Approach To Abdominal Pain Flashcards
What percentage of children presenting to a doctor have abdominal pain?
Up to 10% of children seeing a doctor present with abdominal pain.
What percentage of pediatric hospital admissions are due to abdominal pain?
Up to 15% of pediatric admissions to the hospital are due to abdominal pain.
What are the primary goals when assessing a child with abdominal pain?
- Exclude or treat serious organic pathology.
- Reassure if no serious organic pathology is found.
- Advise on warning signs and when to seek further medical attention.
Why is reassurance particularly important in recurrent abdominal pain of childhood?
Because it is a diagnosis of exclusion, and symptomatic treatment with reassurance is often required.
What is the most common diagnosis for abdominal pain in children
Non-specific abdominal pain (unknown cause).
What is the second most common cause of abdominal pain in children?
Gastroenteritis
What is the third most common cause of abdominal pain in children?
Constipation
Why is it important to check a urine dipstick in a child with abdominal pain?
To rule out a urinary tract infection (UTI), which is a common cause of abdominal pain.
Name four other common causes of abdominal pain in children besides non-specific pain, gastroenteritis, and constipation.
- Viral infection
- Appendicitis
- Streptococcus pharyngitis
- Pneumonia
What percentage of general practitioner visits for abdominal pain are due to appendicitis?
Approximately 1%.
Name two ENT conditions that can present with abdominal pain in children.
- Pharyngitis
- Otitis media
Most common diagnoses in order of frequency for abdominal pain
Most common diagnoses in order of frequency:
1. Non-specific abdominal pain (unknown cause)
2. Gastroenteritis
3. Constipation
4. Urinary tract infection: always check urine dipstick
5. Viral infection
6. Appendicitis: (~1% of general practitioner visits for abdominal pain)
7. Streptococcus Pharyngitis
8. Pharyngitis
9. Pneumonia
10. Otitis Media
What should be done if abdominal pain wakes a child up at night?
Further diagnostic investigation, treatment, or referral is required.
What vital sign abnormality specifically indicates the need for urgent resuscitation and referral?
Haemodynamic changes, especially tachycardia.
What should be done if pyrexia is present in a child with abdominal pain?
Work up the cause of infection, take baseline infectious markers (FBC ± CRP) and cultures, and start antibiotics promptly.
What skin signs might indicate poor perfusion in a child with abdominal pain?
Cool and clammy skin
What skin lesions might support a diagnosis in a child with abdominal pain?
Petechiae, cellulitis, rash, or jaundice.
What gastrointestinal symptom requires urgent surgical referral if it persists for more than 6 hours?
Abdominal tenderness associated with gastrointestinal and inflammatory signs or an acute abdomen.
What are two serious vomiting symptoms that require urgent surgical referral?
Vomiting bile or blood.
What other gastrointestinal symptom requires urgent surgical referral?
Blood per rectum.
What characteristic of pain suggests a surgical cause of abdominal pain?
Pain that precedes vomiting
What associated urinary symptoms indicate the need for further investigation?
Any urinary symptoms accompanying abdominal pain.
What associated signs suggest sepsis in a child with abdominal pain?
Fever, tachycardia, hypotension, altered mental state, or other systemic signs of infection.
What respiratory signs associated with abdominal pain require further evaluation?
Respiratory distress, abnormal breath sounds, or signs of pneumonia.
What is the most-feared cause of abdominal pain in children?
Acute appendicitis.
What is the mortality rate of acute appendicitis in developing countries due to delayed diagnosis?
Up to 1%.
What are the classical symptoms of acute appendicitis in children?
- Abdominal pain localizing to the right iliac fossa.
- Progression of symptoms with pain duration >6 hours.
- Associated gastrointestinal symptoms (nausea, loss of appetite, vomiting, diarrhea).
- Pain preceding gastrointestinal symptoms.
- Signs of inflammation (e.g., pyrexia) with focal or generalized peritonitic signs.
Why is diagnosing acute appendicitis challenging in children under 5 years and neurologically impaired children?
Signs are often picked up late due to communication difficulties, leading to >95% presenting with complicated appendicitis.
What is the recommended approach for children <5 years old with suspected appendicitis and abnormal vital signs?
Have a low threshold for further investigation, surgical review, or admission for observation.
What should be done when a child presents early with abdominal pain and tenderness but no peritonitic signs?
- Further observation for progression or resolution of symptoms.
- Withhold antibiotics unless high-grade pyrexia or systemic illness is present.
- Admit for 12-24 hours with repeated clinical examinations.
Why should antibiotics be withheld in early appendicitis without systemic illness?
To avoid masking symptoms, especially when viral infections like mesenteric adenitis are common.
What special investigations should be considered to rule out other causes of pain/fever in suspected appendicitis?
- Urine dipstick (UTI).
- Clinical exam and chest x-ray (pneumonia).
- ENT exam (middle ear infection).
- Abdominal ultrasound (mesenteric adenitis).
- Menstrual and sexual history with ultrasound (gynaecological pathology).
What percentage of children in South Africa present with perforated appendicitis?
Over 60%.
.
What does a high rate of perforation in South Africa indicate about the timing of presentation?
It indicates a delay of at least 48 hours from the onset of symptoms.
When should medical treatment of acute appendicitis be considered?
Only under the supervision of a surgeon, with confirmation by imaging and exclusion of contraindications (e.g., faecolith, recurrent appendicitis, perforation).
What percentage of acute appendicitis cases in high-income countries are suitable for medical treatment?
About 25%.
What percentage of acute appendicitis cases in low-income countries are suitable for medical treatment?
Less than 5%.
Why is medical management of acute appendicitis less feasible in low-income countries?
Due to limited follow-up care, limited interventional radiology for abscess drainage, and delayed presentations.
When should antibiotics be given for abdominal pain in children?
Only if there is a clear diagnosis (e.g., pneumonia, UTI) or if significant pyrexia or illness justifies further investigation to determine the infection source.
What should be done if significant pyrexia is present but the source of infection is unclear?
Perform further investigations (e.g., imaging, laboratory tests) to identify the cause before initiating antibiotics.
What is an important differential diagnosis of abdominal pain that may present with vaginal discharge?
Primary peritonitis.
What is the most common cause of recurrent abdominal pain in children?
Functional abdominal pain of childhood.
What percentage of children experience recurrent abdominal pain?
More than 10%.
How long do symptoms of functional abdominal pain typically persist?
Nearly half resolve within 6 months, but up to a third may continue into adulthood.
What are the risk factors for functional abdominal pain in children?
- Female gender
- Family history
- History of sexual abuse
- Primary-school-going age
- Comorbid anxiety, depression, or psychological stressors
What are the Rome IV criteria (2016) for diagnosing functional abdominal pain?
- Symptoms for ≥ 2 months, occurring ≥ 4 times per month
- Episodic/continual pain not solely related to meals or menses
- Exclusion of other functional disorders (e.g., IBS, functional dyspepsia, abdominal migraine)
- Exclusion of medical conditions that could explain the pain
What percentage of cases with recurrent abdominal pain have an identifiable organic cause?
Only 5-10%.
Name some common organic causes of recurrent abdominal pain related to the stomach.
- Peptic ulcer disease
- H. pylori-associated gastritis
- NSAID-associated gastritis
What pancreatic condition can cause recurrent abdominal pain?
Pancreatitis
What bowel-related causes should be considered in recurrent abdominal pain?
- Constipation (very common)
- Inflammatory bowel disease
- Aerophagia
- Mesenteric adenitis
- Foreign body ingestion
- Coeliac disease
What urinary tract conditions can cause recurrent abdominal pain?
- Urinary tract infection (UTI)
- Hydronephrosis
- Renal stones
What gallbladder conditions may present with recurrent abdominal pain?
Gallbladder sludge or stones.
What spleen-related condition should be considered in children with sickle cell disease?
Sickle cell crisis or splenomegaly
What should be considered when constipation is the primary issue in recurrent abdominal pain?
- Dietary recommendations and stool softeners (e.g., polyethylene glycol).
- Behaviour modification for stool type 1 & 2 on the Bristol stool chart.
- Screening for anal fissure, anorectal malformation, Hirschsprung’s disease, hypothyroidism, spina bifida, abdominal mass, cystic fibrosis, and calcium imbalances.
