Immediate Questions

A. How old is patient? Many conditions that cause abdominal pain are age specific. Necrotizing enterocolitis only occurs in early infancy, midgut volvulus is most common in the first year, intussusception is seen mostly in toddlers, appendicitis is rare in the newborn and increases in frequency through adolescence, and many gynecologic disorders are seen only in girls after puberty.

B. Where is the pain located? Gastroenteritis and most types of functional abdominal pain are centrally located; pain of appendicitis begins centrally and then migrates to the right lower quadrant; gallbladder and hepatic pain occurs in the right upper quadrant and may radiate to the back or right shoulder; pain from the stomach, duodenum, and pancreas occurs in the epigastrium; pain from the small intestine is central; pain from the large intestine occurs in the hypogastrium; pain from the spleen is felt in the left upper quadrant and may radiate to the left shoulder; pain from the kidneys or ureters is often felt in the flank and may radiate to the groin; and pain from the ovaries or fallopian tubes occurs in the ipsilateral lower quadrant.

C. What is the quality of the pain? Visceral pain, produced by dis-tention of a hollow organ or stretching of the capsule of a solid organ, is colicky and dull (eg, intestinal obstruction, early appendicitis, ureteral calculus, hepatitis). Parietal pain involves inflammation of the peritoneum and is sharp, well localized, and exacerbated by movement (eg, appendicitis in its later stages, necrotic intestine, perforated viscus).

D. Duration of pain? Gastroenteritis and mesenteric adenitis start gradually and plateau over hours. Appendicitis starts gradually and classically increases in severity until perforation occurs. Urinary calculi, ovarian torsion, and ruptured ovarian cyst are sudden in onset and severe from the outset. Pain of intussusception is intermittent over hours and sometimes days. Functional pain is most frequently chronic.

E. Has patient had this pain before? Functional abdominal pain is most likely to be recurrent. However, volvulus and even appendicitis may be self-limited on several occasions and then recur with full-blown manifestations.

F. Are there associated GI symptoms? Individuals with significant intra-abdominal pathology are rarely hungry. Nausea, vomiting, and a change in bowel habits often accompany GI conditions such as gastroenteritis, appendicitis, and intestinal obstruction. Bilious vomiting is indicative of obstruction and possibly volvulus. Vomiting preceding pain is most characteristic of gastroenteritis. Copious diarrhea is typical with enteric infections, and severe constipation itself can be the cause of the pain.

G. Urinary symptoms? UTIs are associated with dysuria, frequency and urgency; calculi may produce dysuria and hematuria.

H. Symptoms from other organ systems? Abdominal pain in children is frequently a manifestation of extra-abdominal disease (eg, pharyngitis, otitis, pneumonia). Intussusception frequently follows a viral illness.

I. Is there a history of trauma? Abdominal injuries may be a source of pain.

J. In postpubertal girls, when was the last period? Is there a history of sexual intercourse? Vaginal discharge? Consider pelvic inflammatory disease (PID), mittelschmerz, and ectopic pregnancy, depending on gynecologic history. K. Fever? With appendicitis, there is typically afebrile or low-grade fever until perforation; with viral conditions and peritonitis, temperature may be highly elevated. L. Chronic systemic illnesses? Children with sickle cell disease may have abdominal pain from a crisis; those with diabetes can have abdominal pain associated with ketoacidosis. Leukemia may produce typhlitis during periods of severe leukopenia. Inflammatory bowel disease can cause abdominal pain during periods of exacerbation.

III. Differential Diagnosis. Because both acute and chronic abdominal pain are extremely common in children, the challenge is to identify the relatively few patients with significant medical and surgical illnesses that require treatment. In a survey of children with acute abdominal pain in the emergency department, 86% had self-limited disease and only 1% required surgical intervention. Diagnostic probabilities are age dependent. A. Patients Older Than 3 Years of Age

1. Appendicitis. The most common cause of abdominal pain that requires surgery in children older than age 2 years; prototype of the so-called acute abdomen. Early diagnosis is most important, because perforation may occur 36-48 hours after onset.

2. Mesenteric lymphadenitis. Usually a diagnosis of exclusion when no other cause is found or a normal appendix is seen during exploration for presumptive appendicitis. Considered to be viral in origin. Pain is more generalized, with fewer peritoneal signs than in appendicitis. Leukocyte count usually is normal.

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