Abdominal Pain

Question 1

What is your impression and goals of management?

A child presents to the emergency department with abdominal pain.

Answer 1

Impression: there are many causes of abdominal pain in a child, including surgical and non-surgical. I would like to focus my assessment to rule out any life threatening or time critical conditions (necrotising enterocolitis, Hirschprung enterocolitis, intussusception, volvulus, incarcerated hernia, trauma, Meckel’s diverticulum, testicular/ovarian torsion, ectopic pregnancy).

Differentials

• GIT → see below
• Non-GIT → sepsis, DKA, pneumonia, sickle cell crisis, UTI/pyelonephritis, migraine, HSP, hip pathology, STI, toxin exposure, psychological

Goals of Management

1. Ensure the patient is haemodynamically stable
2. Take a targeted history/examination to assess the pain and proceed with further investigations as appropriate
3. Management with supportive and definitive treatment, depending on aetiology and involve other teams as appropriate

Question 2

Abdominal pain: history

Answer 2

History

• Symptomatology
  
  • Fever, nausea, vomiting, anorexia (gastroenteritis, mesenteric adenitis)
  • Diarrhoea (gastroenteritis)
  • Fatigue or jaundice (viral hepatitis)
  • Lethargy, headache, photophobia (abdominal migraine)
  • Cough, shortness of breath (pneumonia or empyema)
  • Pain elsewhere (e.g., sudden-onset testicular pain suggests testicular torsion)
  • Blood in stool (ulcerative colitis, necrotising enterocolitis, intussusception, dysentery, haemolytic uraemic syndrome) or mucus in stool (suggests bacterial or parasitic infection)
  • Blood or bile in vomitus (small bowel obstruction)
  • Genitourinary symptoms: dysuria, frequency of micturition, and haematuria (UTI); vaginal discharge (PID); current menstruation (dysmenorrhoea)
• Past medical/surgical history + medications
• Gynaecological/sexual history
• Family history
• Paediatric history → development, vaccinations

Question 3

Abdominal pain: examination

Answer 3

Examination

• Observe the child’s movements, gait, position and level of comfort
• Abdominal examination → focal vs generalised tenderness, peritonism (rebound/percussion tenderness, guarding or rigidity, hop test), masses, distension, palpable faeces
• Assess for non-abdominal causes

Question 4

Abdominal pain: investigations

Answer 4

Most children need no investigations

• Bedside → U/A (+/- culture +/- pregnancy test if indicated), BGL (DKA), VBG, urine bHCG
• Bloods → EUC, LFTs, lipase
• Imaging
  
  • AXR → if obstruction suspected (not helpful for constipation)
  • CXR → if pneumonia suspected
  • U/S → very low yield if used indiscriminately
    
    • It is not clinically indicated for testicular torsion and may delay time critical surgery
    • May be useful for ovarian torsion/cyst, intussusception, appendicitis, trauma

Question 5

Abdominal pain: management

Answer 5

Supportive

• Fluid resuscitation
• Correct hypovolemia with normal saline boluses
• Ongoing IVF for existing deficits + maintenance with normal saline + 5% dextrose
• Analgesia → IV morphine or intranasal fentanyl may be required as initial analgesia in severe pain
• Keep NBM
• Consider a nasogastric tube if bowel obstruction is suspected
• Specific*
• As per diagnosis
• Disposition*
• As per diagnosis
• Consult paediatric/surgical team when surgical cause suspected, severe pain not responding to analgesia or if child requires admission
• Discharge when there are no concerning clinical features, follow-up plan has been arranged with GP and parental education given regarding when to seek medical attention (increasing pain, fevers, new symptomatology)