “fixed down” correctly at the mesentery, and the vascular mesentery will appear more stalk-like in its structure and is at risk later for twisting,
Causes
Necrotizing enterocolitis (NEC) is seen typically in the neonatal intensive care unit, occurring in premature infants in their first few weeks of life. Occasionally, it is encountered in the term infant, usually within the first 10 days after birth. The cause of NEC is unknown, but a history of an anoxic episode at birth and other neonatal stressors are associated with the diagnosis [91], [92].
Pathophysiology
The pathologic finding of NEC is that of a necrotic segment of bowel with gas accumulation in the
Summary
Abdominal pain or gastrointestinal symptoms are common complaints in young children. It is the emergency physician's duty to understand current recommendations regarding the evaluation and management of more benign conditions such as gastroenteritis and also be able to differentiate a true surgical condition such as appendicitis.
References (92)
- et al.
Hypoglycemia and ABC's (sugar)
Ann Emerg Med
(2000) - et al.
A randomized clinical trial comparing ondansetron with placebo in children with vomiting from acute gastroenteritis
Ann Emerg Med
(2002) - et al.
Role of Alvarado score in diagnosis and treatment of suspected acute appendicitis
Am J Emerg Med
(2000) - et al.
Importance of diarrhea as a presenting symptom of appendicitis in very young children
Am J Surg
(1997) - et al.
Acute appendicitis in children: emergency department diagnosis and management
Ann Emerg Med
(2000) - et al.
Clinical application of infrared thermography in the diagnosis of appendicitis
Am J Emerg Med
(1994) - et al.
Sonographic diagnosis of acute appendicitis in children
J Pediatr Surg
(1994) - et al.
Clinical validity of ultrasound in children with suspected appendicitis
Ann Emerg Med
(1993) - et al.
Selective use of ultrasonography for acute appendicitis in children
Am J Surg
(1999) - et al.
Does early ultrasonography affect management of pediatric appendicitis? a prospective analysis
J Pediatr Surg
(1999)