Abdominal pain in children

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-in-Chief:

Synonyms and Keywords: Abdominal pain in kids

Overview

Abdominal pain in children is a common presenting symptom in pediatrics primary care. There's multiple causes of abdominal pain that require different types of investigations and treatment options.

Historical Perspective

  • Celiac disease was first discovered by Dutch pediatricians, in late 1940s[1].
  • In late 1980s, the first classification and diagnostic criteria for functional gastrointestinal disorders was developed by a group of international experts were recruited by Professor Aldo Torsoli from Italy to develop Working Teams for the International Gastroenterology meeting in Rome 1988 to the goal was to answer difficult questions using a consensus methodology through the Delphi approach about a group of gastrointestinal disorders that had little scientific-based evidence to understand etiology pathophysiology and treatment at the time[2].
  • In May of 2016, after Rome III had been in effect for a decade, Rome IV was released[3]. It is a result of collective work by committees that included more than 100 leading functional GI experts[3].

Classification

  • Abdominal pain in children may be classified according to age into two groups:[4]
    • Abdominal pain in children below five years old.
    • Abdominal pain in children above five years old.
  • Other method for classification of abdominal pain can be according to the duration of the pain[5]:
    • Acute Abdominal pain(less than 1 week).
    • Chronic Abdominal pain(more than 1 week).

Pathophysiology

  • The pathogenesis of abdominal pain is related to either insult to intra-abdominal structures or extra-abdominal structure. Also it can be due to injury to somatic structures that's overlay the abdominal wall [6].
  • On Summary the pathophysiology of abdominal pain maybe due to :
    • Visceral Pain:
      • Result when there's a damage to nerve within the abdomen.[6]
      • Due to the fact that visceral nerve fibers that responsible for pain sensation are non-myelinated, the visceral pain is Vague, dull, poorly localized and slow on onset.[6]
      • Different types of stimuli including chemical, osmotic and even normal peristalsis can stimulate these fibers.[6]
      • Visceral pain is always sensed when the threshold of intensity or duration is reached.[6]
      • Mild stimuli may result in sensing non-painful or vaguely un-comfortable sensation, in contrast to powerful stimulation to visceral nerve fibers which causes pain.[6]
      • Example for pain caused due to over-sensation of visceral nerve fibers is functional abdominal pain.[6]
    • Somatic Pain:
    • Referred Pain:

Causes

There is a wide range of causes for pediatric abdominal pain which maybe due to a disease in variety of systems. In general, differentiating between acute and chronic pain in children is not easy, Despite it's being benign conditions in most children presenting with abdominal pain but some serious conditions may be the cause of the abdominal pain. On the table below there's some systems and related diseases that can cause abdominal pain in children:[7]

Causes of Abdominal pain In Children
System Disesease
Gastrointestinal Appendicitis[8], Gastrointestinal reflux disease[9], constipation [9],irritable bowel syndrome[10], celiac disease [11],Meckel's diverticulum[12], Intussusception[13], Volvulus[14].functional dyspepsia (FD)[15], abdominal migraine (AM)[15], functional abdominal pain (FAP) and functional abdominal pain syndrome (FAPS)[15]
Genitourinary Nephrolithiasis[16] , urinary tract infection[17].
Infections viral (mesenteric adenitis)[18], gastroenteritis[19],Multisystem Inflammatory Syndrome in Children (MIS-C) caused by covid-19[20]
Gynecologic Dysmenorrhea.[21]
Psychology Anxiety [22]
Others Toxins (lead poising)[23] , Sickle cell disease[24].

Differentiational Diagnosis of Abdominal Pain Children

For further information about the differential diagnosis, click abdominal pain differential diagnosis.

Epidemiology and Demographics

  • The pooled prevalence of abdominal pain in children is approximately 13.5% per 196,472 individuals worldwide.[15]
  • Abdominal pain is about 5% of presented cases in pediatrics, surgery is required only in 7% of cases, and non-specific diagnosis in up to 15%[25].
  • In 2001,the incidence of nonspecific abdominal pain was estimated to be 25% cases per 1,000 individuals in Netherland.[26]
  • Incidence of appendicitis is 11/10,000 population per year[27]
  • At least,20% of children present with abdominal pain,5% of them need hospitalization[28].

Age

Gender

  • Females are more commonly affected with abdominal pain than males.[31]
  • Appendicitis male to female ratio is (1.4:1) with life time risk of 8.6% in males and 6.7% in females[27]

Race

  • There is no racial predilection for abdominal pain in children

Risk Factors

Natural History, Complications and Prognosis

  • Abdominal pain is a common presenting symptom in pediatrics primary care. Most of times it's due to benign causes without risk for complications, but severe abdominal pain maybe an alarming sign for abdominal pathology that requires surgical intervention[34]
  • Early clinical features of acute appendicitis include pain that's start in the middle of the abdomen and radiate to the right iliac fossa, followed y fever and vomiting[35].
  • Prognosis of infantile colic is generally good,One self-reporting parent questionnaire on crying patterns found that 29% of infants aged 1 to 3 months cried for more than 3 hours a day, but the estimated prevalence of the age of 4 to 6 months found to be between 7% to 11%[36].

Diagnosis

Diagnostic Criteria

  • The diagnosis of appendicitis is made with Pediatrics Appendicitis score[37] :
Pediatrics Appendicitis score
Variable Score
Pain migrating to right lower quadrant 1
Anorexia 1
Nausea/vomiting 1
Fever>38 1
Right Iliac Fossa Pain 2
Pain with Cough/Percussion/Hopping 2
White Blood Cell Count>10,000 cells/ml 1
Neutrophils count>7,500 1
Total score 10
  • If the score is 5 or less: Appendicitis is less likely or excluded, If the score is more than 5: Appendicitis is high likely to be the diagnosis[38].
  • The diagnosis of Functional abdominal pain is established by using New Rome IV Criteria[39]:
    • All aspects of criteria must be reached for at least two month before the diagnosis, and the criteria must be fulfilled for at least four time per month[40].
    • New Rome IV Criteria include all of the following [40]:
      • Abdominal pain that may occur in episodic or continuous manner, pain that not occur only during physiological events like eating[40].
      • Not fulfill the criteria of any other functional GI disorders, like irritable bowel syndrome and abdominal migraine[40].
      • Abdominal pain that can not fully explained after full assessment[40].

Symptoms

  • First, Red flag symptoms must be excluded:
    • Weight loss[41].
    • Hemodynamic instability[41].
    • Bilious vomiting[41].
    • Bloody vomiting or stool[41].
    • Abdominal pain that wake up the child at night[41].
  • Symptoms associated with abdominal pain may vary according to the cause[42]:
Disease Associated Sympyoms
Colic Irritability, paroxysmal crying[43]
Appendicitis Vomiting,fever, localized right lower quadrant tenderness[44].
Irritable bowel syndrome Diarrhea, Constipation[45].
Hepatitis jaundice[46]
Henchon-schonlein purpura Skin Rash[47]
Urolithiasis Hematuria[48]
Pyelonephritis Dysuria, fever, urinary frequency, vomiting.[49]

Physical Examination

  • First, check vital signs, growth parameters and if there is evidence of failure to thrive. [41].
  • Inspect abdominal wall contour, protrusions, or skin abnormalities.[41]
  • Palpate superficially while looking to patient's face.[25]
  • Deep palpation for masses, kidney, spleen and liver[25].
  • Percussion and auscultation[41].
  • Digital rectal examinations and genital examinations[42]

Laboratory Findings

  • Initial laboratory tests according to symptoms include:
    • Complete blood count, Urine analysis, Stool analysis.[50]
    • Liver enzyme, pancreatic enzymes if liver and pancreas diseases in suspected[30].
    • Electrolyte (Sodium and serum bicarbonate levels) and creatinine, and glucose levels are useful in assessment of dehydration in patient with gastroenteritis[51]

Electrocardiogram

There are no ECG findings associated with abdominal pain in children.

X-ray

  • Plain abdominal pain X-ray may show evidence of bowel obstruction, free air and kidney stone[6].
Case courtesy of Dr Jeremy Jones, <a href="https://radiopaedia.org/">Radiopaedia.org</a>. From the case <a href="https://radiopaedia.org/cases/62793">rID: 62793</a>
Case courtesy of Dr Ian Bickle, <a href="https://radiopaedia.org/">Radiopaedia.org</a>. From the case <a href="https://radiopaedia.org/cases/34633">rID: 34633</a>

Ultrasound

  • Ultrasound may be helpful in the diagnosis of appendicitis [30].
  • Findings on an ultrasound suggestive of appendicitis include:
    • aperistaltic, non-compressible, width(>6 mm outer diameter), when compressed it's appears round[52].
Case courtesy of Dr Alborz Jahangiri, <a href="https://radiopaedia.org/">Radiopaedia.org</a>. From the case <a href="https://radiopaedia.org/cases/48029">rID: 48029</a>
  • Ultrasound may be useful in diagnosing urinary tract (including kidneys) anatomical abnormalities, including nephrolithiasis and associated complications such as hydronephrosis [30].
Case courtesy of Dr Bruno Di Muzio, <a href="https://radiopaedia.org/">Radiopaedia.org</a>. From the case <a href="https://radiopaedia.org/cases/21885">rID: 21885</a>
case courtesy of Dr Bruno Di Muzio, <a href="https://radiopaedia.org/">Radiopaedia.org</a>. From the case <a href="https://radiopaedia.org/cases/21885">rID: 21885</a>

CT scan

MRI

  • Abdominal MRI may be helpful in the diagnosis of appendicitis, with sensitivity of 96% and specificity of 96%[54] .Finding on MRI has many similar findings to CT scan[54].

Other Imaging Findings

Positive-meckels-scan-001.jpg

Other Diagnostic Studies

Case courtesy of Dr Aditya Shetty, <a href="https://radiopaedia.org/">Radiopaedia.org</a>. From the case <a href="https://radiopaedia.org/cases/28005">rID: 28005</a>

Treatment

Medical Therapy

  • The mainstay of therapy for acute gastroenteritis depends on the degree of dehydration ranging from simple oral rehydration at home to hospital admission[55].
  • In functional abdominal pain if bloating is predominate symptom, dietary measures may be effective for example, a low-FODMAP diet to exclude foods with certain types of carbohydrates including wheat, various fruits, lactose, fructose, and some artificial sweeteners[40]. If constipation is a predominate symptoms, incorporating non-stimulant laxatives such as PEG-3350 or increased fiber diets can be helpful[40]. Pharmacological treatment with drugs like selective serotonin reuptake inhibitors (SSRIs) or tricyclic antidepressants (TCAs) are often used to treat functional abdominal pain[40].

Surgery

  • Surgery is the mainstay of therapy for appendicitis, which can be done either laparoscopically or open[52] .

Prevention

  • Effective measures for the primary prevention of acute gastroenteritis include handwashing, breastfeeding, and rotavirus vaccination[51].

References

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  12. Keese D, Rolle U, Gfroerer S, Fiegel H (2019). "Symptomatic Meckel's Diverticulum in Pediatric Patients-Case Reports and Systematic Review of the Literature". Front Pediatr. 7: 267. doi:10.3389/fped.2019.00267. PMC 6606722 Check |pmc= value (help). PMID 31294008.
  13. Simon NM, Joseph J, Philip RR, Sukumaran TU, Philip R (January 2019). "Intussusception: Single Center Experience of 10 Years". Indian Pediatr. 56 (1): 29–32. PMID 30806357.
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  17. Simões E Silva AC, Oliveira EA, Mak RH (2020). "Urinary tract infection in pediatrics: an overview". J Pediatr (Rio J). 96 Suppl 1: 65–79. doi:10.1016/j.jped.2019.10.006. PMID 31783012. Vancouver style error: missing comma (help)
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  20. Radia T, Williams N, Agrawal P, Harman K, Weale J, Cook J, Gupta A (August 2020). "Multi-system inflammatory syndrome in children & adolescents (MIS-C): A systematic review of clinical features and presentation". Paediatr Respir Rev. doi:10.1016/j.prrv.2020.08.001. PMC 7417920 Check |pmc= value (help). PMID 32891582 Check |pmid= value (help).
  21. Gieteling MJ, Lisman-van Leeuwen Y, van der Wouden JC, Schellevis FG, Berger MY (2011). "Childhood nonspecific abdominal pain in family practice: incidence, associated factors, and management". Ann Fam Med. 9 (4): 337–43. doi:10.1370/afm.1268. PMC 3133581. PMID 21747105.
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