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The evaluation of abdominal pain is problematic because the pain is often difficult to localize, and the history in children is often nonspecific. In children the differential diagnosis of abdominal pain is extensive.
Localization of Abdominal Pain
Abdominal Pain Abdominal Pain. Generalized pain in the epigastrium usually comes from the stomach, duodenum, or pain in the midgut (small bowel and colon or spleen) usually localizes to the Referred abdominal pain occurs when poorly localized visceral pain is felt.
Pancreatitis, cholecystitis, liver abscess, or a bleeding spleen cause diaphragmatic irritation.
Intraabdominal fluid may produce shoulder pain on reclining.
Gallbladder pain may be felt in the lower back or infrascapular area.
Pancreatic pain often is referred to the posterior flank.
A migrating ureteral stone often is felt as pain radiating toward the ipsilateral groin.
Rectal or gynecological pain often is perceived as sacral pain.
Right lower lobe pneumonia may be perceived as right upper quadrant abdominal pain.
Clinical Evaluation
History should include the quality, timing, and type of abdominal pain.
Pain of sudden onset often denotes colic, perforation or acute ischemia caused by torsion or volvulus.
Slower onset of pain suggests inflammatory conditions, such as appendicitis, pancreatitis, or cholecystitis.
Chronic pain can occur with non-surgical conditions or with early problems that are potentially surgical.
Colic results from spasms of a hollow viscus organ secondary to an obstruction. It is characterized by severe, intermittent cramping, followed by intervals when the pain is present but less intense. When spasms are present, the patient will appear agitated and restless, pale and diaphoretic. Colic pain usually originates from the biliary tree, pancreatic duct, gastrointestinal tract, urinary system, or uterus and tubes.
Inflammatory pain is caused by peritoneal irritation, and the patient presents quietly without much motion and appears ill. The pain is initially less severe and is exacerbated by movement.
Vomiting
The timing of the onset of vomiting is important. Usually abdominal pain will precede vomiting.
The interval between abdominal pain and vomiting is shorter when associated with colic.
Delayed vomiting for many hours is often associated with distal bowel obstruction or ileus secondary to peritonitis.
Diarrhea
Mild diarrhea with the onset of abdominal pain suggests acute gastroenteritis or early appendicitis.
Delayed onset of diarrhea may indicate a perforated appendicitis, with the inflamed mass causing irritation of the sigmoid colon.
Physical Examination
The abdomen should be observed, auscultated, and palpated for distention, localized tenderness, masses, and peritonitis. The groin must be examined to exclude an incarcerated hernia or ovary, or torsion of an ovary or testicle.
Rectal Examination
Gross blood in the stool suggests ectopic gastric mucosa, Meckel's diverticula, or polyps.
Blood and mucus (current jelly stool) suggests inflammatory bowel disease or intussusception.
Melena suggests upper gastrointestinal bleeding, necessitating gastric aspiration for blood.
Tests for occult blood in the stool should be performed.
Pelvic examinations are mandatory for postmenarchal and/or sexually active female patients. The rectal examination may also be used to evaluate the cervix, uterus, adnexa, and other pelvic masses.
Fever
Thoracic disease (eg, pneumonia) may be the cause of abdominal pain associated with fever.
Costovertebral angle tenderness with fever suggests pyelonephritis or a high retrocecal appendicitis.
Appendicitis
The history and abdominal pain, stomach pain physical exam, including rectal (and pelvic exam in females), are diagnostic of abdominal pain, stomach pain appendicitis in 80% of the cases. Perforation often follows the onset of symptoms in 24-48 abdominal pain, stomach pain hours. Beyond the neonatal period, but <2 years old, gastroenteritis and abdominal pain, stomach pain intussusception are also part of the differential diagnosis of abdominal pain.
Fever, vomiting, abdominal pain, stomach pain irritability, lethargy with right lower quadrant (RLQ) tenderness and guarding are diagnostic of appendicitis in the very young patient until proven otherwise.
Masses may be felt on rectal exam in 2-7% of younger patients with appendicitis.
Children Older than 2 years old present with a perforated appendix about 30-60% of the time. This incidence declines as the age of the child increases.