ABDOMINAL PAIN

IN CHILDREN
DR AMANDA O’KEEFFE
PA E D I AT R I C S S T 6 U H C W
MANDYLOUISEOKEEFFE@GMAIL.COM
 LEARNING OUTCOMES

• make an initial assessment of a child with acute abdominal pain and refer
appropriately

• recognise the common causes of chronic abdominal pain

• recognise the common causes of an abdominal mass in infancy, childhood and

adolescence
THIS IS NOT AN EXHAUSTIVE
SESSION!
• It’s a springboard, the topic is vast!

Medical vs Surgical
Acute vs Chronic
Worrying vs Benign
Neonate vs Teenager
ABDOMINAL PAIN

Hx Ex DDx

Ix Mx
HISTORY

• History of presenting complaint

• Associated symptoms
– Diarrhoea/constipation
– Vomiting
– Anorexia
– Fever
SCORE THE PAIN
+
DOCUMENT IT
H I S T OR Y T A K I N G I N
Y OU N G P E O P L E
 • Gatroenteritis
• Pneumonia/LRTI
• Appendicitis
• Mesenteric adenitis
• Constipation

ACUTE
• UTI
• Pyelonepritis

ABDOMINAL PAIN • EBV

• Haematocolpus
• Pregnancy
• Dysmenorhoea
• Obstruction – malrotation, intussuseption,
volvulus
• DKA
 • Coeliac disease
• Constipation
• Functional abdominal pain

CHRONIC • Gastritis
• Dysmenorhoea
ABDOMINAL PAIN • Gallstones
• PID
• Inflammatory Bowel Disease
RED FLAGS • Weight loss/faltering growth

• GI Bleeding

• Unexplained fever

• Back/flank pain

• Family history of IBD

• Bilious vomiting

• Abnormal examination findings

– Child looks unwell
– Masses
EXAMINATION
• End of bed assessment

• Systems examination

• External genitalia

• Height and weight

– Growth chart
– Red book
ABDOMINAL MASSES

Organs

Faeces

Malignancies

Uterus!
INVESTIGATIONS

Bedside
Bloods
Imaging
WHERE NEXT?

• Follow up

• Referral
– Primary care
– Secondary care
– Tertiary care
• ITS FRIDAY EVENING, 8PM CED AT UHCW.

• THERE ARE 45 IN THE DEPARTMENT, 30 waiting to be seen

– 3 ‘crying babies’
– 6 injuries
– 4 fever
– 10 cough
– 7 abdominal pain
MIGUEL – 12 YEARS OLD – MALE

Abdominal pain

Normally fit and well

Differential diagnosis?
TESTICULAR
TORSION
• Ex
– Testicle tender
– May be a little higher
– Lack of cremasteric reflex

• Ix

• Mx
TESTICULAR TORSION

• Biological males

• Twisting of the spermatic cord, cutting off blood supply to testicle

• Age

• 4 to 6 hours, the testicle - can be saved 90% of the time.

– 12 hours, this drops to 50%
– after 24 hours, the testicle can be saved only 10% of the time.
JACK JACK – 1 YEAR – MALE

Parental concerned he has

abdominal pain

Vomiting, off milk

Differential diagnosis?
BOWEL OBSTRUCTION
 INTUSSUSEPTION
• Hx - Pain intermittent

• Ex – mass?
– Redcurrent jelly stools, guarding, distension

• Ix – US

• Mx - enema

• Path
– Invagination of proximal bowel in to distal bowel
– Ileum in to ileo-caecal valve.
– Bowel obstruction – venous congestion – bowel infarction
MEI MEI – 13 YEARS OLD - FEMALE

Abdominal pain

Non blanching rash

Normally fit and well

Differential
diagnosis?
HSP

• Hx
– Recent history of viral illness
– Well, afebrile

• Ex
– Rash – look and feel
– Abdomen
– All joints – look, feel, move
HSP
• Ix
– Bedside • Mx
• Obs – blood pressure – Analgesia
• Urine dip – protein and blood – Hydration
– Bloods – Follow up
• U+Es – renal function • BPs and
• FBC – platelets, Hb urinalysis

• Blood cultures and CRP

– Imaging
 HENOCH SCHONLEIN PURPURA

• IgA vasculitis – IgA deposits in the vessels

• Triggered by viral illness

• Purpura (100%), Joint pain (75%), abdominal

pain (50%), renal (50%).

• IgA nephritis can lead to heamaturia/proteinuria

and nephrotic syndrome
MIRABEL – 15 YEARS - FEMALE

Abdominal pain

Nausea and vomiting

Fever

Differential diagnosis?
URINARY TRACT INFECTION

• Hx • Ix
– Abdominal pain – Bedside – Urinalysis
– Fever – Bloods
– Nausea, vomiting, anorexia – Imaging

• Ex • Mx
– Tender to palpate – Antibiotics
URINARY TRACT INFECTION

Urinalysis result Diagnosis and Action

Leucocyte –ve, nitrite –ve Child does not have a UTI, don’t send the sample.
Explore other causes for presentation

Leucocyte +ve, nitrite -ve Child may have a UTI – send sample for MC+S
Start antibiotic only if convincing Hx/in nappies

Leucocyte +ve, nitrite +ve Child has a UTI, start antibiotics

Only send sample if unwell/atypical

Leucocyte –ve, nitrite +ve Child likely has a UTI if fresh catch, can start
antibiotics. Send sample for MC+S.
RILEY – 12 YEARS - FEMALE

Abdominal pain

Change in bowel habit

Has missed at least 1 day of school a

week for 8 weeks

PMH: headaches
FUNCTIONAL ABDOMINAL PAIN

• Hx • Ix
– Abdominal pain – Bedside
– Nausea – Bloods
– Anorexia – Imaging

• Ex • Mx
– Discomfort on palpation
 FUNCTIONAL ABDOMINAL PAIN
• Up to 25% of those seen for abdo pain by gastroenteologists

• Gut more sensitive to triggers that would not normally cause significant pain e.g. gas.

• Variable location and intensity, usually umbilical.

• +/- dyspepsia, nausea, early satiety, diarrhoea/constipation

• Significant impact on functioning

• Management serves to mitigate this impact/manage symptoms associated with it

 Functional abdominal pain ▪ Episodic or continuous abdominal pain

ROME III CRITERIA

▪ Insufficient criteria for other functional gastrointestinal disorders

▪ Functional abdominal pain for at least 25% of the time and one or more of the
following:

Functional abdominal pain syndrome

 1. Some loss of daily functioning

• no evidence of an inflammatory,  2. Additional somatic symptoms such as headache, limb pain, or difficulty
sleeping

anatomical, metabolic or neoplastic

process to explain symptoms.
Functional dyspepsia ▪ Persistent or recurrent pain or discomfort centred in the upper abdomen

▪ Not relieved by defecation or associated with a change in stool frequency or

form

• Criteria must be fulfilled at least once a Irritable bowel syndrome

▪ Abdominal discomfort or pain associated with two or more of the following at
least 25% of the time:

week for at least 2 months before

 1. Improved with defecation

diagnosis, except
 2. Onset associated with a change in frequency of stool

 3. Onset associated with a change in form of stool

• Abdominal migraine criteria must be

fulfilled two or more times in the Abdominal migraine
▪ Paroxysmal episodes of intense, acute peri-umbilical pain that last for one or
more hours.

preceding 12 months.
▪ Intervening periods of usual health lasting weeks to months

▪ The pain interferes with normal activities

▪ The pain is associated with two or more of the following: anorexia, nausea,
vomiting, headache, photophobia, pallor
BONNIE – 4 YEARS – FEMALE

Abdominal pain

Off food

Normally fit and well

Differential diagnosis?
CONSTIPATION

• Hx • Ex
– Abdominal pain – Discomfort on palpation
– Nausea – Palpable mass
– Anorexia
– Other… • Ix
– Bedside
– Bloods
• PMH
– Imaging
CONSTIPATION

• Management
– Conservative

– Medical

– Surgical
RED FLAGS
• Delayed passage of meconium

• Onset first few weeks of life

• Failure to thrive/ faltering growth

• Abdominal distension

• Abnormal examination of anus or spine

• Neurological signs – weakness in lower legs,

abnormal reflexes,
STACEY – 12 YEARS – FEMALE

• Abdominal pain and vomiting

• PMH – Type 1 diabetes mellitus

• Differential diagnosis?
DKA
 • Gatroenteritis
• Pneumonia/LRTI
• Appendicitis
• Mesenteric adenitis
• Constipation

ACUTE
• UTI
• Pyelonepritis

ABDOMINAL PAIN • EBV

• Haematocolpus
• Pregnancy
• Dysmenorhoea
• Obstruction – malrotation, intussuseption,
volvulus
• DKA
 • Coeliac disease
• Constipation
• Functional abdominal pain

CHRONIC • Gastritis
• Dysmenorhoea
ABDOMINAL PAIN • Gallstones
• PID
• Inflammatory Bowel Disease
 LEARNING OUTCOMES

• make an initial assessment of a child with acute abdominal pain and refer appropriately

• recognise the common causes of chronic abdominal pain

• recognise the common causes of an abdominal mass in infancy, childhood and

adolescence

• recognise the radiological appearance of intestinal obstruction

 NICE guidelines/local
guidelines

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THE BEST CAREER…