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Abdominal pain in children

Abdominal pain in childhood

The differential diagnosis of abdominal pain in childhood contains many of the conditions found in adults. However, making the correct diagnosis can be more difficult as younger children may have difficulty expressing themselves, and if the child is able to describe the pain they frequently have difficulty in localising it accurately.

Also in children there are a few conditions which are rarely, if ever, described in adults. In many hospitals younger children with abdominal pain are frequently admitted under the paediatricians rather than the surgeons.

Classifying the causes into some memorable list through which one can sift under the watchful eye of the examiner (or worse, the parents) is difficult. It can be helpful to think of the abdominal structures and the pathology that may affect them. It is sometimes helpful to separate acute and chronic/recurrent conditions though, of course, the first attack of a chronic condition has to happen at some time.

As with most branches of medicine it is important to remember the common conditions well but not to forget the important rare ones. Misdiagnosing a first abdominal migraine as mesenteric adenitis is unlikely to make much difference but missing appendicitis in a young child can rapidly lead to perforation and peritonitis.

GI Causes

Appendicitis

In the older child this can often be diagnosed as easily as in an adult. However, in younger children, particularly those below 5 years the diagnosis is frequently much less clear. In children of all ages the progression of appendicitis can be extremely rapid, sometimes taking no more than a few hours from the first symptoms to perforation.

This author has recently seen a fifteen year old with clear signs described by the GP apparently settle before being reviewed by the surgical registrar only to develop signs of peritonitis from his perforated appendix the next morning. Older children more typically present with anorexia and central abdominal pain progressing to signs of peritonism in the right iliac fossa (tenderness, guarding and rebound). A good differentiating symptom/sign for peritonism is that movement hurts the child.

They may be pyrexial or apyrexial, may or may not vomit and may or may not have an abnormal blood count. Reviewed at the right time the diagnosis is easy unless, of course, the appendix is abnormally positioned.

Younger children usually go off their food too. Those that are old enough usually complain of tummy pain. Most are very miserable. There may be associated vomiting and sometimes diarrhoea though this is rarely profuse. Abdominal tenderness is usually present but not always clearly focal. Ileus usually develops as the condition progresses.

Unfortunately there is little else to aid the diagnosis. A PR is generally distressing for a younger child and generally best left to a surgeon if he feels it will help decide whether to take the child to theatre. In more advanced cases an appendix mass may be felt.

In simple terms a high index of suspicion is probably the best way to avoid missing the this relatively common diagnosis. The diagnosis is frequently made through the combined efforts of paediatrician and surgeon though treatment is clearly surgical.

Intussusception

This is a condition that usually presents between 3 months and one year of age. In this condition the distal ileum folds in on itself and is peristalsed into the ascending colon. Why this should happen is not clear, it may be as a result of an enlarged lymph node in the intestinal wall being moved by the effect of peristalsis.

Sometimes it is associated with a Meckel's diverticulum. Curiously intussusception can sometimes resolve by itself. On other occasions treatment is required.

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