Approach To Abdominal Pain

Question 1

What percentage of children presenting to a doctor have abdominal pain?

Answer 1

Up to 10% of children seeing a doctor present with abdominal pain.

Question 2

What percentage of pediatric hospital admissions are due to abdominal pain?

Answer 2

Up to 15% of pediatric admissions to the hospital are due to abdominal pain.

Question 3

What are the primary goals when assessing a child with abdominal pain?

Answer 3

1. Exclude or treat serious organic pathology.
   
   2. Reassure if no serious organic pathology is found.
   3. Advise on warning signs and when to seek further medical attention.

Question 4

Why is reassurance particularly important in recurrent abdominal pain of childhood?

Answer 4

Because it is a diagnosis of exclusion, and symptomatic treatment with reassurance is often required.

Question 5

What is the most common diagnosis for abdominal pain in children

Answer 5

Non-specific abdominal pain (unknown cause).

Question 6

What is the second most common cause of abdominal pain in children?

Answer 6

Gastroenteritis

Question 7

What is the third most common cause of abdominal pain in children?

Answer 7

Constipation

Question 8

Why is it important to check a urine dipstick in a child with abdominal pain?

Answer 8

To rule out a urinary tract infection (UTI), which is a common cause of abdominal pain.

Question 9

Name four other common causes of abdominal pain in children besides non-specific pain, gastroenteritis, and constipation.

Answer 9

1. Viral infection
   
   2. Appendicitis
   3. Streptococcus pharyngitis
   4. Pneumonia

Question 10

What percentage of general practitioner visits for abdominal pain are due to appendicitis?

Answer 10

Approximately 1%.

Question 11

Name two ENT conditions that can present with abdominal pain in children.

Answer 11

1. Pharyngitis
   
   2. Otitis media

Question 12

Most common diagnoses in order of frequency for abdominal pain

Answer 12

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

Question 13

What should be done if abdominal pain wakes a child up at night?

Answer 13

Further diagnostic investigation, treatment, or referral is required.

Question 14

What vital sign abnormality specifically indicates the need for urgent resuscitation and referral?

Answer 14

Haemodynamic changes, especially tachycardia.

Question 15

What should be done if pyrexia is present in a child with abdominal pain?

Answer 15

Work up the cause of infection, take baseline infectious markers (FBC ± CRP) and cultures, and start antibiotics promptly.

Question 16

What skin signs might indicate poor perfusion in a child with abdominal pain?

Answer 16

Cool and clammy skin

Question 17

What skin lesions might support a diagnosis in a child with abdominal pain?

Answer 17

Petechiae, cellulitis, rash, or jaundice.

Question 18

What gastrointestinal symptom requires urgent surgical referral if it persists for more than 6 hours?

Answer 18

Abdominal tenderness associated with gastrointestinal and inflammatory signs or an acute abdomen.

Question 19

What are two serious vomiting symptoms that require urgent surgical referral?

Answer 19

Vomiting bile or blood.

Question 20

What other gastrointestinal symptom requires urgent surgical referral?

Answer 20

Blood per rectum.

Question 21

What characteristic of pain suggests a surgical cause of abdominal pain?

Answer 21

Pain that precedes vomiting

Question 22

What associated urinary symptoms indicate the need for further investigation?

Answer 22

Any urinary symptoms accompanying abdominal pain.

Question 23

What associated signs suggest sepsis in a child with abdominal pain?

Answer 23

Fever, tachycardia, hypotension, altered mental state, or other systemic signs of infection.

Question 24

What respiratory signs associated with abdominal pain require further evaluation?

Answer 24

Respiratory distress, abnormal breath sounds, or signs of pneumonia.

Question 25

What is the most-feared cause of abdominal pain in children?

Answer 25

Acute appendicitis.

Question 26

What is the mortality rate of acute appendicitis in developing countries due to delayed diagnosis?

Answer 26

Up to 1%.

Question 27

What are the classical symptoms of acute appendicitis in children?

Answer 27

1. Abdominal pain localizing to the right iliac fossa. 2. Progression of symptoms with pain duration >6 hours. 3. Associated gastrointestinal symptoms (nausea, loss of appetite, vomiting, diarrhea). 4. Pain preceding gastrointestinal symptoms. 5. Signs of inflammation (e.g., pyrexia) with focal or generalized peritonitic signs.

Question 28

Why is diagnosing acute appendicitis challenging in children under 5 years and neurologically impaired children?

Answer 28

Signs are often picked up late due to communication difficulties, leading to >95% presenting with complicated appendicitis.

Question 29

What is the recommended approach for children <5 years old with suspected appendicitis and abnormal vital signs?

Answer 29

Have a low threshold for further investigation, surgical review, or admission for observation.

Question 30

What should be done when a child presents early with abdominal pain and tenderness but no peritonitic signs?

Answer 30

1. Further observation for progression or resolution of symptoms. 2. Withhold antibiotics unless high-grade pyrexia or systemic illness is present. 3. Admit for 12-24 hours with repeated clinical examinations.

Question 31

Why should antibiotics be withheld in early appendicitis without systemic illness?

Answer 31

To avoid masking symptoms, especially when viral infections like mesenteric adenitis are common.

Question 32

What special investigations should be considered to rule out other causes of pain/fever in suspected appendicitis?

Answer 32

1. Urine dipstick (UTI). 2. Clinical exam and chest x-ray (pneumonia). 3. ENT exam (middle ear infection). 4. Abdominal ultrasound (mesenteric adenitis). 5. Menstrual and sexual history with ultrasound (gynaecological pathology).

Question 33

What percentage of children in South Africa present with perforated appendicitis?

Answer 33

Over 60%. .

Question 34

What does a high rate of perforation in South Africa indicate about the timing of presentation?

Answer 34

It indicates a delay of at least 48 hours from the onset of symptoms.

Question 35

When should medical treatment of acute appendicitis be considered?

Answer 35

Only under the supervision of a surgeon, with confirmation by imaging and exclusion of contraindications (e.g., faecolith, recurrent appendicitis, perforation).

Question 36

What percentage of acute appendicitis cases in high-income countries are suitable for medical treatment?

Answer 36

About 25%.

Question 37

What percentage of acute appendicitis cases in low-income countries are suitable for medical treatment?

Answer 37

Less than 5%.

Question 38

Why is medical management of acute appendicitis less feasible in low-income countries?

Answer 38

Due to limited follow-up care, limited interventional radiology for abscess drainage, and delayed presentations.

Question 39

When should antibiotics be given for abdominal pain in children?

Answer 39

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.

Question 40

What should be done if significant pyrexia is present but the source of infection is unclear?

Answer 40

Perform further investigations (e.g., imaging, laboratory tests) to identify the cause before initiating antibiotics.

Question 41

What is an important differential diagnosis of abdominal pain that may present with vaginal discharge?

Answer 41

Primary peritonitis.

Question 42

What is the most common cause of recurrent abdominal pain in children?

Answer 42

Functional abdominal pain of childhood.

Question 43

What percentage of children experience recurrent abdominal pain?

Answer 43

More than 10%.

Question 44

How long do symptoms of functional abdominal pain typically persist?

Answer 44

Nearly half resolve within 6 months, but up to a third may continue into adulthood.

Question 45

What are the risk factors for functional abdominal pain in children?

Answer 45

1. Female gender 2. Family history 3. History of sexual abuse 4. Primary-school-going age 5. Comorbid anxiety, depression, or psychological stressors

Question 46

What are the Rome IV criteria (2016) for diagnosing functional abdominal pain?

Answer 46

1. Symptoms for ≥ 2 months, occurring ≥ 4 times per month 2. Episodic/continual pain not solely related to meals or menses 3. Exclusion of other functional disorders (e.g., IBS, functional dyspepsia, abdominal migraine) 4. Exclusion of medical conditions that could explain the pain

Question 47

What percentage of cases with recurrent abdominal pain have an identifiable organic cause?

Answer 47

Only 5-10%.

Question 48

Name some common organic causes of recurrent abdominal pain related to the stomach.

Answer 48

1. Peptic ulcer disease 2. H. pylori-associated gastritis 3. NSAID-associated gastritis

Question 49

What pancreatic condition can cause recurrent abdominal pain?

Answer 49

Pancreatitis

Question 50

What bowel-related causes should be considered in recurrent abdominal pain?

Answer 50

1. Constipation (very common) 2. Inflammatory bowel disease 3. Aerophagia 4. Mesenteric adenitis 5. Foreign body ingestion 6. Coeliac disease

Question 51

What urinary tract conditions can cause recurrent abdominal pain?

Answer 51

1. Urinary tract infection (UTI) 2. Hydronephrosis 3. Renal stones

Question 52

What gallbladder conditions may present with recurrent abdominal pain?

Answer 52

Gallbladder sludge or stones.

Question 53

What spleen-related condition should be considered in children with sickle cell disease?

Answer 53

Sickle cell crisis or splenomegaly

Question 54

What should be considered when constipation is the primary issue in recurrent abdominal pain?

Answer 54

1. Dietary recommendations and stool softeners (e.g., polyethylene glycol). 2. Behaviour modification for stool type 1 & 2 on the Bristol stool chart. 3. Screening for anal fissure, anorectal malformation, Hirschsprung’s disease, hypothyroidism, spina bifida, abdominal mass, cystic fibrosis, and calcium imbalances.