Typical features Diagnosis History Acute appendicitis Abdominal pain becomes increasingly severe, and often localises to RIF

Examination tenderness, guarding, and rebound usually greatest in right iliac fossa, though may be more diffuse. Pallor, lethargy. A sausage-shaped mass is palpable in about 2/3 of cases, crossing the midline in the epigastrium or behind the umbilicus Distension, tenderness

Intussusception Intermittent colicky abdominal pain, vomiting and the passage of blood and/or mucus per rectum. There is frequently a preceding respiratory or diarrhoeal illness. Midgut volvulus Bowel obstruction - abdominal pain, distension; usually bile-stained vomiting Constipation can present with quite severe abdominal pain in children; often recurrent infants: fever, vomiting, lethagy. older children: dysuria, haematuria

Firm stool palpable in lower abdomen (sometimes entire colon) fever; suprapubic tenderness; loin tenderness if associated pyelonephritis; FWT may be +ve (leukocyte esterase, nitrites) fever; tachypnoea, recession; focal signs at one base tenderness, increased bowel sounds; signs of dehydration

UTI

Pneumonia

fever; may have cough, vomiting

Gastroenteritis

vomiting, diarrhoea, fever

Management
y

Establish intravenous access, and measure electrolytes if the patient appears dehydrated, and cultures of blood and stool if potentially septic. Fluid resuscitation may be required (initial bolus 20ml/kg normal saline) Keep the patient fasted until surgical assessment Provide adequate analgesia Place a nasogastric tube if bowel obstruction

y y y y

Notes
y

Acute appendicitis must be considered in any child with severe abdominal pain. In the very young child, in whom the risk of perforation is higher, the presenting symptoms are less specific. The diagnosis is clinical - no laboratory or radiological tests are required. The peak age for intussusception is 6-12 months. Plain AXR may show signs of bowel obstruction, with decreased gas in the right colon. The diagnosis is confirmed by air insufflation or barium enema, with reduction usually possible by the same means (unless signs of peritonitis - risk of perforation). Midgut volvulus is commonest in the newborn period, but can occur in later childhood. Predisposing factors include malrotation and abnormal mesentery. Vomiting is rarely due to constipation. Some children suffer recurrent non-specific abdominal pain, with no organic cause identifiable. Constipation is often an important contributing factor. Psychogenic factors (eg. family, school issues) need to be considered. These children should be referred for general paediatric assessment. Some less common diagnoses need to be considered in patients with certain underlying chronic illnesses. Hirschsprungs disease can be complicated by enterocolitis, with sudden painful abdominal distension and bloody diarrhoea. These patients can become rapidly unwell with dehydration, electrolyte disturbances, and systemic toxicity, and are at risk of colonic perforation. Primary bacterial peritonitis can occur in children with nephrotic syndrome, splenectomy and those with VP shunts.

y y

Abdominal pain (or stomach ache) can be one of the symptoms associated with transient disorders or serious disease. Making a definitive diagnosis of the cause of abdominal pain can be difficult, because many diseases can result in this symptom. Abdominal pain is a common problem. Most frequently the cause is benign and/or self-limited, but more serious causes may require urgent intervention.

Differential diagnosis
y

Gastrointestinal
o

GI tract


Inflammatory: gastroenteritis, appendicitis, gastritis, esophagitis, diverticulitis, Crohn's disease, ulcerative colitis, microscopic colitis

Obstruction: hernia, intussusception, volvulus, post-surgical adhesions, tumours, superior mesenteric artery syndrome, severe constipation, hemorrhoids Vascular: embolism, thrombosis, hemorrhage, sickle cell disease, abdominal angina, blood vessel compression (such as celiac artery compression syndrome), Postural orthostatic tachycardia syndrome digestive: peptic ulcer, lactose intolerance, coeliac disease, food allergies

 o

Glands


Bile system
 

Inflammatory: cholecystitis, cholangitis Obstruction: cholelithiasis, tumours

Liver


Inflammatory: hepatitis, liver abscess

Pancreatic


Inflammatory: pancreatitis

Renal and urological

o o o

Inflammation: pyelonephritis, bladder infection Obstruction: kidney stones, urolithiasis, Urinary retention, tumours Vascular: left renal vein entrapment

Gynaecological or obstetric
o o o o o

Inflammatory: pelvic inflammatory disease Mechanical: ovarian torsion Endocrinological: menstruation, Mittelschmerz Tumors: endometriosis, fibroids, ovarian cyst, ovarian cancer Pregnancy: ruptured ectopic pregnancy, threatened abortion

Abdominal wall
o

muscle strain or trauma

o o

muscular infection neurogenic pain: herpes zoster, radiculitis in Lyme disease, abdominal cutaneous nerve entrapment syndrome (ACNES), tabes dorsalis

Referred pain
o o o

from the thorax: pneumonia, pulmonary embolism, ischemic heart disease, pericarditis from the spine: radiculitis from the genitals: testicular torsion

Metabolic disturbance
o

uremia, diabetic ketoacidosis, porphyria, C1-esterase inhibitor deficiency, adrenal insufficiency, lead poisoning, black widow spider bite, narcotic withdrawal

Blood vessels
o

aortic dissection, abdominal aortic aneurysm

Immune system
o o o

sarcoidosis vasculitis familial Mediterranean fever

Idiopathic
o

irritable bowel syndrome (affecting up to 20% of the population, IBS is the most common cause of recurrent, intermittent abdominal pain)

Acute abdominal pain Acute abdomen can be defined as severe, persistent abdominal pain of sudden onset that is likely to require surgical intervention to treat its cause. The pain may frequently be associated with nausea and vomiting, abdominal distention, fever and signs of shock. One of the most common conditions associated with acute abdominal pain is acute appendicitis. Selected causes of acute abdomen
y y

Traumatic : blunt or perforating trauma to the stomach, bowel, spleen, liver, or kidney Inflammatory :

Infections such as appendicitis, cholecystitis, pancreatitis, pyelonephritis, pelvic inflammatory disease, hepatitis, mesenteric adenitis, or a subdiaphragmatic abscess Perforation of a peptic ulcer, a diverticulum, or the caecum Complications of inflammatory bowel disease such as Crohn's disease or ulcerative colitis

o o

Mechanical :
o

Small bowel obstruction secondary to adhesions caused by previous surgeries, intussusception, hernias, benign or malignant neoplasms Large bowel obstruction caused by colorectal cancer, inflammatory bowel disease, volvulus, fecal impaction or hernia

Vascular : occlusive intestinal ischemia, usually caused by thromboembolism of the superior mesenteric artery

By location Location[1]
y

Upper middle abdominal pain

o o

Stomach (gastritis, stomach ulcer, stomach cancer) Pancreas pain[1] (pancreatitis or pancreatic cancer, can radiate to the left side of the waist, back, and even shoulder) Duodenal ulcer, diverticulitis Appendicitis (starts here, after several times moves to lower right abdomen)

o o y

Upper right abdominal pain

o

Liver (caused by hepatomegaly due to fatty liver, hepatitis, or caused by liver cancer, abscess) Gallbladder and biliary tract (gallstones, inflammation, roundworms) Colon pain (below the area of liver - bowel obstruction, functional disorders, gas accumulation, spasm, inflammation, colon cancer)

o o

Upper left abdominal pain

o

Spleen pain (splenomegaly)

o o

Pancreas Colon pain (below the area of spleen - bowel obstruction, functional disorders, gas accumulation, spasm, inflammation, colon cancer)

Middle abdominal pain (pain in the area around belly button)

o o

Appendicitis (starts here) Small intestine pain (inflammation, intestinal spasm, functional disorders)

Lower right abdominal pain

o o

Cecum (intussusception, bowel obstruction) Appendix point (Appendicitis location)

Lower left abdominal pain

o

Sigmoid colon (polyp, sigmoid volvulus, obstruction or gas accumulation)

Pelvic pain
o o

bladder (cystitis, may secondary to diverticulum and bladder stone, bladder cancer) pain in women (uterus, ovaries, fallopian tubes)

Right lumbago and back pain

o o

liver pain (hepatomegaly) right kidney pain (its location below the area of liver pain)

Left lumbago and back pain

o o

less in spleen pain left kidney pain

Low back pain

o o

kidney pain (kidney stone, kidney cancer, hydronephrosis) Ureteral stone pain

Diagnostic approach

When a physician assesses a patient to determine the etiology and subsequent treatment for abdominal pain the patient's history of the presenting complaint and physical examination should derive a diagnosis in over 90% of cases. It is important also for a physician to remember that abdominal pain can be caused by problems outside the abdomen, especially heart attacks and pneumonias which can occasionally present as abdominal pain. Investigations that would aid diagnosis include
y

Blood tests including full blood count, electrolytes, urea, creatinine, liver function tests, pregnancy test, amylase and lipase. Urinalysis Imaging including erect chest X-ray and plain films of the abdomen An electrocardiograph to rule out a heart attack which can occasionally present as abdominal pain

y y y

If diagnosis remains unclear after history, examination and basic investigations as above then more advanced investigations may reveal a diagnosis. These as such would include
y y y

Computed Tomography of the abdomen/pelvis Abdominal or pelvic ultrasound Endoscopy and colonoscopy (not used for diagnosing acute pain)

Management Butylscopolamine (Buscopan) is used to treat cramping abdominal pain with some success.[2]