Abdominal pain, acute

Question 1

The commonest causes

Answer 1

acute appendicitis (21%)

colics (16%)

mesenteric adenitis (16%).

Question 2

Probability diagnosis

Answer 2

Infant ‘colic‘ (2–16 weeks)

Gastroenteritis (all ages)

Mesenteric adenitis

Question 3

Serious disorders not to be missed

Answer 3

Infection:

• acute appendicitis (mainly 5–15 years)
• pneumonia (esp. right lower lobe)
• pyelonephritis
• peritonitis

Cancer:

• colon cancer (rare)

Other:

• intussusception (peaks at 6–9 months)
• bowel obstruction
• coeliac disease
• strangulated inguinal hernia

Drugs:

including cigarette smoking (nicotine), marijuana, cocaine and heroin.

Question 4

Pitfalls (often missed)

Answer 4

1. Child abuse
2. Constipation
3. Torsion of testes
4. Lactose intolerance
5. Peptic ulcer
6. Infection: mumps, tonsillitis, pneumonia (esp. right lower lobe), EBM, UTI, hepatitis
7. Adnexal disorders in females (e.g. ovarian)
8. Rarities:

• Meckel diverticulitis
• Henoch–Schönlein purpura
• inflammatory bowel disease
• sickle crisis
• lead poisoning

Question 5

Masquerades checklist

Answer 5

Diabetes mellitus

Drugs

UTI

Question 6

Important cause

Answer 6

Psychogenic consideration

Question 7

Key history

Answer 7

Differentiate the severe problems demanding surgery from the non-surgical ones.

About 1 in 15 will have a surgical cause for pain.

The causes are often age specific so a family history is important.

Question 8

Key examination

Answer 8

Note general appearance, vital signs and oral cavity

Abdominal examination: inspection, auscultation, palpation and percussion (in that order)

Rectal examination is mandatory: look for constipation including impacted faeces

Examine lungs, especially if lower lobe pneumonia suspected

Consider gentle abdominal palpation with a soft toy

Question 9

Key investigations

Answer 9

Rule out urinary infection with urinalysis.

• Blood, protein and leucocytes may all be present with acute appendicitis.
• Nitrites are more specific for UTIs

FBE/ESR/CRP

Scanning according to findings

Imaging (e.g. oxygen/barium enema) as appropriate

Question 10

Diagnostic tips

Answer 10

Consider mesenteric adenitis in a flushed febrile child with an URTI or tonsillitis.

Vomiting occurs in at least 80% of children with appendicitis and diarrhoea in about 20%.

A pale infant with severe colic and vomiting indicates acute intussusception.