Y2

West Visayas State University – College of Medicine | AUREUM B11

M11
Acute & Chronic Abdominal Pain in Pediatric Patients L31

BY: Dr. Mendoza | 10/26/2022 | 8:00-10:00 AM

OUTLINE Characteristics of visceral, somatic, and referred

pain
I. Patholophysiology of Pain Visceral Referred
II. Acute Abdominal Pain Characteristics Somatic Pain
III. Characteristics of Abdominal Pain Pain Pain
A. Organic Causes Based on Regional Intra- Parietal
Same
B. Location Differential Diagnosis of Acute abdominal peritoneum,
C. Abdominal Pain by Predominant age dermatome
Origin organs with abdominal wall,
IV. Assessment as diseased
visceral retroperitoneal
A. History organ
B. Physical Examination peritoneum muscles
C. Laboratory Studies Intensity Dull Sharp, intense Sharp
D. Indications for Surgical Consultation
E. Algorithm for Acute Pain Difficult to Remote
F. Validated Prediction Scores for Appendicitis in Location Localized
localize areas
Children
V. Chronic Abdominal Pain Cause Inflammation, ischemia, stretching
A. Definition
B. Prevalence
C. Alarm Symptoms and Alarm Signs
D. Acid Peptic Disease • Visceral Pain – visceral fibers are bilateral and
E. Differential Diagnosis for Chronic unmyelinated, enter the spinal cord at multiple levels;
F. Abdominal Pain usually dull, poorly localized, and felt at the midline.
G. Functional GI Disorders
H. Potential alarm features in children with • Somatic Pain – pain is transmitted by myelinated
Chronic Abdominal Pain afferent fibers to specific dorsal root ganglia on the
VI. Treatment same side and same dermatomal level as the origin of
A. Functional Dyspepsia the pain, making the pain localized.
B. Irritable Bowel Syndrome
C. Abdominal Migraine • Referred pain – felt far away from the diseased organ.
Summary Results from a shared central pathway for afferent
Review Questions neurons from different sites.
References
Pneumonia – may present with abdominal pain
Appendices
because the T9 dermatome distribution is shared
by the lung and abdomen.
I. PATHOPHYSIOLOGY OF PAIN ○ Parietal pleural inflammation = pain is referred
• Abdominal pain in children is a frequent and to right or left upper quadrant.
challenging problem; a common cause of ER or clinic ○ Parietal pleura shares the same dermatomal
visit. origin with peritoneum.
• It can be acute or chronic
• Pain may herald as a surgical or medical emergency Characteristics of visceral, somatic, and referred
• Timely diagnosis is the challenge so that treatment pain
can be initiated and morbidity can be prevented Location of pain
Organs involved
• Chronic abdominal pain is long-lasting, intermittent, or manifestation
constant pain which can be organic or functional in Esophagus up to 2nd part
etiology. Foregut Epigastric Region
of duodenum

2nd part of duodenum up

MIdgut Periumbilical Region
to mid-transverse colon

Mid-transverse colon up
Hindgut Hypogastric Region
to rectum
II. ACUTE ABDOMINAL PAIN Pyelonephritis, Renal stone, Ovarian
▪ Usually self-limiting, however, initial assessment torsion/cyst, PID
should focus on severity and whether there is a
potential surgical cause of abdominal pain. Cystitis, Bladder anomalies, Sigmoid
Hypogastrium
▪ In children presenting in the ER with acute abdominal volvulus, PID
pain, the incidence of appendicitis or other cause
Left Lower UPJ obstruction, Pyelonephritis, Renal
needing surgical intervention ranges from 10-30%.
Quadrant stone, Ovarian torsion/cyst, PID
• However, in general, the incidence of surgical acute
abdominal pain is 2%. CAUSES OF ACUTE ABDOMINAL PAIN:
• Emergent cause
A.DIFFERENTIAL DIAGNOSIS OF ACUTE ABDOMINAL
Surgical in nature
PAIN BY PREDOMINANT AGE Located intra-abdominally or extra-abdominally
▪ Understanding the pathophysiology of abdominal pain Can be acute or chronic
helps in the differential diagnosis. • Non-emergent cause
▪ Good history and PE helps narrow it down.
• In taking the history of the patient, always know the
III. CHARACTERISTICS OF ABDOMINAL
age.
PAIN
Differential diagnosis of acute abdominal pain by
predominant age Organic causes based on regional location
Age Differential Diagnosis Pain Characteristic
Appendicitis (common cause of acute • Perforation
abdominal pain), Bowel obstruction, Child • Torsion-twisted bowel
Sudden
All Ages abuse, Constipation, Gastroenteritis, HUS, • Intussusception (apparently well child
Onset
Mesenteric adenitis, Pancreatitis, Sickle suddenly crying)
cell crisis, Trauma, URTI, UTI • Ectopic pregnancy
Hirschsprung disease, Infantile colic, • Appendicitis: dull, periumbilical to RLQ
0-4 yo Inguinal hernia, Intussusception, Lactose • Pancreatitis: steady pain slowly increasing in
intolerance, Malrotation, Volvulus Slow
character localizing in epigastric area, then
Onset
Abdominal migraine, Functional pain, HSP, radiating to the back
5-11 yo
Intussusception, Lead poisoning • Cholecystitis
Colicky
Ectopic pregnancy, Functional pain, IBD, Pain
12-18 yo • From: Intestines, biliary tree, pancreatic
IBS, Dysmenorrhea, Mittelschmerz, PID (Organs
with duct, uterus, fallopian tube
lumen, • Usually intermittent
B. ORGANIC CAUSES BASED ON REGIONAL tubular
LOCATION structures)
Organic causes based on regional location • Sickle cell anemia
Regional • IBD (Inflammatory Bowel Disease)
Organic Causes Severe
Location
Chronic • Cystic Fibrosis
Right Upper PUD, Cholecystitis, Cholangitis, Pain • Does not move, lie still, and usually
Quadrant Cholelithiasis, Pneumonia persistent

Hepatobiliary disorders, GERD,

Epigastrium
Esophagitis, Gastritis, PUD, Pancreatitis IV. ASSESSMENT
A. HISTORY
Left Upper Gastritis, PUD, Esophagitis, Pneumonia, • Age
Quadrant Splenic infarction • Pain History
Gastroenteritis, Lactose intolerance, • Associated symptoms:
Periumbilical Vomiting
Intussusception, Appendicitis, Intestinal
Area ○ Color – Hematemesis? Billous vomiting?
parasitism, Peritonitis
Fecaloid?
Right Lower Appendicitis, Mesenteric adenitis, Diarrhea
Quadrant Meckel’s diverticulitis, UPJ obstruction, Cough
Urinary changes

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 ○ Does the patient strain? Cry during urination? OB Gyne Hx
○ UTI is common in patient with constipation • Menarche at age 12
because of the pressure of the fecal material • Irregular menstruation lasting for 2-3 days
in the rectum to the urethra which causes consuming 2 to 3 pads/day
urinary stasis • PMP: Aug 4, 2019
Vaginal discharges • LMP: Oct 1, 2019, of 2 days duration
○ Check for PID especially in sexually active consuming 1 to 2 pads/day
adolescent females
HEADSSS
○ Foul smelly discharges in her underwear?
• Drugs: occasional alcoholic beverage drinker
Joint pains/rash with boyfriend, denies illicit drug use or
○ To rule out autoimmune problems cigarette smoking
• Gynecologic history • Sex: Patient revealed that she had 2
LMP, menarche unprotected sexual contact with her first
• Trauma history boyfriend of 6 months. Last sexual contact
was November 1st week.
• Diet history
• Past health B. PHYSICAL EXAMINATION
Same kind of acute pain before? • Observe the child
Use of maintenance meds, history of trauma? Does the child walk with a limp?
• Drug use Preferential posture?
Antibiotic-associated problems – complains of • General appearance
bloatedness, abdominal distention, watery stools, Note color, turgor, and perfusion
vomiting, anorexia Look for rashes, assess posture guarding
• Family history • Vital signs
PUD – has a genetic predisposition Does the child have fever? Tachycardic?
IBD Tachypneic? Hypertensive?
Autoimmune diseases
• HEENT
• Social/Psych history
Examine for inflammatory and infectious
Sexual history processes
• Chest
Doc’s Case on Nov 28, 2019
Observe for effort and rate of breathing
L.J.L., 16/F, ILOILO CITY Listen for adventitious breath sounds which might
suggest a pneumonic process
Pain Hx and Associated symptoms ▪ Abdomen
• 2 days PTA Inspect for shape, visible bowel loops, masses or
o Vague abdominal pai noted in the
external trauma
periumbilical area, colicky in
character ○ Remember that the abdomen of a child,
o (+) 1 episode of vomiting of especially in a much younger child, is globular.
previously ingested food ○ As long as the umbilicus is not seen to be
o (+) 1 episode of soft stool inverted, no visible bowel loops, no masses, or
• 1 day PTA external trauma, it may be normal
o Abdominal pain localized in the right ○ No redness, bulging; umbilicus should be
lower quadrant and became more
everted
persistent
o Note of anorexia with low grade Look for splinting of muscles and presence of
fever inguinal hernia
o (+) 2 episodes of vomiting Listen for bowel sounds
• On day of consult Palpation
o Persistence of signs and symptoms ○ When you palpate, especially the liver, start
• Pertinent negatives: diarrhea, urinary from the RLQ and try to go up until you can feel
changes, jaundice, cough, rash if the liver is enlarged, feel the edge of the liver
and take note if it is firm, soft, or hard.
Percussion – bowel sounds tympanitic
▪ Rectum
All children with abdominal pain require a rectal
exam
Assess for areas of tenderness, masses, and stool
characteristics
Check for blood

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▪ GUS C. LABORATORY AND IMAGING STUDIES
Inspect the genital area for trauma, discharge, or LABORATORY STUDIES
inflammation ▪ Test depends on your initial working impression
Percuss the costovertebral angle
▪ CBC
▪ Electrolytes
*If in doubt, consider hospitalization for careful and
▪ BUN, Creatinine
frequent observation.
▪ Liver function tests
▪ Amylase – to rule out pancreatitis
Doc’s Case on Nov 28, 2019
▪ HCG, if indicated
L.J.L., 16/F, ILOILO CITY ▪ Urinalysis
UTI usually presents with abdominal pain and
Physical Examination vomiting

Vital Signs
• BP 100/60 Doc’s Case on Nov 28, 2019
• CR 117
• RR 21 L.J.L., 16/F, ILOILO CITY
• Temp 39.2°C
Laboratory Studies
General Survey
• Arrives at ER ambulatory but limping, in pain, CBC
not in CP distress • Hemoglobin 122 g/L
• Hematocrit 0.36 L/L
HEENT • WBC 13.02 10^9 /L
• Slightly pale conjunctivae, PERRLA o Segmenters 0.70
• Dry lips and buccal mucosa, anicteric sclerae o Lymphocyte 0.25
o Eosinophil 0.00
Chest o Monocyte 0.05
• Symmetric chest expansion, CBS • Platelet count 232 10^9 /L

Heart Urinalysis
• Regular rhythm but tachycardic • Specific gravity 1.025
• No murmur • Pus cells 3-5
• RBC 0-5
Abdomen • Squamous epithelial cells many
• Slightly distended, hypoactive bowel sounds
• (+) direct tenderness on all quadrants IMAGING STUDIES
• (+) rebound tenderness right and left lower ▪ Radiographs
quadrants 2 abdominal views – if you want to rule out
possible surgical etiology
Pelvic Exam
• IE: admits 2 fingers with ease, cervix firm o Cross table lateral – if child cannot stand up
close with wriggling tenderness, no vaginal o Upright supine view – if child can stand up
discharge Chest X-ray if indicated
• Uterus small, adnexa not fully assessed due ▪ Sonograms, if indicated
to guarding ▪ CT scans, if indicated
Rectal Exam
• Soft stools palpated on rectal vault KEY RECOMMENDATIONS FOR PRACTICE
• (+) para-rectal tenderness Key recommendations for practice
Evidence
Clinical Recommendation
Extremities Rating
• Grossly normal extremities Urinalysis, CBC, pregnancy test, and erythrocyte
sedimentation rate or C-reactive protein should be the C
• Full pulses
initial laboratory tests in the evaluation of acute
• CRT <2 sec abdominal pain in children

Ultrasonography is the imaging of choice for acute

C
abdominal pain in children

Opiates may be safely used in children with acute

abdominal pain without delaying or affecting the A
accuracy of diagnosis

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 A = consistent, good-quality patient oriented evidences; B = inconsistent; C E. ALGORITHM FOR ACUTE PAIN
= consensus, disease-oriented evidence, usual practice, expert opinion or
case series.
* Also request for fecalysis.

PEDIATRIC APPENDICITIS SCORE of Doc’s Px

Patients
Pediatric Appendicitis Score
Score
Anorexia 1 1
Nausea/Emesis 1 1
Fever 1 1
Migration of pain 1 1
Tenderness in the RLQ 2 2
Cough/Percussion/Hop
2 2
Tenderness
Leukocytosis 1 1
Neutrophilia 1 0
Total 10 9

D. INDICATIONS FOR SURGICAL CONSULTATION

▪ Increasing pain with signs of deteriorations Algorithm for Acute Pain
Pain aggravates with movement
▪ Bile stained or feculent vomitus ▪ Remember: Acute Gastroenteritis (AGE) should have a
▪ Involuntary abdominal guarding or rigidity history of diarrhea
▪ Rebound abdominal tenderness – when you directly ▪ Less common diagnoses: Henoch-Schonlein purpura,
palpate the abdomen and you release your hands, vasculitis, etc.
there is pain.
▪ Marked abdominal distension with diffuse tympany F. VALIDATED PREDICTION SCORES FOR
▪ Signs of acute fluid or blood loss into the abdomen APPENDICITS IN CHILDREN
▪ Significant abdominal trauma
▪ Suspected surgical cause of the pain
▪ Abdominal pain without an obvious pathology

Validated prediction scores for appendicitis in

children

▪ Alvarado scoring is also used in adults

▪ Difference:
No rebound pain in Pediatric Appendicitis Score
because it is hard for a very young child to tell you
that there is pain after the direct palpation.
Cough/Percussion/Hopping pain in the RLQ –
child walks with a limp, percussion causes
changes in the appearance of the child.
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▪ PAS (Pediatric Appendicitis Score) Gastritis
8 – high risk for appendicitis PUD
4 to 7 – intermediate risk for appendicitis; Duodenitis
sometimes ultrasound is requested to look at the ▪ Esophagitis, Gastritis, and Duodenitis are diagnosis
appearance sonologically (there may be fluid based on histology
accumulation, + for appendicolith, size of the ▪ PUD – established through endoscopy
appendix)
<4 – low risk for appendicitis; no imaging required

V. CHRONIC ABDOMINAL PAIN

DEFINITION
▪ Recurrent abdominal pain (RAP)
>3 episodes of abdominal pain severe enough to
affect daily activities over a period for >3 months
(Apley & Nash)
Long-lasting, intermittent, or constant abdominal
pain that is functional or organic (NASPGHAN,
2005)
▪ May start as acute abdominal pain but will progress
beyond 8 weeks Acid peptic disease signs & symptoms
▪ Acute pain – around 4 weeks only
▪ Chronic pain – at least 8 weeks GASTRITIS
▪ Functional abdominal pain – starts as young as 6 ▪ Inflammation of the gastric mucosa
months of age ▪ Presence of inflammatory cells
▪ Histologic diagnosis
PREVALENCE
▪ 2-4% of all pediatric visits (Pediatrics, 1984)
PEPTIC ULCER
▪ 2.5-16% in population-based studies
▪ Discontinuities of gastric/duodenal mucosa
▪ 13-17% of pediatric population report chronic
▪ With penetration to muscularis mucosa and exposure
abdominal pain
of the submucosa
COMMUNITY-BASED SURVEY (CLINICAL GASTRO & ▪ Duodenum – most common site of ulcer in pediatric
HEPA, OCT. 2009) patients
▪ 3-17 years old
▪ 3 month prevalence of pain was 71.1% Pathogenesis
▪ Girls are more affected

ALARM SYMPTOMS AND ALARM SIGNS

Alarm symptoms and alarm signs
Alarm Symptoms
▪ Pain that awakens
the child from sleep
▪ Persistent pain
▪ Dysphagia
▪ Persistent vomiting
▪ Unexplained fever
▪ Chronic severe
diarrhea
▪ Weight loss
▪ Delayed puberty
Family history of PUB or IBD
Alarm Signs
▪ GI blood loss
▪ Abdominal tenderness
▪ Presence of mass or
organomegaly
▪ Tenderness over the
costovertebral angle or
Pathogenesis of peptic ulcer formation
spine
▪ Perianal abnormalities
▪ Arthritis ▪ GI mucosa – least site for preferential flow of blood
▪ Blood flow prefers the brain and lungs at the expense
of the GI tract

Clinical Manifestations
ACID PEPTIC DISEASE Clinical manifestations of Acid Peptic
▪ Umbrella Term that refers to the following disorders: Disease
Reflux esophagitis (GERD)
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 Infants/Young Children School Age/Adolescents ▪ Urea breath test
▪ Feeding difficulty ▪ Epigastric Pain/Nausea The 13C-UBT is a reliable non-invasive test to
▪ Crying ▪ Nocturnal pain determine whether H. pylori has been eradicated.
▪ Vomiting ▪ Dyspepsia/Fullness Not standardized in young patient
To determine responsiveness to treatment
Hematemesis/Melena
Not for diagnosis
o Patient drinks a solution of urea labeled with
Diagnosis the nonradioactive isotope 13C and then blows
in the tube.
o If H. pylori urease is present, the urea is
hydrolyzed, and the labeled carbon dioxide is
detected in breath samples (Harrison’s IM,
20th Ed.)
▪ Stool antigen test
A 2-step monoclocal stool H. pylori antigen test
can be used to determine whether H. pylori has
Upper GI Series (left) and Upper GI Endoscopy (right)
been eradicated.
Polyclonal stool antigen – cannot be used as a
screening test due to low sensitivity; only used to
▪ Upper GI series will require the child to be sedated
establish the diagnosis.
▪ Endoscopy readily visualizes ulcers
▪ Endoscopic test
The diagnosis of H. pylori infection should be
CAUSES OF ACID PEPTIC DISEASE based on either:
▪ Primary: Helicobacter pylori infection o Positive culture
▪ Secondary: o H. pylori gastritis on histopathology
NSAID and other drug use o With at least 1 other positive biopsy-based test
Stress ulcerations o Giemsa stain can be used

Helicobacter pylori infection Prevalence of H. pylori Infection

▪ First seen 1983 by Warren & Marshall
▪ Human – primary natural reservoir
▪ Most common cause of duodenal ulcers in children
▪ Iron deficiency anemia
▪ Growth retardation

Prevalence of H. pylori infection in the Philippines.

H&E stained slide with H. Pylori

Diagnosis of H. pylori infection ESPGHAN/NASPGHAN

Guidelines 2016
▪ Non-endoscopic Tests
Antibody test, Urea breath test, Stool antigen test
▪ Endoscopic Tests
Biopsy Urease test, Histology, Culture Global prevalence of H. pylori infection in children
▪ Antibody (IgA, IgG) test (Doc’s slides)
Tests based on the detection of antibodies (IgG, TREATMENT
IgA) against H. pylori in serum, whole blood, urine, ▪ Use clarithromycin, metronidazole, PPI combination if
and saliva are NOT RELIABLE for use in the clinical patient is allergic to the amoxicillin or penicillin family.
setting.

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▪ Ranitidine is discouraged by Doc because of its ▪ Eosinophilic esophagitis
possible carcinogenic potential. > 20 eosinophils/hpf in biopsy sample
Please see Appendix A for treatment of H. Pylori infection. ▪ Hepatobiliary/gallbladder disorders

ALGORITHIM FOR ACID PEPTIC DISEASE FUNCTIONAL GI DISORDERS

▪ Accounts for 70-80%
▪ Due to disorders of the brain-gut function
▪ It is classified by GI symptoms related to any
combination of the following:
Motility disturbance
Visceral hypersensitivity
Altered mucosal and immune function
Altered gut microbiota
Altered CNS processing

EPIDEMIOLOGY
▪ Philippine study
15.4% abdominal pain related FGID
o 8.4% dyspepsia
o 5.6% IBS
Acid Peptic Disease algorithm. o 1.3% childhood functional abdominal pain
▪ Therapeutic trial is not done in very young patients
DIFFERENTIAL DIAGNOSIS BIOPSYCHOSOCIAL CONCEPTUAL MODEL
▪ Inflammatory Bowel Disease (Crohn’s Disease and
Ulcerative Colitis) – chronic inflammation of the bowel

IBD PRESENTATION
Crohn’s disease vs Ulcerative colitis
Signs/Symptoms Crohn’s Disease Ulcerative Colitis
Rectal Bleeding ++ ++++
Abdominal pain ++++ +++
Diarrhea ++ ++++
Weight loss ++++ ++
Growth failure +++ +
Perianal disease ++
Mouth ulcers ++ + A biopsychosocial approach to understanding the
Erythema nodosum + + development of chronic abdominal pain.
Fevers ++ +
Anemia +++ +++ ▪ The child really has abdominal pain but the way the
Arthritis + + child perceives the abdominal pain is affected by a lot
of factors
DIAGNOSTIC APPROACH TO IBD If there is an imbalance of good and bad bacteria
▪ Suspect the diagnosis where the bad bacteria predominate, there will be
History, exam, CBC, ESR, CRP, albumin abdominal pain.
▪ Exclude other etiology ▪ If the child is stressed or the pain threshold is very low,
Stool culture, C. difficile, TB skin test simple stretching of the intestine will cause him a lot
▪ Classify disease of pain compared to a child who can eat a lot that
Upper endoscopy, colonoscopy would lead to the stretching of the intestine but will not
▪ Identify extra-intestinal manifestations cause him pain.
Liver function tests, joint, skin, eye exams Please see Appendix B for Biopsychosocial Conceptual
Model.

DIFFERENTIAL DIAGNOSIS FOR CHRONIC POTENTIAL ALARM FEATURES IN CHILDREN WITH

ABDOMINAL PAIN CHRONIC ABDOMINAL PAIN
▪ Carbohydrate intolerance ▪ Family history of IBD, Celiac Disease, or PUD
▪ Intestinal parasitism ▪ Persistent RU or RL quadrant pain
▪ Genitourinary disorder ▪ Dysphagia
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▪ Odynophagia ▪ Gastritis – inflammation of the gastric mucosa
▪ Persistent vomiting ▪ Peptic Ulcer – discontinuities of gastric/ duodenal
▪ GI blood loss mucosa
▪ Nocturnal diarrhea ▪ Diagnosis: Upper GI Series and Upper GI Endoscopy
▪ Arthritis ▪ Helicobacter pylori – primary cause of acid peptic
▪ Perirectal disease disease
▪ Involuntary weight loss ▪ NSAIDS, Drugs, Stress ulcer – secondary cause of acid
▪ Deceleration of linear growth peptic ulcer
▪ Delayed puberty ▪ Diagnosis of H. Pylori is through:
▪ Unexplained fever Non-endoscopic Tests
Please see Appendix C for Algorithim to determine Endoscopic Tests
Functional Abdominal Pain. Antibody (IgA, IgG) Test
Urea breath test
Stool antigen test
I. TREATMENT Endoscopi test
▪ Treatment of H. pylori would include:
A. FUNCTIONAL DYSPEPSIA
Clarithromycin
▪ Avoidance of NSAID
Metronidazole
▪ Avoidance of caffeine, spicy, and fatty foods PPI
▪ Prokinetics (Domperidone, Erythromycin) ▪ Inflammatory Bowel Disease – Differential diagnosis of
▪ H2 blockers or PPI acid peptic disease; aka Chron’s disease and
▪ Famotidine may be effective in children with RAP Ulcerative colitis
especially when dyspeptic symptoms dominate. ▪ Biopsychosocial concept model – is an approach to
Please see Appendix D for Effectiveness of treatment for understanding development of chronic abdominal
Abdominal Pain in Children. pain.
B. IRRITABLE BOWEL SYNDROME ▪ Treatment:
▪ Peppermint oil – menthol component causes Prokinetics, H2 blockers/ PPI – Functional
inhibition of smooth muscle contractions by blocking Dyspepsia
Peppermint oil- Irritable bowel Syndrome
calcium channels.
Avoid potential triggers, prohylactic treatment, poor
C. ABDOMINAL MIGRAINE prognostic factors – Abdominal migraine
▪ Avoid potential triggers: ▪ Visceral Pain
Caffeine, nitrite, and amine containing foods Stretching of Glisson’s capsule ihepatomegaly
Emotional arousal, travel, prolonged fasting Appendicitis
Altered sleep patterns ▪ Somatic Pain
Exposure to flickering or glaring lights Acute Appendicitis
▪ Prophylactic treatment: Peritonitis
Propanolol ▪ Referred Pain
Pizotifen Pneumonia ( diaphragm is irritated)
▪ Characteristics of abdominal pain
▪ Poor prognostic factors:
Location of Pain
Male gender
Timing
Onset below 6 years old Aching, burning, gnawing
A delay in diagnosis of more than 6 months Severitiy of the pain in scale (1-10)
Family history of somatic pain

SUMMARY
▪ Three characteristics of pain are classified as Visceral,
Somatic and Referred Pain
▪ Posturing, inability to walk is the usual sign of
abdominal pain.
▪ Pain characteristics are sudden onset, slow onset,
colicky pain and severe chronic pain.
▪ Acute abdominal pain is self-limiting, initial REVIEW QUESTIONS
assessment should focus on severity and whether 1. If pain manifested at the epigastric region, what is
there is a potential surgical cause of abdominal pain. the most probable embryonic derivative involved?
A. Foregut
▪ Chronic Abdominal Pain is recurrent and long lasting.
B. Midgut
▪ Acid Peptic disease is and umbrella term for GERD,
C. Hindgut
Gastritis, PUD and Duodenitis
D. None of the above

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 A. Urea Breath test
2. It is a sharp, intense, discrete/localized pain? B. Polyclonal stool antigen test
A. Parietal pain C. Endoscopic Test
B. Somatic pain D. Antibody test
C. Visceral pain
D. Both A and C 9. These are protective factors of Peptic Ulcer
formation, except:
3. In the physical examination of the abdomen, what is A. Bicarbonate
the correct order of events? B. NSAIDS
A. Inspect, Auscultate, Percuss, Palpate C. Protaglandins
B. Inspect, Auscultate, Palpate, Percuss D. Mucus Production
C. Inspect, Palpate, Percuss, Auscultate
D. Inspect Percuss, Palpate, Auscultate 10. In the Biopsychosocial Conceptual Model,
psychosocial factors include:
4. It is the gold standard in identification of H. pylori A. Sensation
A. Culture B. Food and diet
B. Urea breath test C. Life Stress
C. Rapid urease test D. Altered microflora
D. Biopsy
1.A 2.D 3.A 4.A 5.D 6.C 7.A 8.B 9.B 10.C
5. Which of the following is used in treating IBS?
A. Peppermint Oil
B. Antidiarrheals TRANS COMM
C. Non-stimulating laxatives Prepared by: Capalla, Catalan
D. A, B, and C are correct Editor: Castor

6. Evidence rating of A. A = consistent, good-quality

patient oriented evidences
A. Urinalysis, CBC, pregnancy test, and erythrocyte
sedimentation rate or C-reactive protein should
be the initial laboratory tests in the evaluation of
acute abdominal pain in children Antidiarrheals
B. Ultrasonography is the imaging of choice for
acute abdominal pain in children
C. Opiates may be safely used in children with
acute abdominal pain without delaying or
affecting the accuracy of diagnosis
D. A, B, and C are correct

7. Functional abdominal pain can manifest with

symptoms typical of functional dyspepsia, irritable
bowel syndrome, abdominal migraine or functional
abdominal pain syndrome REFERENCES
A. Functional abdominal pain • Bickley, L. S., Szilagyi, P. G., & Hoffman, R. M. (2017).
B. Functional dyspepsia
Bates guide to physical examination and history
C. Irritable bowel syndrome
taking. Philadelphia: Wolters Kluwer.
D. Functional abdominal pain syndrome
• MADIWA. (2021). Acute & Chronic Abdominal Pain in
Pediatric Patients. B11M1L3

8. This test cannot be used as a screening test due to

low sensitivity; only used to establish the diagnosis.
APPENDICES
APPENDIX A

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 APPENDIX B

APPENDIX C

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 APPENDIX D

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