Abdominal pain in children is perhaps the most commonly reported symptom in paediatric practice. Since this symptom can be caused by a vast array of underlying conditions, it is of paramount importance that relatively non-emergent conditions like viral gastroenteritis, constipation and functional abdominal pain be differentiated from surgical emergencies like appendicitis, torsion or volvulus.
If a child has fever and vomiting along with abdominal pain, it should always be taken seriously, especially if the pain is in the right lower quadrant. Similarly, abdominal pain associated with blood and mucus in stools, or a visible mass in the abdomen signifies an important pathology. Other important features that can alert the parents are constipation, persistent vomiting, rapid breathing, jaundice, blood in stool or vomitus and a low/absent urine output.
The symptom complex of abdominal pain
- Where is it located?
Most children point to the belly button, which is indicative of a diffuse process like constipation, especially if fecaliths (hard stony mass of faeces in the intestinal tract) are palpable. Pains in the right or left lower quadrant or those radiating to the back should be evaluated for appendicitis, colitis and pancreatitis respectively. Pain in the upper part of mid abdomen, especially aggravated or relieved by eating food, is related to the digestive process and might involve the stomach or duodenum. Pain in the suprapubic region, which is exacerbated by a full bladder, is indicative of inflammation in the urinary tract.Pain in the groin, especially in boys, is a symptom that almost always requires an urgent evaluation. Testicular torsion is a condition in which the testis twists on its own support and cuts off the blood supply. Though the condition is extremely painful, the child might be embarrassed. So, it is always prudent to examine the genitalia in a child complaining of pain.
- What is the duration?
Transient pain relieved on burping or during hiccups is commonly experienced by children and is not of much significance. Sharp shooting pain on the right side of the abdomen, which happens spasmodically and is usually associated with vomiting, is characteristically associated with gallstones. A similar spasmodic, colicky pain in the lower abdomen, which might be unbearable at times, is indicative of a stone lodged in the urinary tract. Recurrent episodes of abdominal pain interspersed with periods of wellness are well described in paediatric literature and should be evaluated accordingly.
- What is the child’s appearance?
This question can be answered easily by the caregivers. A child who is vomiting or sweating profusely and does not seem to be his/her normal self should be rushed to a physician. Excessive sleepiness, inability to retain food or water and a fast heart rate are other pointers to the severity of illness. If a child with abdominal pain can be distracted or is able to eat and drink despite the pain, the underlying pathology might not be sinister.
Diagnosing the abdominal pain
Sometimes, the diagnosis can be made on the basis of a detailed history and examination by the paediatrician. For example, abdominal pain associated with a rash over the buttocks is indicative of a purpura (red or purple discolourations on the skin) or vomiting and abdominal pain associated with diarrhoea, which is pathognomonic of a viral gastroenteritis.
Imaging studies like X-rays, although getting outdated rapidly, are still useful in certain conditions like intestinal obstruction and perforation, to make a rapid clinical diagnosis. Contrast studies like barium scans can be done to rule out stones, growths and strictures in aerodigestive and urinary tracts. Barium enema has been the gold standard for both diagnosis and treatment of intussusception, for decades. Saline enemas have also been used successfully. Newer modalities such as air enemas and ultrasonographically guided enemas have emerged recently.
Ultrasonography (USG) is considered by many experts to be the imaging test of choice in children. Ultrasonography is non-invasive, rapid, and can be performed at the bedside. It does not require oral contrast, which is an advantage for patients who may require surgery. It also spares the paediatric patient exposure to radiation. Diagnosis of appendicitis, gallstones, abdominal lymph nodes or stones in the urinary tract can be made easily by USG.
In recent years, CT has become the test of choice for paediatricians and surgeons alike when USG fails to give a definitive diagnosis. Every variation, from triplecontrast (intravenous, oral, and rectal) CT scanning to non-contrast, unenhanced CT, has been used. CT offers the advantage of greater accuracy, the ability to identify alternative diagnoses, and in some studies, lower negative laparotomy rates. Although CT appears to be better than ultrasonography in making the diagnosis of appendicitis in children, it is slower, requires oral contrast in most centres, and exposes the young child to significant radiation. If the child is vomiting, keeping the oral contrast in the gastrointestinal tract can be a challenge, and antiemetics may be required.
Blood investigations are mainly supportive but sometimes can be useful diagnostic aids. For example, amylase and lipase levels can diagnose acute pancreatitis, while a high total leucocyte count in an appropriate clinical setting can diagnose acute appendicitis with a high degree of reliability.
A urine analysis should be done to rule out a urinary tract infection, which should then be confirmed by a urine culture. Nonspecific elevation of the urinary leukocyte counts may be seen with inflammatory processes elsewhere in the body.
The treatment of abdominal pain is tailored to the cause. It ranges from giving plenty of fluids to rehydrate a child with gastroenteritis, to giving antibiotics to a child with urinary tract infection. Most of the diarrheal illnesses in children are viral and do not require an antibiotic, except when they are associated with blood in stools (dysentery). Medication for constipation in children should always be ante grade and include non-absorbable sugars and mild stimulants. Children with pancreatitis usually require admission in a high dependency unit and require close monitoring of their laboratory parameters. Treatment is mainly supportive till the child recovers.
Treatment of certain other conditions is purely surgical e.g. intussusception, volvulus, pyloric stenosis, testicular torsion, gallstones or stones in the urinary tract.
The prognosis for abdominal pain in children is as diverse as the causes themselves. Abdominal pain left identified and treated early carries a good prognosis overall; however, pain undiagnosed and untreated can be life threatening. Consequently, early in the child’s illness, a parent or caregiver should work with the paediatrician and the hospital to ensure the child receives appropriate care.