Abdominal Pain, Pediatric

Basics

Description

Abdominal pain is a subjective symptom that can originate from any intra-abdominal organ but also be secondary to non-abdominal sources (e.g., peridiaphragmatic conditions [e.g., pneumonia], referred pain, systemic infection [e.g., strep A or viral pharyngitis], depression).
Acute abdominal pain is often due to benign and self-limited etiologies but may also be due to potentially life-threatening conditions.
Chronic abdominal pain, defined as present >2 months, can either be of organic origin (anatomic, infectious, inflammatory, or metabolic) or, more frequently, part of a functional gastrointestinal disorder (FGID) based on specific diagnostic criteria (Rome III).

Epidemiology

Abdominal pain is one of the most common complaints in pediatric patients.
Chronic abdominal pain represents 2-4% of general pediatrics office visits and more than 50% of pediatric gastroenterology visits and can be associated with significant morbidity. Thus, chronic pain also warrants careful consideration and management.

Pathophysiology

The nature of abdominal pain is multifactorial and may evolve in nature over time (i.e., in acute appendicitis, pain typically migrates from periumbilical to right lower quadrant).
Visceral pain (particularly from small intestine) is often poorly localized and is described as dull, diffuse, cramping, or burning. Visceral pain may be associated with autonomic reflex responses (diaphoresis, pallor, nausea, and/ or vomiting).
More localized, sharp somatoparietal pain typically indicates peritoneal involvement (appendicitis, cholecystitis).
Referred pain is related to the level of spinal cord entry of visceral afferent nerves (e.g., scapular pain in cholecystitis).

Etiology

Right upper quadrant
- Cholelithiasis/cholecystitis
- Hepatitis/perihepatitis
- Nephrolithiasis
- Ureteropelvic junction obstruction
- Right lower lobe pneumonia
Epigastric area
- Gastroesophageal reflux disease (GERD)
- Esophagitis (GERD, eosinophilic)
- Gastritis (NSAID, allergic, Helicobacter pylori, Crohn disease)
- Functional dyspepsia
- Ulcer disease (NSAID, H. pylori)
- Pancreatitis
- Cholecystitis
- Gastric/small intestinal volvulus
Left upper quadrant
- Splenic hematoma
- Renal disease (see above)
- Left lower lobe pneumonia
- Constipation
Right lower quadrant
- Appendicitis/perforation/psoas abscess
- Mesenteric adenitis
- Intussusception
- Inflammatory bowel disease (IBD)
- Infection (tuberculosis, Yersinia)
- Ovarian/testicular torsion
- Ectopic pregnancy
- Inguinal hernia
Left lower quadrant
- Constipation
- Colitis (inflammatory/infectious)
- Sigmoid volvulus
- Genitourinary disease (see above)
Hypogastric area
- Constipation
- Colitis
- Cystitis
- Dysmenorrhea/uterine disease
- Pelvic inflammatory disease
Periumbilical area
- FGID
- Constipation
- Gastroenteritis (infectious/eosinophilic)
- Pancreatitis
- Gastric/small bowel volvulus
- Appendicitis (early)
- Incarcerated umbilical hernia
Diffuse
- Constipation
- FGID
- Giardiasis
- Carbohydrate malabsorption
- Celiac disease
- Streptococcal/viral pharyngitis
- IBD
- Allergic/eosinophilic gastroenteritis
- Ischemic necrotizing enterocolitis (NEC)
- Perforation/peritonitis
- Malrotation with volvulus
- Lead/iron poisoning/pica syndrome
- Cyclic vomiting syndrome
- Porphyria
- Sickle cell crisis
- Familial Mediterranean fever
- Diabetic ketoacidosis
- Henoch-Sch ¶nlein purpura (HSP)
- Tumor
- Trauma
- Hemolytic uremic syndrome (HUS)

Diagnosis

Approach to the Patient

Initial step is to establish the acuity and severity of symptoms and to rule out a potentially life-threatening emergency (e.g., appendicitis, perforation, bowel obstruction associated with volvulus, adhesions, or intussusception).

History

Onset and duration of symptoms
- Acute versus chronic
Age of patient may be indicative of certain etiologies particularly in acute presentation.
- NEC (newborn/prematurity), malrotation/volvulus (80% present in first month of life), intussusception (more frequent in infants/ toddlers), foreign body ingestion in young child
Localization and radiation of pain
- May point to specific organ-see etiologies
Triggering or relieving factors
- Meals/spices, specific foods (lactose, sucrose)
- General position with knees bent can be relieving in acute appendicitis.
- Pain relieved by defecation (constipation) versus pain worsened by defecation (colitis)
Bowel pattern and stool appearance
- Stool frequency and consistency: diarrhea versus constipation
- Urgency or nocturnal diarrhea (colitis)
- Presence of bloating and excessive flatulence (giardiasis, carbohydrate malabsorption)
- Presence of mucus (may be normal but can be associated with colitis)
- Hematochezia (fissure, hemorrhoid, polyp, colitis, HSP); if bright red "currant jelly"¯ appearance, suspect intussusception
- Melena (upper gastrointestinal bleeding/ulcer)
- Pale/acholic stools (hepatic or biliary disease)
- Perirectal disease (IBD)
Anorexia/nausea/vomiting
- If postprandial, indicative of upper gastrointestinal condition; nausea may be functional.
- May indicate extraintestinal disease (urinary tract infection, UPJ obstruction, or pneumonia)
- Hematemesis suggests esophagitis/gastritis; more significant blood volume suggests ulcer disease, Mallory-Weiss tear (lower esophagus)
- Bilious emesis indicates intestinal obstruction (volvulus, intussusception, NEC in newborns)
Dysphagia/food impaction
- In older children, suspect eosinophilic esophagitis
- GERD
Fever
- Acute infection, acute appendicitis, chronic inflammatory process
Weight loss/growth failure/delayed puberty
- Chronic inflammatory process, celiac disease
Extraintestinal symptoms
- Dysuria
- Skin rash (atopy may point to eosinophilic process; purpura: abdominal pain may be first symptom of HSP)
- Respiratory symptoms (pneumonia)
- Arthralgias (IBD, HSP)
Preexisting conditions (infectious diarrhea preceding HUS; hemoglobinopathy or cystic fibrosis risk factors for cholecystitis)
Exposures
- Lead/iron in young children
- Travel/well water/pets (giardiasis)
- Insect bite (HSP)
- NSAID use (gastritis)
- Tetracycline (pill esophagitis)
Dietary history to assess fiber and fluid intake; excessive use of sugar-free gum (sorbitol malabsorption); intake of sucrose-, fructose-, or lactose-containing foods (various disaccharidase deficiencies, most commonly lactose intolerance)
Prior abdominal surgical history (adhesions)
Family history of IBD, H. pylori, celiac disease, atopy, migraine
Social history and identification of stressors, school attendance, signs of mood disorder

Physical Exam

In an acute setting, an abdominal exam may need to be serially performed, as location of pain may change over time.
Signs of acute appendicitis:
- Exquisite pain at McBurney point on percussion or palpation
- Involuntary guarding
- Rovsing sign (palpation LLQ), psoas sign, obturator sign
- Rebound tenderness (peritoneal inflammation)
- Pain on movement (walking, jumping)
- Pain may be relieved temporarily if the appendix ruptures followed by signs of peritonitis.
- Right upper quadrant pain on inspiration (cholecystitis)
- Flank tenderness (renal pathology)
- Perianal examination may reveal skin tags/fissures (constipation, IBD), perianal abscess (IBD), hemorrhoids
Rectal examination done carefully can be indicative of
- Peritoneal irritation (appendicitis/peritonitis)
- Hematochezia (IBD, HSP), perianal disease
- Fecal retention/abnormal sphincter tone (anal stricture, absent relaxation of IAS suggesting anal achalasia)
Skin rashes (eczema, purpura)
Other signs of chronic disease include pallor, clubbing, edema

Diagnostic Tests & Interpretation

Laboratory testing, if any, should be carefully guided by the history and clinical picture.
- If a benign acute condition such as acute viral gastroenteritis is suspected, any further testing can be delayed with close follow-up (in absence of clinical evidence of dehydration).
- In the presence of "red flags"¯ (see "Referral"¯), blood and stool testing should be performed
CBC/differential
- Leukocytosis (appendicitis/abscess, acute infectious process); normal white blood cell count may indicate low risk for acute appendicitis
- Anemia (gastrointestinal blood loss)
- Microcytosis (chronic inflammation, IBD, celiac disease)
Elevated ESR or CRP (acute infection, chronic inflammation)
Hypoalbuminemia and low ferritin (IBD, celiac disease); diarrhea may be absent
Pancreatic enzymes, hepatic enzymes
Fecal cultures in the presence of bloody diarrhea (colitis); ova and parasites (giardiasis)
Fecal calprotectin and lactoferrin (inflammation or infection)
Urinalysis to rule out urinary tract infection (leukocyturia may be present in acute appendicitis)
Celiac screening (anti-tissue transglutaminase IgA or anti-endomysial IgA in presence of normal total IgA levels) should be considered if abdominal pain and/or constipation do not respond to bowel regimen or if unexplained diarrhea, weight loss/growth failure; also at risk: type 1 diabetes, autoimmune thyroiditis, Down/Turner syndrome
Thyroid screen if abdominal pain/chronic constipation unresponsive to therapy
Radiologic evaluation (abdominal decubitus and upright films)
- Dilatation or air-fluid levels: acute obstruction
- "Double bubble"¯ sign and airless abdomen: midgut volvulus/malrotation
- Air-fluid level or fecalith in right lower quadrant: acute appendicitis if suspected
- Radiopaque renal stones or dilated ureters
Upper gastrointestinal contrast study to document anatomic anomalies (i.e., malrotation)
Ultrasound/CT scan in the evaluation of trauma, acute appendicitis, intussusception, suspected abscess in IBD, tumors, pancreatitis/ pseudocyst, cholecystitis
Use of CT scan in suspected acute appendicitis should be carefully considered, as it can both lead to unnecessary appendectomies or be falsely negative. In patients identified as "low risk"¯ for appendicitis (absent leukocytosis with left shift), ultrasound and/or close observation should be considered as alternative to CT scan.

Alert
H. pylori testing is NOT indicated in the evaluation of chronic abdominal pain, nonulcer dyspepsia, or newly diagnosed GERD unless the patient has endoscopically documented peptic ulcer disease, a family history of gastric cancer, documented mucosa-associated lymphoid tissue (MALT) lymphoma, or unexplained iron deficiency anemia.

Treatment

General Measures

In the acute setting of abdominal pain suggesting a potential life-threatening condition (acute appendicitis, acute obstruction, volvulus), the patient should be stabilized and referred appropriately for further management including surgery if indicated.
In the setting of extraintestinal conditions (i.e., pneumonia, pharyngitis, or urinary tract infection), antibiotic therapy should be initiated if indicated.
In the setting of chronic pain and in the absence of red flags (see "Referral"¯), the most likely diagnoses can be categorized as abdominal pain-related FGIDs. These include functional dyspepsia, IBS, abdominal migraine, and functional abdominal pain syndrome. The diagnosis of these entities is based on specific symptom based criteria (Rome III).

Surgery/Other Procedures

Functional dyspepsia: trial of proton pump inhibitor (PPI) therapy for 4 weeks to rule out postviral dyspepsia. Avoid use of NSAIDs, spicy and fatty foods, and caffeine. If no response or unable to tolerate progressive taper of PPIs, refer to a gastroenterologist for endoscopic evaluation.
Irritable bowel syndrome: address bowel pattern: diarrhea (antidiarrheals); constipation (nonstimulating laxatives); peppermint oil or antispasmodics may alleviate pain; probiotics
Functional abdominal pain syndrome: Use biopsychosocial approach; behavioral treatment with or without trial of tricyclic antidepressants (particularly in presence of anxiety)

Alert
Psychological comorbidities should be addressed in all FGIDs.

Issues for Referral

The presence of clinical red flags, in the setting of acute or chronic abdominal pain, may indicate an underlying mucosal pathology of the gastrointestinal tract (other than infectious), warranting referral to a gastroenterologist for further endoscopic evaluation and management. These include the following:
- Nocturnal pain: pain that wakes from sleep
- Persistent vomiting and/or dysphagia
- GERD non responsive to PPI trial
- Hematemesis
- Nocturnal diarrhea
- Hematochezia
- Perianal disease
- Weight loss/delayed growth and/or puberty
- Family history of PUD or IBD

Additional Reading

Chitkara DK, Rawat DJ, Talley NJ. The epidemiology of childhood recurrent abdominal pain in Western countries: a systematic review. Am J Gastroenterol. 2005;100(8):1868-1875. [View Abstract]
Kharbanda AB, Dudley NC, Bajaj L, et al. Validation and refinement of a prediction rule to identify children at low risk for acute appendicitis. Arch Pediatr Adolesc Med. 2012;166(8):738-744. [View Abstract]
Koletzko S, Jones NL, Goodman KJ, et al. Evidence-based guidelines from ESPGHAN and NASPGHAN for Helicobacter pylori infection in children. J Pediatr Gastroenterol Nutr. 2011;53(2):230-243. [View Abstract]
Korterink JJ, Ockeloen L, Benninga MA, et al. Probiotics for functional gastrointestinal disorders: a systematic review and meta-analysis. Acta Paediatr. 2014;103(4):365-372. [View Abstract]
McCollough M, Sharieff GQ. Abdominal pain in children. Pediatr Clin North Am. 2006;53(1):107-137, vi. [View Abstract]
Nurko S, Di Lorenzo C. Functional abdominal pain: time to get together and move forward. J Pediatr Gastroenterol Nutr. 2008;47(5):679-680. [View Abstract]
Rasquin A, Di Lorenzo C, Forbes D, et al. Childhood functional gastrointestinal disorders: child/adolescent. Gastroenterology. 2006;130(5):1527-1537. [View Abstract]
Ross A, LeLeiko NS. Acute abdominal pain. Pediatr Rev. 2010;31(4):135-144. [View Abstract]
Saps M, Youssef N, Miranda A, et al. Multicenter, randomized, placebo-controlled trial of amitriptyline in children with functional abdominal gastrointestinal disorders. Gastroenterology. 2009;137(4):1261-1269. [View Abstract]

Codes

ICD09

789.00 Abdominal pain, unspecified site
789.09 Abdominal pain, other specified site
789.03 Abdominal pain, right lower quadrant
789.01 Abdominal pain, right upper quadrant
789.07 Abdominal pain, generalized
540.9 Acute appendicitis without mention of peritonitis
535.50 Unspecified gastritis and gastroduodenitis, without mention of hemorrhage
536.8 Dyspepsia and other specified disorders of function of stomach
789.04 Abdominal pain, left lower quadrant
789.02 Abdominal pain, left upper quadrant
789.06 Abdominal pain, epigastric
789.05 Abdominal pain, periumbilic
575.10 Cholecystitis, unspecified

ICD10

R10.9 Unspecified abdominal pain
R10.0 Acute abdomen
R10.31 Right lower quadrant pain
R10.11 Right upper quadrant pain
R10.30 Lower abdominal pain, unspecified
R10.33 Periumbilical pain
R10.12 Left upper quadrant pain
R10.10 Upper abdominal pain, unspecified
R10.13 Epigastric pain
R10.84 Generalized abdominal pain
K29.70 Gastritis, unspecified, without bleeding
K35.80 Unspecified acute appendicitis
R10.32 Left lower quadrant pain
K81.9 Cholecystitis, unspecified
K30 Functional dyspepsia
R10.2 Pelvic and perineal pain

SNOMED

21522001 abdominal pain (finding)
116290004 Acute abdominal pain (finding)
111985007 Chronic abdominal pain (finding)
301717006 right upper quadrant pain (finding)
4556007 Gastritis (disorder)
102614006 Generalized abdominal pain
162031009 Indigestion (finding)
301754002 right lower quadrant pain (finding)
443503005 Periumbilical pain
76581006 Cholecystitis (disorder)
74400008 Appendicitis (disorder)

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