Pediatric Primary Care (78 page)

A.  Etiology.

1.  Pain located in abdomen with 2 weeks' duration. Symptom can originate from within or outside gastrointestinal (GI) tract.

2.  Pain from visceral (stomach, intestine), parietal (peritoneum), or referred areas.

3.  Frequently caused by viral gastroenteritis, urinary tract infection (UTI), constipation.

4.  Other possible causes vary by age:

a.  Infant: colic, intussusception, incarcerated hernia, testicular torsion.

b.  Preschool: appendicitis, intussusception, pneumonia, pharyngitis, trauma.

c.  School age: appendicitis, pneumonia, pharyngitis, pancreatitis, trauma.

d.  Adolescent: appendicitis, pancreatitis, cholelithiasis. Female: mittelschmerz, pelvic inflammatory disease (PID), dysmenorrhea, ectopic pregnancy, ovarian cyst.

B.  Occurrence.

1.  Gastroenteritis, appendicitis are most common causes.

C.  Clinical manifestations.

1.  Must take child's age, developmental level into consideration regarding location, duration of pain. Younger children often indicate periumbilical region.

2.  Associated symptoms: fever, vomiting, diarrhea, cough, anorexia depending on etiology.

3.  Important subjective data should include:

a.  Location, duration, frequency of pain.

b.  Stool frequency, consistency; history of hematochezia or melena.

c.  Vomiting: frequency, presence of bile or hematemesis.

d.  Symptoms outside GI tract (cough, congestion, dysuria, sore throat, fever).

e.  Medication and diet history.

f.  Sexual activity, vaginal discharge.

g.  Alleviating and aggravating factors.

D.  Physical findings.

1.  Weight, temperature, vital signs.

2.  General appearance: Assess degree of discomfort and hydration.

3.  Complete physical exam with attention to following:

a.  Abdominal exam: Ask child to indicate location of pain. Observe for peristaltic waves, distention, guarding. Palpate for masses, stool, hepatosplenomegaly, tenderness. Percuss for rebound tenderness. Have child stand, jump to assess for signs of peritoneal irritation.

b.  Rectal exam: Assess for fissures, erythema.

E.  Diagnostic tests.

1.  May include CBC, comprehensive metabolic panel, amylase, lipase, and urinalysis. Consider pregnancy test in postmenarchal girls.

2.  Test stool for occult blood if history dictates.

3.  Chest X-ray (CXR) if pneumonia suspected.

4.  Abdominal X-ray if intestinal obstruction or perforation suspected. Useful to rule out fecal impaction.

5.  Abdominal ultrasound if appendicitis, ovarian cyst, ectopic pregnancy suspected.

F.  Differential diagnosis.

1.  Appendicitis.

a.  Vague periumbilical pain, localized to right lower/middle quadrant.

b.  Often associated with fever, vomiting; may see elevated WBC count.

c.  Guarding, rebound, signs of peritoneal irritation on abdominal exam.

2.  Constipation, gastroenteritis, intussusception, incarcerated hernia, colic, peptic ulcer.

3.  Pancreatitis.

a.  Inflammation of pancreas from infection, medications, trauma, genetic defect, or structural abnormality.

b.  Epigastric pain often with nausea, vomiting.

c.  Elevated amylase, lipase.

4.  Cholelithiasis.

a.  Epigastric or right upper quadrant pain, often radiates to back.

b.  Ultrasound shows stones in gallbladder or bile duct.

G.  Treatment.

1.  Appendicitis, cholelithiasis: surgical consult.

2.  Pancreatitis: possible hospital admission for IV hydration, pain control.

3.  Intussusception: admission for diagnosis and barium enema incarcerated hernia: admission for surgery.

H.  Follow up.

1.  Telephone contact for any changes/increase in symptoms.

2.  Ensure follow through with any consults that have been requested.

I.  Complications.

1.  School absence.

J. Education.

1.  Reassure if physical exam consistent with nonsurgical abdomen. Parents most often concerned about appendicitis.

2.  Review hydration/nutrition needs.

3.  Treat fever as needed.

4.  Monitor for any changes in symptoms or worrisome signs such as hematochezia, hematemesis, increased or newly localized pain.

5.  Education otherwise depends on final diagnosis.

II. ABDOMINAL PAIN, CHRONIC: CHILDHOOD FUNCTIONAL ABDOMINAL PAIN (FAP)

A.  Diagnostic criteria: Must experience
all
of the following symptoms, at least once per week for at least 2 months prior to diagnosis:

1.  Episodic or continuous abdominal pain.

2.  Insufficient criteria for other functional gastrointestinal disorders.

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

B.  Functional abdominal pain syndrome (FAP-S) includes all of the above plus at least 25% of the time one or more of the following:

1.  Some loss of daily functioning.

2.  Additional somatic symptoms such as headache or difficulty sleeping.

C.  Etiology.

1.  Considered to be functional disorder: defined as absence of specific structural, infectious, inflammatory, or biochemical abnormalities as cause of pain.

2.  No longer thought to be caused by psychologic stressors. However, coping skills may be different in patients with FAP. Stress may affect pain experience, perpetuate symptoms.

3.  May be greater likelihood of anxiety, somatization in parents of children with FAP.

D.  Occurrence.

1.  Equal incidence among males and females until age 10 years; then female- to-male ratio is 1.5:1.0. Most common between 8-15 years of age.

E.  Clinical manifestations.

1.  Periumbilical abdominal pain lasts from 1 hour to 3 hours.

2.  Occurs daily or intermittently (at least once per week) over at least 8-week period.

3.  May be associated with nausea, fatigue, headache, pallor.

4.  Patient may assume fetal position, grimace/cry during episode.

5.  Pain does not wake child from sleep.

6.  Patient may have school absence, withdraw from social/extracurricular activities.

7.  No weight loss or growth delay.

8.  Not associated with fever, vomiting, melena, or hematochezia.

9.  Important subjective data to obtain:

a.  Description of normal elimination pattern; alleviating or aggravating factors.

b.  Dietary history, medications.

c.  Psychosocial stressors, parent/caregiver usual reaction to the pain.

F.  Physical findings.

1.  Weight/height: Plot on growth curve and compare with previous.

2.  Perform thorough physical exam at first visit with attention to following:

a.  Abdominal exam: Ask patient to indicate location of pain. Assess for tenderness, masses, hepatosplenomegaly.

b.  Rectal exam: inspect for erythema, fissures, skin tags. Perform digital exam.

3.  Tanner staging.

G.  Diagnostic tests.

1.  No diagnostic test to make diagnosis of FAP.

2.  Screening laboratories to obtain:

a.  Urinalysis, urine culture.

b.  Complete blood count, erythrocyte sedimentation rate (ESR), and/or CRP, comprehensive metabolic panel, amylase, lipase.