Associated Fever, vomiting (bilious?), diarrhea (bloody?), symptoms abdominal distention
Extraintestinal Cough, dyspnea, dysuria, urinary frequency, symptoms flank pain
Course of Worsening or improving, change in nature or symptoms location of pain, aggravating and alleviating factors
General Growth and nutrition, general appearance, position hydration, degree of discomfort, body position
Abdominal Tenderness, distention, bowel sounds, rigidity, guarding, mass
Genitalia Testicular torsion, hernia, pelvic inflammatory disease, ectopic pregnancy
Surrounding Breath sounds, rales, rhonchi, wheezing, flank structures tenderness, tenderness of abdominal wall structures, ribs, costochondral joints
Rectal Perianal lesions, stricture, tenderness, fecal examination impaction, blood
CBC, C-reactive Evidence of infection or inflammation protein, ESR
AST, ALT, GGT, Biliary or liver disease bilirubin
Amylase, lipase Pancreatitis
Urinalysis Urinary tract infection; bleeding due to stone, trauma, or obstruction
Plain flat Bowel obstruction, appendiceal fecalith, free and upright intraperitoneal air, kidney stones abdominal films
CT scan Intra-abdominal or pelvic abscess, appendicitis, Crohn’s disease, pancreatitis, gallstones, kidney stones
Barium enema Intussusception, malrotation
Ultrasound Gallstones, appendicitis, intussusception, pancreatitis, kidney stones
ALT, Alanine aminotransferase; AST, aspartate aminotransferase; CBC, complete blood count; CT, computed tomography; ESR, erythrocyte sedimentation rate; GGT, γ-glutamyltransferase.
Intussusception* Malrotation with volvulus Ileus* Incarcerated hernia Postoperative adhesion
Children with functional abdominal pain characteristically have pain almost daily. The pain is not associated with meals Meconium ileus equivalent (cystic fibrosis) or relieved by defecation and is often associated with a ten-Duplication cyst dency toward anxiety and perfectionism. Symptoms often result from stress at school or in novel social situations. The *Common.
pain often is worst in the morning and often prevents or delays children from attending school. Irritable bowel syndrome (IBS) is a subset of functional abdominal pain, characterized by onset of pain at the time of a change in stool frequency or consistency, a stool pattern fluctuating between diarrhea and constipation, and relief of pain with defecation. Symptoms in IBS are linked to gut motility. Pain is commonly accompanied in both groups of children by school avoidance, secondary gains, anxiety about imagined causes, lack of coping skills, and disordered peer relationships (Table 126-5).
One needs to distinguish between functional pain/IBS andmore serious underlying disorders. Warning signs for underlying illness are listed in Table 126-6. If present, further investigation is necessary. Some laboratory evaluation is warranted
Table 126-3 Distinguishing Features of Abdominal Pain in Children DISEASE ONSET LOCATION REFERRAL QUALITY COMMENTS Functional: irritable bowel syndrome Recurrent Periumbilical, splenic and hepatic flexures None Dull, crampy, intermittent; duration 2 h Family stress, school phobia, diarrhea and constipation; hypersensitive to pain from distention
Esophageal Recurrent, after Substernal Chest Burning Sour taste in mouth; reflux meals, at bedtime
Pancreatitis Acute Epigastric-hypogastric Back Constant, sharp, Nausea, emesis, marked boring tenderness
Inflammatory Recurrent Depends on site of
Dull cramping, Fever, weight loss, ±