Abdominal Pain

Alarm findings / Red flags in History & Physical

History (CUBED BUMS WtF)

• Chronic severe diarrhea (≥3 loose or watery stools per day for more than two weeks) or nocturnal diarrhea
• Enteric infection (parasitic, bacterial, viral), IBD, immune deficiency, celiac disease, food protein-induced enteropathy
• Unexplained fever
  
• Infectious or inflammatory process; familial Mediterranean fever
• Back pain
  
• Referred pain (eg, chronic pancreatitis)
• Emesis -Significant vomiting (bilious, protracted, projectile, or otherwise worrisome)
  
• Acid-peptic disease, cyclic vomiting syndrome, eosinophilic gastroenteritis, bowel obstruction, hepatobiliary disease, metabolic (eg, DKA, adrenal crisis), cholecystitis, intracranial lesion
• Difficulty swallowing (dysphagia) or painful swallowing (odynophagia)
  
• Eosinophilic esophagitis, pill esophagitis, infectious esophagitis, achalasia
• Bloody diarrhea
  
• IBD
• Urinary symptoms (change in bladder function, dysuria, hematuria, flank pain)
  
• Recurrent urinary tract infection; nephrolithiasis
• Melena (black, tarry stools)
  
• Acid peptic disease, Meckel diverticulum
• Skin changes (rash, eczema, hives)
  
• IBD, celiac disease, food allergy
• weight loss that is involuntary
  
• Malabsorption (IBD, celiac disease, pancreatitis), malignancy
• Family history of IBD, celiac disease, peptic ulcer disease
  
• IBD, celiac disease, peptic ulcer disease

Physical

• Deceleration in linear growth (eg, height gain <5 cm/year in a prepubertal child) and/or delayed puberty
  
• IBD, celiac disease
• Oral aphthous ulcerations
  
• IBD
• Localized right upper quadrant tenderness
  
• Hepatobiliary disease (eg, gallstones, cholecystitis, extrahepatic bile duct [choledochal cyst])
• Localized right lower quadrant pain
  
• Ovarian cyst or mass, chronic appendicitis
• Left lower quadrant pain
  
• Constipation, ovarian cyst or mass, ulcerative colitis
• Suprapubic tenderness
  
• Urinary tract infection
• Hepatomegaly
  
• Chronic hepatitis, hepatobiliary disease, storage disease (eg, Gaucher disease)
• Splenomegaly
  
• Hemolytic disease, splenic infarct, splenic abscess, storage disease
• Costovertebral angle tenderness
  
• Pyelonephritis
• Perianal abnormalities (eg, skin tags, fissures, fistulae)
• IBD
• Skin changes (rash, eczema, hives)
  
• IBD, celiac disease, food allergy
• Guaiac-positive stool
  
• Enteric infection, IBD, juvenile polyps, acid-peptic disease, foreign body, vasculitis (eg, polyarteritis nodosa); proximal small bowel disease (Crohn disease, Helicobacter pylori, peptic disease, celiac disease)

Causes of abdominal pain in Peds

Common Causes

• Acid peptic disorders (eg, reflux esophagitis, gastritis, gastric and duodenal ulcers, Helicobacter pylori infection)

  • Early morning pain, pain awakens at night

  • Early satiety, nausea, sour breath, burping

  • Occult blood in stool

    • Epigastric, upper abdomen

• Carbohydrate malabsorption (eg, lactose)

  • Crampy pain, diarrhea (bulky, watery, frothy), bloating, and/or intestinal gas related to ingestion of foods containing the malabsorbed carbohydrate (eg, dairy products and foods containing dairy products for lactose malabsorption)

    • Periumbilical, lower abdomen

• Celiac disease

  • Crampy, nonspecific abdominal pain, chronic diarrhea, anorexia, abdominal distension, poor weight gain or weight loss, malnutrition, steatorrhea, flatulence

  • Iron deficiency anemia

  • Secondary amenorrhea

    • Less likely to be epigastric

• Constipation (may have organic or functional etiology)

  • Infrequent stooling, incomplete evacuation, fecal incontinence, history of large stools or stools that clog the toilet, abdominal distention, mass in the left lower abdominal quadrant, hard stool in rectal vault on digital examination

    • Left-sided

• Dysmenorrhea*

  • Cyclical pain related to menstruation

    • Lower abdomen

• Gastroesophageal reflux

  • Respiratory symptoms, such a chronic cough, wheezing, laryngitis

    • Epigastric, upper abdomen

• Musculoskeletal pain (eg, hernia, hematoma, anterior cutaneous nerve entrapment syndrome)

  • Pain with specific physical activity

  • Muscle tenderness on examination

  • Positive Carnett sign - Focal pain increases or remains the same during abdominal wall contraction (elicited by asking the child to sit halfway forward from the supine position).

    • Abdominal wall

• Parasitic infection (eg, Giardia, cryptosporidium)

  • Diarrhea, crampy pain, bloating

  • Exposure history

    • Diffuse

Less common causes

• Endometriosis*

  • Severe progressive dysmenorrhea

  • May also have bowel symptoms (eg, rectal pain, constipation, painful defecation) and bladder symptoms (eg, dysuria, urgency, hematuria)

    • Lower abdomen, pelvis

• Eosinophilic esophagitis

  • Feeding dysfunction, vomiting, dysphagia, food impaction, association with allergic conditions (eg, food allergy, environmental allergy, asthma, atopic dermatitis)

    • Upper abdomen or chest

• Food allergy

  • IgE-mediated:

    • Onset of abdominal pain, nausea, or vomiting within minutes to 2 hours after ingestion of offending food

    • Onset of diarrhea within 2 to 6 hours after ingestion of offending food

  • Non-IgE-mediated:

    • Chronic vomiting and diarrhea

    • Poor weight gain

    • Blood or mucus in stools

      • Nonspecific

• Inflammatory bowel disease

  • Short stature

  • Poor weight gain

  • Delayed sexual maturation

  • Oral ulcers

  • Perianal fistulae, skin tags, and fissures

  • Diarrhea

  • Gross or occult blood in stool

  • Uveitis, arthritis

  • Elevated ESR or CRP

    • Lower abdomen

• Pelvic inflammatory disease*

  • Cervical motion tenderness, adnexal tenderness, or adnexal mass on pelvic examination

  • Pain may have onset or worsen during or shortly after menses

  • Abnormal uterine bleeding

    • May have RUQ pain with perihepatitis

    • Lower abdomen pelvis

• Urinary tract infection

  • Fever, urinary symptoms (dysuria, urgency, frequency, incontinence, macroscopic hematuria), flank pain

    • Lower abdomen, flank

Rare causes

• Bezoar

  • Nausea, vomiting, early satiety, anorexia, weight loss

  • Patchy alopecia in patients with trichobezoars

  • History of gastric surgery

    • Epigastric

• Burkitt lymphoma

  • Ascites, bowel obstruction, gastrointestinal bleeding

    • Diffuse, RLQ

• Chronic hepatitis

  • Tender hepatomegaly

    • RUQ

• Chronic pancreatitis

  • Malabsorption, obstructive jaundice, growth failure, epigastric or upper abdominal tenderness that radiates to the back, pain worse after eating (especially fatty food), nausea, vomiting

    • Epigastric, upper abdomen

• Familial Mediterranean fever

  • Recurrent unexplained fever

    • Diffuse

• Foreign body

  • Clinical features vary with location of foreign body

    • Variable

• Gallstones/chronic cholecystitis/choledochal cyst

  • Jaundice, abnormal liver tests (elevation of AST and ALT early in the course; elevation of bilirubin, alkaline phosphatase, and GGT later in the course)

    • RUQ or epigastric

• Heavy metal poisoning (eg, lead)

  • Exposure history

  • Crampy pain

  • Sporadic vomiting

  • Constipation

    • Diffuse

• Hereditary angioedema

  • Gastrointestinal colic, nausea, vomiting, diarrhea

  • Skin symptoms

  • Prodromal symptoms

  • Attacks may be triggered by mild trauma, medications, hormonal changes

  • Recurrent angioedema without urticaria

  • Low C4 levels

  • Family history of allergy

    • Nonspecific

• Imperforate hymen with hematocolpos*

  • Absence of menarche despite sexual maturity

  • Cyclic abdominal or pelvic pain

  • Imperforate hymen with bluish discoloration

  • May have back pain, pain with defecation, or difficulties with urination

    • Lower abdomen/pelvis

• Malrotation (late presentation)

  • Episodic episodes of vomiting (not necessarily bilious) and abdominal pain

    • Diffuse

• Mesenteric ischemia

  • Postprandial abdominal pain, weight loss, nausea, vomiting, diarrhea

    • Diffuse

• Nephrolithiasis

  • Lower abdominal pain may radiate to the genitalia, may have gross hematuria, dysuria, urgency, nausea/vomiting

    • Lower abdomen

• Pregnancy*

  • Amenorrhea, nausea, breast enlargement, urinary frequency fatigue

    • Lower abdomen

• Psoas abscess

  • Back or flank pain

• Radiation to hip or posterior thigh

  • Positive psoas sign – pain is worse with extension of the hip

    • Lower abdomen

• Slipping rib syndrome

  • Sharp unilateral pain, worse with twisting, turning or extension of the thorax

  • Pain reproduced by displacing the lower ribs upward and anteriorly with the patient in the supine position

    • Upper abdomen

• Superior mesenteric artery syndrome

  • Progressive symptoms of postprandial epigastric pain and early satiety

  • Nausea, weight loss

  • Abdominal distension

  • High pitched bowel sounds

  • Symptoms may be relieved in certain positions (eg, prone, left lateral decubitus, knee-chest)

    • Epigastric

• Ureteropelvic junction obstruction

  • Intermittent flank or abdominal pain

  • Pain may worsen during brisk diuresis (eg, after consumption of caffeine or alcohol), nausea, vomiting

  • Periumbilical

• Vasculitis (eg, Henoch-Schönlein purpura, polyarteritis nodosa)

  • Extragastrointestinal manifestations (eg, arthritis, purpura, hematuria)

    • Diffuse

Functional Diagnosis:

Rome IV diagnostic criteria for functional abdominal pain disorders in the child/adolescent

• Functional dyspepsia 
• In addition to the universal criterion, at least two months with ≥1 of the following bothersome symptoms on ≥4 days per month: 
• Postprandial fullness
• Early satiation
• Epigastric pain or burning not associated with defecation

• Irritable bowel syndrome

  • In addition to the universal criterion, ≥2 months with abdominal pain associated with one of the following on ≥4 days per month:

    • Related to defecation

    • Change in frequency of stool

    • Change in form (appearance) of stool

  • In children with constipation, the pain does not resolve with the resolution of the constipation (resolution of pain indicates functional constipation)

  
  
• Abdominal migraine
• In addition to the universal criterion, all of the following:
• Paroxysmal episodes of intense, acute, periumbilical, midline, or diffuse abdominal pain lasting ≥1 hour (abdominal pain is the most severe and distressing symptom) at least twice within a six month period
• Episodes are separated by weeks or months
• The pain is incapacitating and interferes with normal activities
• Stereotypical pattern and symptoms in the individual patient
• The pain is associated with ≥2 of the following:
• Anorexia
• Nausea
• Vomiting
• Headache
• Photophobia
• Pallor
  

• Functional abdominal pain - not otherwise specified

  • In addition to the universal criterion, all of the following:

    • Occurs ≥4 times per month for ≥2 months

    • Episodic or continuous abdominal pain that does not occur solely during physiologic events (eg, eating, menses)

    • Insufficient criteria for irritable bowel syndrome, functional dyspepsia, or abdominal migraine

• Functional constipation (not usually included in Abd pain ROME criteria)

  • In addition to the universal criterion, ≥2 of the following occurring ≥1 time per week for >1 month with insufficient criteria for a diagnosis of irritable bowel syndrome:

    • ≤2 defecations in the toilet per week in a child of a developmental age of ≥4 years

    • ≥1 episode of fecal incontinence per week

    • History of retentive posturing or excessive volitional stool retention

    • Presence of a large fecal mass in the rectum

    • History of large diameter stools that can obstruct the toilet