Pediatric Abdominal Pain - Dubai Pediatric Clinic

• Pediatric Abdominal pain is the most frequent gastrointestinal complaint that brings child to a physician. The majority of pediatric abdominal complaints are relatively benign (e.g. constipation) but it is important to pick up on the cardinal signs that might suggest a more serious underlying disease.
• Diagnosing abdominal pain in children is a challenging task.

ACUTE ABDOMINAL PAIN (Last hours to days)

Acute abdominal pain in children may be the result of:

• Extra abdominal disease (e.g. lower lobe pneumonia; pharyngitis)
• Intra-abdominal disease (acute gastroenteritis; hepatitis; gastritis; pancreatitis; UTI; intestinal obstruction; hernias and masses)
• Metabolic ( ketotic acidosis)
• Hematologic cause (sickle cell crises)
• Genitourinary problems (testicular torsion ovarian cyst; and ovarian torsion; ectopic pregnancy for adolescent girls.
• Surgical cases (intussusception; appendicitis; intestinal obstruction; and hernias)

Good history and physical examination is very important to detect the cause and can guide the physician to perform the appropriate investigations for final diagnosis and treatment.

HISTORY

• Location of the pain and quality (localized; generalized; dull; sharp; colic pain)
• Radiation; severity; and timing of pain.
• Alleviating factors and aggravating factors.
• Associated symptoms (vomiting; constipation; diarrhea; melena; weight loss; jaundice and testicular pain)
• Dietary history
• Family history
• Female (menstruation cycle)

PHYSICAL EXAMINATION

• Vital signs
• Growth parameters
• General examination
• Abdominal examination: palpation; auscultation; and percussion
• Digital rectal examination

After history and physical examination, it is very important to discover the surgical cases for abdominal pain that needs immediate surgical intervention. Red flag signs include:

• Bilious vomiting
• Abdominal distention
• Rigidity and rebound in abdominal examination.
• Bloody stool or emesis
• hemodynamic instability

COMMON DIFFERENTIAL DIAGNOSIS FOR ABDOMINAL PAIN

• CONSTIPATION – infrequent bowel evacuation or painful defecation. Blood can be seen in stool from anal fissure.
• GASTROENTERITIS- abdominal pain, diarrhea, vomiting, fever. (can be bacterial or viral etiology)
• ACUTE APPENDICITIS – right lower abdominal pain, fever, anorexia, vomiting, can rupture and lead to sepsis.
• TRAUMA – history of trauma or signs of bruising.
• URINARY TRACT INFECTION – dysuria, frequency, and hematuria.
• ACUTE TONSILLITIS; STREPTOCOCCAL AND MESENTERIC LYMPHADENITIS
• PNEUMONIA (LOWER LOBE) – tachycardia, tachypnea, fever, chest and abdominal pain.
• DYSMENORRHEA

LESS COMMON CAUSE

• Intussusception – colicky pain; fever; lethargy; vomiting; peak incidence in age 6m
• Meckel's diverticulum – similar presentation of appendicitis
• Mesenteric adenitis
• Small bowel obstruction
• Volvulus
• Hernias
• Viral hepatitis
• Acute pancreatitis
• Splenic infarction
• Nephrolithiasis
• Testicular torsion
• Ovarian torsion
• Ruptured ovarian cyst
• Ectopic pregnancy
• Pelvic inflammatory disease
• Cholecystitis

INVESTIGATIONS

• Complete Blood Count
• Erythrocyte Sedimentation Rate
• Urinalysis
• Stool analysis
• Cultures
• Amilase or lipase
• Abdominal ultrasound
• CT scan
• Abdominal Xray
• According to the history and physical examination can help to establish the diagnosis. 

TREATMENT: It depends on the cause of abdominal pain.

CHRONIC ABDOMINAL PAIN

Chronic abdominal pain in children is defined as pain for more than 2 weeks in duration and or recurrent pain for more than 3 episodes of pain, which is severe enough to affect activity within 3 months.

CAUSES:

• Irritable Bowel Syndrome:
  • Isolated recurrent abdominal pain or associated with dyspepsia or altered bowel pattern; nausea; vomiting; satiety; constipation; or diarrhea and or alternating period of both.
  • The symptoms have functional basis. Disorders such as fears, nocturnal enuresis, and sleep disturbance are seen in 30% of affected child.
  • Social factors such as: new teacher; new school; stress; parental pressure for achievement are associated with attacks of pain.
  • Antispasmodic medication is used for relief of pain. 
• Constipation:
  • It is a major cause of chronic abdominal pain.
  • It is treated with laxative and fiber diet to resolve the recurrent pain.
• Peptic disorder:
  • Esophagitis; gastritis; gastric and duodenal ulcer; H pylori infection.
  • Child present with chronic epigastric pain; early satiety and nausea.
  • Endoscopic investigation is generally indicated treatment with H2 receptor blockers, proton pump inhibitor and erythromycin, Flagyl for H pylori infections.
• Abdominal migraine:
  • Periodic nausea, vomiting, abdominal pain, that last 6-8 hours with intervals of weeks or months with no symptoms or signs. Treatment is usually with antiemetic or migraine medications.
• Lactose Intolerance:
  • Abdominal pain; bloating; after mild consumption.
  • Diagnosis: Hydrogen breath test after lactose ingestion and the treatment is free lactose diet. 

• Inflammatory Bowel disease:
  • Ulcerative colitis; Chrohns disease; lower abdominal pain, fever, weight loss, fatigue, joint pain, rashes, hematochezia , diarrhea, and recurrent mouth ulceration.
  • Barium enema and colonoscopy is indicated for diagnosis.
  • Treatment with prednisolone, special diet and sometimes surgical intervention. 

• Familial Mediterranean fever:
  • Recurrent fever, abdominal pain, joint pain, chest pain, and family history.
  • Treatment with (NSAID) and observance of kidney function.

• Porphyria
  • Abdominal pain; tachycardia, increase BP and NEUROLOGIC_ symptoms such as paralysis, seizure or coma.

Dubai Pediatric Clinic at Dr Rami Hamed Center provides one of the leading pediatricians in Dubai.