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.
