Gastroenteritis May be caused by a virus or Salmonella

Shigella, Campylobacter, or Yersinia. Vomiting and diarrhea precede pain. Tenesmus and blood in stool may be noted, but peritonitis is absent. Stool cultures are usually diagnostic.

4. Meckel diverticulitis. Presentation is similar to appendicitis but is much less common, and pain is not as localized to the right lower quadrant. Diagnosis is rarely made before surgery.

5. Intestinal obstruction. Causes in older children include Meckel diverticulum that twists or telescopes, and adhesions from previous surgery.

6. Constipation. Frequent cause of acute or recurrent pain in children. Usually functional but may be due to Hirschsprung disease, an anteriorly displaced anus, defects of the spinal cord, or metabolic abnormalities (ie, hypokalemia, hypothyroidism).

7. Inflammatory bowel disease. Ulcerative colitis or Crohn disease is frequently accompanied by pain; either condition may also give rise to toxic megacolon. Crohn disease may appear as acute ileitis (10% of cases) and have a presentation similar to appendicitis.

8. Typhlitis. Occurs in immunosuppressed patients (eg, leukemia) when leukocytes < 1000/mm3. Involves terminal ileum and right colon and is probably infectious.

9. Biliary colic, cholecystitis. Gallstones are most common in adolescent girls; may also occur in children with hemolytic anemias and those who have received long-standing TPN.

10. UTI. Cystitis is usually associated with dysuria, frequency, and urgency; pyelonephritis with fever and flank tenderness.

11. Urinary calculus. May produce excruciating "writhing" pain in flank or abdomen as well as hematuria.

12. Ovarian cyst. Rare before puberty. May produce pain when it bleeds, ruptures, or twists. Torsion is a surgical emergency.

13. PID. Salpingitis or tuboovarian abscess is common among adolescent girls.

14. Mittelschmerz. Ovulatory bleeding can cause peritoneal irritation; occurs midway in cycle.

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