Clinical Practice Guidelines : Abdominal pain

http://www.rch.org.au/clinicalguide/guideline_index/Abdominal_pain/

Abdominal pain
This guideline has been adapted for statewide use with the support of the Victorian Paediatric Clinical Network See also: Guidelines linked from table below Adolescent Gynaecology

Background to condition:
Abdominal pain in children can be caused by a wide range of surgical and non-surgical conditions. Repeated examination may be useful to look for the persistence or evolution of abdominal signs. Some children will have a cause found, however a significant number of children will be diagnosed with nonspecific abdominal pain. Neonates often present due to parental concern over perceived abdominal pain and broad differentials for presentation should be considered. Common causes of Abdominal Pain Notes: There is overlap between groups and classical symptoms may not be present; eg appendicitis in the preschool age group. Functional abdominal pain is very common but is a diagnosis of exclusion. Highlighted in red=time critical illness Neonates Infants and Preschool Hirschprungs enterocolitis Incarcerated hernia Intussuception Irritable/unsettled infant Meckels diverticulum UTI Volvulus Appendicitis Gastroenteritis Intussusception Pneumonia UTI Volvulus Constipation Appendicitis DKA Gastroenteritis Henoch Schonlein Purpura Mesenteric adenitis Migraine Ovarian Pathology Pneumonia Constipation Testicular torsion UTI Viral Illness Appendicitis DKA Ectopic pregnancy Cholecystitis/ Cholelithiasis Gastroenteritis Inflammatory Bowel disease Ovarian cyst-torsion or rupture Pancreatitis Pelvic Inflammatory Disease Renal calculi Testicular torsion UTI Viral illness School age child Adolescents

Assessment:

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Clinical Practice Guidelines : Abdominal pain

http://www.rch.org.au/clinicalguide/guideline_index/Abdominal_pain/

History
Onset of pain sudden onset of pain, consider testicular or ovarian torsion intussusception perforated viscus. Character of pain Episodic severe pain intussusception mesenteric adenitis, gastroenteritis constipation Testicular torsion in patients with pain referred to the scrotum. Associated Symptoms Bilious vomiting implies volvulus or bowel obstruction and warrants surgical review. Pallor and lethargy during episodes of abdominal pain occurs in intussusception. Rash and purpura on extensor surface of lower limbs/buttocks: consider Henoch Schonlein Purpura Cough and fever with RUQ or LUQ pain- pneumonia Dysuria, and frequency - UTI. Polyuria, polydipsia, loss of weight - diabetic ketoacidosis Menstrual and sexual history in post-pubertal girls as ectopic pregnancy can be fatal. Past medical history: associated with rarer causes of abdominal pain Hirschprungs disease and Cystic Fibrosis - complicated by enterocolitis with sudden painful abdominal distension and bloody diarrhoea. These patients can rapidly deteriorate with dehydration, electrolyte disturbances and systemic toxicity and are at risk of colonic perforation. Primary bacterial peritonitis can occur in children with liver disease, nephrotic syndrome, splenectomy, ascites and those with VP shunts. Pancreatitis can be caused by drugs including chemotherapy and immunosuppressant agents. Inflammatory bowel disease- toxic megacolon

Examination
Assess hydration status Children with peritonism: will often not want to move in the bed be unable to walk or hop comfortably Abdominal tenderness with percussion. Internal rotation of the right hip can irritate an inflamed appendix. Examine abdomen focal vs generalised tenderness, rebound tenderness, guarding or rigidity abdominal masses, distension palpable faeces. Respiratory examination. Inguinoscrotal examination including testes. Look for hernia Rectal or vaginal examination is rarely indicated in a child and should only be performed by one person.

Investigations
These will depend on differential diagnosis but may include the following. Many children need no investigations. urine MCS blood sugar for DKA

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Clinical Practice Guidelines : Abdominal pain

http://www.rch.org.au/clinicalguide/guideline_index/Abdominal_pain/

electrolytes +/- LFTs Lipase (pancreatitis) urine pregnancy test/ quantitative beta hCG Imaging AXR if obstruction suspected. Not helpful in diagnosing constipation. CXR if pneumonia suspected Ultrasound May be requested after discussion with senior staff Is not clinically indicated for testicular torsion.

Acute Management:
ABC Early referral of patients with possible diagnoses requiring surgical management. Fluid resuscitation may be required (initial bolus 20ml/kg normal saline) Establish and maintain intravenous access in sick children. Measure electrolytes and blood sugar if the patient appears dehydrated Keep patients fasting if surgical cause suspected Provide adequate analgesia iv morphine may be required or intranasal fentanyl as initial analgesia in severe pain (see Analgesia and sedation) Consider a nasogastric tube if bowel obstruction suspected Consider IV antibiotics in surgical causes (discuss with surgeon first) Other investigations and management will be guided by clinical findings Note : When transferring infants or children with possible surgical conditions, ensure analgesia, venous access and intravenous fluids as third space losses can be large and lead to haemodyanamic collapse.

Discharge advice
Many children with nonspecific abdominal pain can be discharged home after history, examination and urine dipstick or microscopy with expectant management. A clear follow up plan should be arranged often with a local GP. Parents should be informed of when to seek medical attention.

Consider consultation with local paediatric or surgical team:

Severe pain Diagnosis unclear Patient requiring admission

When to consider transfer to tertiary centre:

Child requiring care beyond the comfort level of the hospital. For advice and inter-hospital (including ICU level) transfers ring the Sick Child Hotline: (03) 9345 7007

Additional Notes:
Appendicitis in young children Rarely presents with classical symptoms Often presents as perforation or sepsis Usually a late diagnosis and requires careful attention to fluid and antibiotic management. Intussusception Usually severe bouts of episodic pain Followed by episodes of pallor and lethargy.

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Clinical Practice Guidelines : Abdominal pain

PR bleeding or redcurrent jelly stool is a late sign. Non-specific abdominal Pain:

http://www.rch.org.au/clinicalguide/guideline_index/Abdominal_pain/

Some children suffer recurrent nonspecific abdominal pain, with no organic cause identifiable. This is usually termed functional abdominal pain and affects 10-15% of children. Constipation is sometimes a contributing factor, but tends to be overdiagnosed as a cause of abdominal pain. Psychogenic factors (eg: family, school issues) need to be considered in some cases. Non-pharmacological measures (reassurance, relaxation, heat packs) can be tried. Follow-up is important. Consider outpatient referral for General Paediatric / Adolescent clinic assessment. Last updated March 2013

Last updated 9 March 2013. Content authorised by: Webmaster. Enquiries: Webmaster. Portal.

Staff

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