Abdominal pain

Mohamed Ahmed Fouad Pediatric Lecturer

Jazan Faculty of Medicine

Objectives • Understand the principal causes of acute abdominal pain in children.

• Describe the characteristics of visceral versus somatic abdominal pain.

• Be familiar with the differential diagnosis of abdominal pain based on symptoms and location of pain.

• Discuss the evaluation of acute abdominal pain.

• Distinguish surgical from medical abdominal pain.

• Develop a differential diagnosis of chronic abdominal pain in children.

• Be aware of alarming signs and symptoms that could indicate organic disease.

• Differentiate the four abdominal pain–associated functional gastrointestinal disorders in children

Acute Abdominal Pain

Definition

• Abdominal pain in a previously healthy child of less than 7 days duration .

*Evaluating the child with abdominal pain of acute onset must decide quicklywhether the child has a “surgical abdomen” (a serious medical problemnecessitating treatment and admission to the hospital) or a process that canbe managed on an outpatient basis.

*Even though surgical diagnoses are fewer than 10% of all causes ofabdominal pain in children, they can be life-threatening if untreated.

• The challenge for the clinician is to identify patients with abdominal pain who may have the following:

• Serious, potentially life-threatening conditions, such as appendicitis or bowel obstruction (as can occur from volvulus, intussusception, or adhesions)

• Infections that require specific treatment (such as streptococcal pharyngitis, urinary tract infection, or pneumonia)

• Unusual manifestations of less common diseases (such as primary bacterial peritonitis with nephrotic syndrome)

• a small number of patients who may present early in the course of an illness (such as appendicitis) or with subtle and/or atypical signs do not receive the definitive diagnosis on the first evaluation .

• Consequently, repeat examination and reliable follow-up are essential components of the evaluation and management of children with acute abdominal pain

Causes

History • Age&sex :

Analysis of the pain• Site:

• Characteristics of abdominal pain :

• Infants and children younger than two years of age infer that they have abdominal pain from symptoms such as drawing the legs up,

• The preschool child may be able to describe pain and other symptoms, Above five years of age, children can typically characterize the onset, frequency, duration, and location of their symptoms.

• Specific diagnoses may be associated with the following characteristic patterns of pain:

• Appendicitis – Periumbilical, migrating to the right lower abdomen

• Intussusception – Intermittent, colicky

• Gastroenteritis – Diffuse or vague

• Hepatitis and cholecystitis – Right upper quadrant

• Gastritis, gastric ulcer disease – Epigastric

• Pancreatitis – Steady periumbilical pain, often radiating to the back

• For children with peritoneal irritation (as with advanced appendicitis), pain can be aggravated by movements that change tension on the abdominal wall (such as traveling in the car or walking).

• Improvement in pain after a bout of emesis may occur with conditions localized to the small bowel . Pain relief after a bowel movement suggests a colonic condition.

Associated symptoms

• Abd. Pain&fever :

• Patients with appendicitis often have fever, which may be initially low grade

• gastroenteritis

• Streptococcal pharyngitis

• Urinary tract infections

• Lower lobe pneumonia

• Pelvic inflammatory disease

Abd.Pain &Vomiting

• vomiting and abdominal pain (particularly in the absence of diarrhea) should be carefully evaluated for life-threatening conditions such as bowel obstruction and appendicitis.

• Volvulus must be excluded as the cause of bilious emesis and apparent abdominal pain in a neonate.

• With intussusception, vomiting (initially non-bilious, but becoming bilious as the obstruction progresses) may occur following episodes of pain.

• Small bowel obstruction(postoperative or post inflammatory adhesions)

Abd.Pain &Diarrhea

• viral gastroenteritis

• Urinary tract infections

• Diarrhea may develop from appendicitis

• Children with intussusception may have bloody stools

• Bloody diarrhea suggests infectious enteritis, hemolytic uremic syndrome (HUS)

Past medical history

• Bowel obstruction from adhesions can occur among children who have had abdominal surgery.

• Cholecystitis may be the cause of abdominal pain for older adolescents or children with predisposing conditions such as sickle cell disease, spherocytosis.)

• Abdominal pain may be the manifestation of vasoocclusive crisis (VOC) for children with sickle cell disease.

• Children with diabetic ketoacidosis may have abdominal pain.

• Primary bacterial peritonitis occurs with increased frequency among children with nephrotic syndrome.

Physical examination• Appearance — Appearance and hydration should be noted. Patients with

hypovolemia (as with abdominal injury, volvulus, or intussusception) or peritonitis (as from perforated appendicitis) may have signs of poor perfusion.

• Children with peritonitis typically prefer to lie still, while those with biliary or renal colic may writhe in pain.

• Pharyngeal erythema with pharyngitis .

• Rales, decreased breath sounds suggestive of pneumonia.

• Muffled heart sounds with pericarditis.

• Bruising suggests trauma.

• Petechiae may seen with Henoch-Schönlein purpura

• Vital signs — Abnormal vital signs may provide a clue to the diagnosis:

• Fever suggests infection (such as gastroenteritis, urinary tract infection, pneumonia, or pharyngitis).

• Tachypnea can be a sign of respiratory illness (such as pneumonia) or metabolic acidosis (causing rapid breathing in children with dehydration from gastroenteritis, diabetic ketoacidosis, peritonitis, or intestinal obstruction).

• Hypotension in a child with acute abdominal pain can develop from intravascular volume loss (as with hemorrhage from injury, gastroenteritis, or capillary leak from bowel obstruction with volvulus or intussusception) or peritonitis (as with perforated appendicitis).

• Colours — Children with jaundice may have hepatitis or gall bladder disease with obstruction and hemolysis(Sickle).

• Pallor : hemolytic Anemia (sickle)

Abdominal examination

• The following features should be noted:

• Distention may be the result of obstruction or a mass.

• Bowel sounds may be decreased (as with an ileus in response to peritoneal irritation from appendicitis) or increased (as with gastroenteritis or bowel obstruction).

• Pain may be localized with gentle palpation performed in all four quadrants.

• Considerations include:

• Children can be asked to point with one finger to the spot that hurts the most.

• Serious causes of abdominal pain are less likely for otherwise healthy children who are not uncomfortable with deep palpation throughout the abdomen, who have no focal tenderness, and who have no extra-abdominal findings.

• Percussive tenderness, rebound, and involuntary guarding are most often signs of peritoneal irritation (as with appendicitis or cholecystitis).

• Other findings that may be noted with percussion include increased tympany (as with distended bowel), dullness (as with a mass), and shifting dullness (as with ascites).

• Flank tenderness may be a sign of pyelonephritis or urolithiasis.

• Tender scrotal swelling suggests testicular torsion or incarcerated hernia.

incarcerated hernia

Lab. Studies • CBC: ↑WBC : infection or inflammation (such as appendicitis),

Hematocrit – For children with bleeding↓Hb with abnormal red cell morphology can be seen with

hemoglobinopathies (sickling) and hemolytic uremic syndrome (microangiopathic changes)

↓ PLT in HUS.

• Serum chemistries

• with upper abdominal pain, ↑ ↑ liver enzyme tests or amylase measurements suggest hepatitis, pancreatitis

• Metabolic acidosis can occur with dehydration, diabetic ketoacidosis (DKA).

• An elevated blood glucose in the setting of acidosis is also consistent with DKA.

• A urine dipstick evaluation

( nitrites, leukocyte esterase, glucose, ketones, and protein) should be obtained for most children with abdominal pain.

• Hematuria can occur with urolithiasis, Henoch-Schönlein purpura,hemolytic uremic syndrome, and urinary tract infection (UTI).

• Pyuria usually indicates a UTI

• Children with DKA have glucosuria and ketonuria.

• A child with nephrotic syndrome and bacterial peritonitis typically has proteinuria.

Imaging

• Imaging is an essential component of the evaluation of some children with acute abdominal pain who have concerning clinical features such as :

• trauma,

• peritoneal irritation,

• signs of obstruction,

• masses, distension, or focal tenderness and/or pain.

• Children with a typical clinical presentation for acute appendicitis are likely to have appendicitis.

• Ultrasonography (US)

• US is the preferred imaging modality to diagnose gall stones and genitourinary conditions (such as ovarian torsion, ruptured ovarian cyst, and testicular torsion).

• Intussusception can be diagnosed by experienced ultrasonographers

• Focused abdominal sonography for trauma (FAST examination), typically performed in the emergency department, can detect free fluid (usually blood) in the abdomen.

•

• Computed tomography (CT) with contrast is useful for the evaluation of patients with acute abdominal pain when a wide variety of diagnoses are being considered (such as appendicitis, pancreatitis, intraabdominal abscess, and for the evaluation of an intraabdominal mass).

•Chronic abdominal pain

DEFINITION Chronic abdominal pain :is defined by pain of at least three months'

duration

Recurrent abdominal pain

The classic definition is based upon four criteria :

◦ History of at least three episodes of pain

◦ Pain sufficiently severe to affect activities

◦ Episodes occur over a period of three months

◦ No known organic cause

• Chronic abdominal pain in childhood accounts for 2% to 4% of office visits to primary care clinicians and 50% to pediatric gastroenterologists.

Chronic abdominal pain can be organic or nonorganic, depending on

whether a specific etiology is identified.

Nonorganic abdominal pain or functional abdominal pain refers to pain

without evidence of anatomic, inflammatory, metabolic, or neoplastic

abnormalities.

Child with Recurrent Abdominal Pain(Functional

gastrointestinal disorders )(FGIDs)

*Because the exact etiology and pathogenesis of functional pain are unknown, functional abdominal pain is too often perceived as a diagnosis of exclusion.

* Diagnostic criteria for functional gastrointestinal disorders provide a framework for a working diagnosis of functional pain based on the absence of alarm signals from history, physical examination, and a focused laboratory evaluation.

pathophysiology*There is general agreement that functional pain is genuine.

*Painful sensations may be provoked by physiological phenomena or concurrent physical and psychological stressful life events.

* Examples of physiological phenomena that may trigger pain include postprandial gastric or intestinal distension, intestinal contractions

Intraluminal physical stress factors that may trigger pain include aerophagia, simple constipation, , minor noxious irritants such as spicy foods, or drug therapy.

* psychological stress factors may also provoke or reinforce the pain behavior by altering the conscious threshold of GI sensory input in the central nervous system.

Psychological stress factors may include death or separation of a significant family member, physical illness or chronic handicap in parents or sibling, school problems, altered peer relationships, family financial problems, or a recent geographic move.

*The morbidity associated with functional abdominal pain is rarely physical but results from interference in normal school attendance and performance, peer relationships, participation in organizations, sports, and personal and family activities.

*Only one of 10 children with functional abdominal pain attends schools regularly

Children with ch. abdominal pain may be sub-classified by one of three clinical presentations:

(1) abdominal pain associated with symptoms of upper abdominal distress .

(2) abdominal pain associated with altered bowel pattern,

(3) isolated paroxysmal abdominal pain.

Alarm signals that pain may have an organic cause(points in history)

*Pain awakening the child at night

*Localized or persistent pain away from the umbilicus

*Involuntary weight loss or growth deceleration

* Extraintestinal symptoms (fever, rash, joint pain, recurrent aphthous ulcers, dysuria)

*Consistent sleepiness following pain attacks

*Vomiting & Blood in stools (guaiac-positive)

*Positive family history of peptic ulcer disease, inflammatory bowel disease

*Anemia

* ↑ESR

*In the absence of historical or physical alarm signals, the diagnosis of functional abdominal pain should be introduced into the differential diagnosis of abdominal pain

Parents should be told that a diagnosis of functional pain can be made when the duration of pain exceeds 3 months.

A brief explanation of the concepts of an altered sensitivity to normal bowel activities (visceral hypersensitivity) and altered motility, the concept of stress factors.

They should also be told early on that functional pain is difficult to eradicate, and some continuing pain will often have to be accepted by the patient.

ABDOMINAL PAIN ASSOCIATED WITH SYMPTOMS OF UPPER ABDOMINAL DISTRESS

Symptoms of upper abdominal distress include pain or discomfort localized in the upper abdomen, pain related to eating, nausea, episodic vomiting, bloating, early satiety, and occasional heartburn and oral regurgitation.

DD abdominal pain associated with symptoms of upper abdominal distress.

Gastroesophageal reflux disease (GERD)

Peptic ulcer

NSAID ulcer

Crohn disease

Idiopathic gastroparesis

Chronic pancreatitis

Chronic hepatitis

Chronic cholecystitis

celiac disease

Alarm signals such as anorexia, vomiting, weight loss, and evidence of GI bleeding (hematemesis, melena, occult bleeding) suggest an upper GI inflammatory, infectious, structural, or biochemical disorder.

Diagnostic Criteria for Functional Dyspepsia

1. Persistent or recurrent pain or discomfort centered in the upper abdomen (above the umbilicus)

2. Not relieved by defecation or associated with the onset of a change in stool frequency or stool form (i.e., not IBS)

3. No evidence of an inflammatory, anatomic, metabolic, or neoplastic process that explains the subject’s symptoms

* Criteria fulfilled at least once per week for at least 2 months before diagnosis

ABDOMINAL PAIN ASSOCIATED WITH SYMPTOMS OF ALTERED BOWEL PATTERN

Altered bowel pattern may include a change in frequency and/or consistency of stools (diarrhea or constipation), pain relieved with defecation, straining or urgency, feeling of incomplete evacuation, passage of mucus, or a feeling of bloating or abdominal distention.

DD of abdominal pain associated with symptoms of altered bowel pattern

Ulcerative colitis

Crohn disease

Infectious disorders Parasitic (Giardia, Blastocystis)

Lactose intolerance

Neoplasia (lymphoma, carcinoma)

Bacterial (Clostridium difficile, TB)

• Alarm signals including evidence of GI bleeding, tenesmus, pain or diarrhea repeatedly wakening the patient from a sound sleep, involuntary weight loss, linear growth deceleration, extraintestinal symptoms (fever, rash, joint pain, recurrent aphthous ulcers), positive family history of inflammatory bowel disease, iron deficiency anemia, or an elevated ESR are indications to pursue a diagnosis of inflammatory bowel disease by colonoscopy and UGI with small bowel follow-through.

Diagnostic Criteria for Irritable Bowel Syndrome (IBS)

1. Abdominal discomfort or pain associated with 2 or more of the following at least 25% of the time:

a) Improved with defecation

b) Onset associated with a change in frequency of stool

c) Onset associated with a change in form (appearance) of stool

2. No evidence of an inflammatory, anatomic, metabolic, or neoplastic process that explains the subject’s symptoms

* Criteria fulfilled at least once per week for at least 2 months before diagnosis

ISOLATED PAROXYSMAL RECURRENT ABDOMINAL PAIN

The most common pattern of isolated recurrent abdominal pain involves episodes of acute, intense midline abdominal pain lasting a few hours to several days with intervening symptom-free intervals lasting days to months.

.

DD of ISOLATED RECURRENT ABDOMINAL PAIN

Intermittent intestinal obstruction(Crohn diseas)

Small-bowel lymphoma

Appendiceal colic

Ectopic pregnancy

Linea alba hernia

Mesentertic thrombosis

intermittent porphyria

Alarm signals including pain repeatedly awakening the patient from a sound sleep, anorexia, involuntary weight loss, linear growth deceleration, evidence of GI bleeding, and extraintestinal symptoms (fever, rash, joint pain)

Diagnostic Criteria for Abdominal Migraine

1. Paroxysmal episodes of intense, acute periumbilical pain that lasts for 1 hour or more

2. Intervening periods of usual health lasting weeks to months

3. The pain interferes with normal activities

4. The pain is associated with 2 or more of the following:

a. Anorexia b. Nausea c. Headache

d. Photophobia d. Pallor5. No evidence of an inflammatory, anatomic, metabolic, or neoplastic

process that explains the subject’s symptoms

* Criteria fulfilled at least once per week for at least 2 months before diagnosis

Appropriate work-up

• majority of patients that present with chronic, recurrent abdominal pain and no red flag symptoms do not need any work-up apart from a detailed H&P in order to exclude other pathologic diagnoses.

• In fact, additional work-up may only add unnecessary anxiety and cost be reinforcing that health care providers are worried that something is being missed or that “they can’t figure it out.”

Treatment *The primary goal of treatment is resumption of normal lifestyle, not eradication of abdominal pain.

• Psychological based treatment, particularly cognitive behavioral therapy and gut directed hypnotherapy are the most effective, evidence-based treatments , However Peppermint oil , Rifaximin , Lactobacillus GG and Amitriptyline may have benefits

*A careful explanation of the pathophysiology of the symptoms and the fact that functional pain disorders will not affect future health can have positive therapeutic effects.

*In many patients the symptoms spontaneously resolve or lessen after a positive diagnosis, suggesting that allaying the patient's or parent's unwarranted fears may remove a significant stress factor triggering symptoms.

*The first goal is to identify, clarify, and possibly reverse physical and psychological stress factors that may have an important role in onset, severity, exacerbations, or maintenance of pain.

*Regular school attendance is essential regardless of the continued presence of pain.

* In many cases it is helpful for the physician to communicate directly to school officials to explain the nature of the problem.

*School officials must be encouraged to be responsive to the pain behavior but not to let it disrupt attendance, class activity, or performance expectations.

*Within the family, less social attention should be directed toward the symptoms.

*Consultation with a child psychiatrist or psychologist may be indicated when there is concern about maladaptive family coping mechanisms or if attempts at environmental modification do not result in a return to a normalized life style.

*The role of dietary modifications in the management of functional pain disorders is not established except if there is certain food known to the patient that it cause pain eg: spicy food.

*Postprandial symptoms in functional dyspepsia may be improved by eating low-fat meals or by ingesting more frequent but smaller meals throughout the day.

A high-fiber diet is recommended for both diarrhea-predominant and constipation-predominant irritable bowel and isolated functional pain.

*Excessive gas in patients with IBS can be managed by advising the patient to eat slowly, to avoid chewing gum, and to avoid excessive intake of carbonated beverages, legumes, foods of the cabbage family, and foods or beverages sweetened with aspartame.

Thank You