PAEDIATRIC SCENARIO – COLICKY ABDO PAIN

You are an intern at GCUH ED. Marie, has brought her son, Jason aged 6 months.

Task
Take a history and do relevant exam on the Jason. Report back to the registrar regarding
your findings, and include your assessment and plan.
SP information

Jason, age 6 months

 Been lethargic and refusing to eat since this morning.
 Cries 2-3 times an hour; appears to be in pain
 Becomes quite pale and grabs his tummy
 Vomited three times since this morning
 Has also had some diarrhoea just before coming into the hospital (bloodied)
 Got sick two weeks ago with some respiratory infection

Past medical history

 Bronchiolitis at age 2 months – was hospitalised for 7 days
 Immunizations UTD
 No meds
 No allergies

Birth history
 Born at 32 weeks via emergency LSCS for placental abruption
 In SCN for a week
 Birth weight 1650g (18th)

Family history
 Older sister has asthma
 Paternal grandparents have diabetes

Social history
 Lives at home with mom, dad and two other siblings (age 3 and 12)
 Father smokes but always outside the house
Intussusception

Key Points
1. Repeated examination is useful to look for the persistence or evolution of signs and
evaluate response to treatment.
2. Analgesia should be used and will not mask potentially serious causes of pain.
3. Investigations are guided by the most likely cause. Most children need no
investigations.
4. True bilious vomiting is dark green and warrants urgent surgical input.
Background
 The key consideration in acute abdominal pain is the differentiation between
surgical and non-surgical causes.
 Non specific abdominal pain is very common but is a diagnosis of exclusion once red
flags are considered. See below for more details.
 Symptoms in neonates may be attributed by parents as abdominal pain. A thorough
examination and a broad differential should be considered in this group.
See unsettled baby.
Common Causes of Abdominal Pain by Age
Time critical illnesses are in Red
Neonates Infants and Children Adolescents

Hirschprung’senterocolitis Appendicitis Appendicitis

Incarcerated hernia Abdominal trauma Abdominal trauma
Intussusception Constipation Cholecystitis/
Irritable/unsettled infant DKA Cholelithiasis
Meckel’s diverticulum Gastroenteritis Constipation
Necrotisingenterocolitis Henoch Schonlein Purpura DKA
Testicular torsion Incarcerated hernia Ectopic pregnancy
UTI Intussusception Gastroenteritis
Volvulus Meckel’s diverticulum Inflammatory Bowel
Mesenteric adenitis disease
Migraine Migraine
Pneumonia Ovarian cyst-torsion or
Pyloric stenosis rupture
Testicular torsion Pancreatitis
UTI Pelvic Inflammatory
Volvulus Disease/STI
Renal calculi
Testicular torsion
UTI
Important non-abdominal causes of abdominal pain to consider:
 Pneumonia
 DKA
 Sepsis
 Toxin exposure or overdose
Assessment
History

Symptoms and signs with associated differential diagnose

Past medical history: associated with rarer causes of abdominal pain

 Children with Hirschprung’s disease and Cystic Fibrosis can develop a complication
known as enterocolitis which presents with sudden painful abdominal distension
and bloody diarrhoea. These children can rapidly deteriorate with dehydration,
electrolyte disturbances and systemic toxicity and are at risk of colonic perforation.
 In children with liver disease, nephrotic syndrome, splenectomy, ascites and those
with VP shunts primary bacterial peritonitis can occur.
 Children on chemotherapy and immunosuppressant agents are at increased risk
of pancreatitis.
 Children who are tube fed including PEG/NG/NJ are at increased risk of pancreatitis.
 In children with inflammatory bowel disease, especially those with concurrent C.
difficile infection or immunocompromised children, toxic megacolon can occur.
Examination:
 Observe the child’s movements, gait, position and level of comfort
 Examine the abdomen for:
 focal vs generalised tenderness
 rebound tenderness
 guarding or rigidity
 abdominal masses
 distension
 palpable faeces
 Children with peritonism:
 will often not want to move in the bed
  will be unable to walk or hop comfortably
 will have abdominal tenderness with percussion
 internal rotation of the right hip can irritate an inflamed appendix
 Inguinoscrotal examination, including testes.
 Look for hernia.
 Look for basal pneumonia.
 Rectal or vaginal examination is rarely indicated in a child, this should be discussed
with a senior clinician and if needed should only be performed once.
Management
Investigations
Most children need no investigations.
Investigations to consider, depending on differential diagnosis, may include the following:
 Urine analysis (+/- culture +/- pregnancy test if indicated)
 Electrolytes +/- LFTs
 Lipase for pancreatitis
 Venous blood gas
 Blood sugar for DKA
 LFTs, lipase and UEC in abdominal injury
 Imaging
 AXR if obstruction suspected. It is not helpful in diagnosing
constipation.
 CXR if pneumonia is suspected.
 Ultrasound
 May be requested after discussion with senior staff (very low
yield if used indiscriminately)
 Is not clinically indicated for testicular torsion and may delay
time critical surgery.
 Useful if the history is suggestive of intussusception, even if
examination is normal.
Treatment
 Fluid resuscitation may be required. (see Intravenous fluids)
 Provide adequate analgesia. IV morphine may be required or intranasal
fentanyl as initial analgesia in severe pain. (see Analgesia and sedation)
 Keep children fasting and commence maintenance fluids if a surgical cause is
suspected.
 Early referral of children with possible diagnoses requiring surgical
management.
 Consider a nasogastric tube if bowel obstruction is suspected.
 Consider IV antibiotics in surgical causes (discuss with the surgical team first).
Consider consultation with local paediatric or surgical team when:
 Surgical cause suspected
 Severe pain not responsive to analgesia
 Child requiring admission

Consider transfer when:

Child requiring care beyond the comfort level of the hospital.
Note: When transferring infants or children with possible surgical conditions, ensure the
child has adequate analgesia, venous access and intravenous fluids prior to transfer as third
space losses can be large and lead to haemodyanamic collapse.
For emergency advice and paediatric or neonatal ICU transfers, call the Paediatric Infant
Perinatal Emergency Retrieval (PIPER) Service: 1300 137 650.
Consider discharge when:
 Many children with Non-specific abdominal pain can be discharged home after
history and examination (see below).
 A clear follow up plan should be arranged, often with a local GP.
 Parents should be informed of when to seek medical attention.
Parent information
Kids Health Info: Abdominal pain
Additional Notes
Appendicitis in young children (pre-school)
 Rarely presents with classical symptoms
 Often presents as perforation or sepsis
 Usually a late diagnosis and requires careful attention to fluid and antibiotic
management.
Non-specific abdominal Pain
 Some children suffer recurrent nonspecific abdominal pain, with no organic cause
identifiable. This is usually termed Non-specific abdominal pain and affects 10-15%
of children (usually primary school aged).
 Children present with intense severe pain. They often cannot bend over or get
comfortable. In between episodes they feel completely fine.
 Diagnosis can only be made if pain remits completely and there is no associated
vomiting, change in bowel habit or oral intake or any fever.
 Constipation is sometimes a contributing factor, but tends to be overdiagnosed as a
cause of abdominal pain.
 Psychogenic factors (eg: family, school or other stressful issues) need to be
considered in some cases.
 Non-pharmacological measures (reassurance, relaxation, rubbing and heat packs)
can be tried and often help.
 Follow-up is important. Consider outpatient referral for General Paediatric /
Adolescent clinic assessment.