Abdominal Pain
Abdominal Pain
Abdominal Pain
Abdominal Pain
A common and difficult diagnostic
and therapeutic problem
3 Forms
Acute
Recognizable organic entities; aim to prevent tissue damage
Recurrent
Recognizable organic entities are less common
The patient will probably continue living with this symptom
without the MD knowing the cause
Chronic
A physical disease usually coexists with significant functional
disability that is only partially responsive to therapy
Understand disease process, promote optimal psychosocial
functioning
Clinical Classification
Organic
Intraabdominal origin of a specific disease; TREAT.
Psychogenic
Pain seems not to originate in intraabdominal sensory
nerve endings; pain is related to psychological events
Dysfunctional
Pain originates intraabdominally from normal
physiologic processes, but still interferes with normal
activity (may be specific or nonspecific)
Gastritis
Esophagitis
Hiatal hernia
Volvulus
Obstruction
IBD
Meckel diverticulum
Neoplasms
Yersinia enterocolitica infection
Hepatitis
Intussusception
Gallstones
Hirschsprung
disease
Traumatic hemobilia
Pancreatitis
Malrotations
Pancreatic pseudocyst
Infestations
Lead poisoning
Subserosal
intestinal
Abdominal
epilepsy/migraine
Annular
pancreas
Acute
intermittent
hemorrhage
Anorexia
Polyps
porphyria
Abdominal wall strain
Sickle
cell
disease
Foreign
body
Hereditary
angioedema
Familial
fever
Mesenteric
adenitis
Familial Mediterranean
hyperlipidemia
Riley-Day
syndrome
Malformations
Multiple
endocrine adenomatosis
Hydronephrosis
Blood
Lower dyscrasias
tract obstruction
Lymphomas
Pyelonephritis
Coxsackievirus
Renal stones infection
Meconium
ileus syndrome
Ovarian cyst
Brain/spinal
cord neoplasm
Testicular/ovarian
torsion
Epilepsy
Hematocolpos
Gastrointestinal
Hepatobiliary
Trauma
Metabolic
Miscellaneous
Dysfunctional Etiologies of
Chronic stool
Abdominal
Pain (85%)
retention
Heightened
awareness of
intestinal motility
Spontaneous
Lactose intolerance
resolution
Sucrose
Persistent
intolerance
unresolved
Alcohol sugars
intolerance
Intestinal gas
syndromes
Menses
Primary
dysmenorrhea
Mittelschmerz
Pregnancy
Reaction to normal
stress and anxiety
Overeating
Irritable colon
Specific (35%)
Nonspecific (50%)
Psychogenic Etiologies of
Abdominal Pain (10%)
Reaction anxiety
(acute or chronic)
Complaint modeling
Maintenance or manipulation for
Depression
secondary gain
Conversion
Hypochondriasis
reaction
School phobia
Factitious
Stress related
Behavioral
Psychiatric
Other
History
PQRST
Precipitating factors
Quality of pain
Radiation
Severity
Timing
Organic Disease
More likely if pain is well localized,
constant, wakes the child from sleep,
or is located in an area other than
the periumbilical region
Associated SSx may contribute to the
suspicion of organic disease, eg UTI
Pain becomes more localized as the
patient gets older increasing
language facility vs maturation of
pain mechanism?
Dysfunctional Pain
Ask about constitutional and
environmental factors, remember
physiologic changes
GI motility: eg chronic stool retention
Enzyme activity: eg lactose intolerance
Menstrual cycle: dysmenorrhea
Psychogenic Pain
Pain may be associated with special
meaning
Anger, separation, punishment
(unpleasant)
Anticipation of increased attention
(pleasure and relief)
It is easier for patients to discover
emotionally significant feelings than
to describe them in response to
direct questioning
Physical Examination
Inspection
Palpation
Percussion
Auscultation
Rectal examination
Gynecologic evaluation
Differential Diagnosis
1. In acute pain presentations, first
consider entities with potentially
severe consequences requiring early
definitive treatment, then move
down the differential diagnosis list
2. In recurrent presentations, first
consider entities that are most
common, then move up the
differential diagnosis list
Differential Diagnosis
3. Noninvasive baseline tests should
be used for occult common disease
processes early in the investigation
4. More invasive procedures should be
used selectively, and the
investigation should be staged
according to relative priorities
Differential Diagnosis
5. In recurrent pain, further
investigation for organic disease
seldom will be indicated if the
complaint of pain is the only
symptom
6. In both acute and recurrent
presentations, repeat observation
and examinations often are
essential once the acute surgical
Likelihood of presentation
Laboratory Evaluation
of
Acute
Recurrent
Nonspecific Abdominal Pain
Common Causes
Conditions to
consider
Tests to be
performed
Urinary tract
pathology
UA, Urine CS
Inflammatory
Causes
ESR, WBC
Anemia, blood
loss
Liver disease
++++
++++
++++
++++
++++
++++
Liver function
tests
++
Pancreatitis
Amylase
++
Lactose
intolerance
Lactose breath H
test
+++
Stool retention,
renal stones,
pancreatic
calcification,
spinal
dysrhaphism
+++
Conditions to
consider
Tests to be
performed
Likelihood of presentation
Acute
Recurrent
Uncommon Causes
Inflammatory
bowel disease
Barium enema,
UGIS
++
Appendicitis
Barium enema
+++
Urinary tract
pathology
Intravenous
pyelogram
+++
PID
Cultures, UTZ
laparoscopy
+++
+++
Esophagitis,
ulcer
Esophagoscopy,
culture
++
Pregnancy
HCG
++
++
Gallbladder
disease
Ultrasound
++
Abdominal
masses
detected on PE
Ultrasound
+
+++
Pneumonia
Chest radiography
Strep throat
Strep throat
Treatment
Diagnose the disease
Treat the organic disease
Deal with factors predisposing the
child to the symptom
Diary of symptoms
Focus parental anxiety rather than
dismissing it
Treatment
Drugs are usually not indicated in
nonorganic pain
Psychotherapy/counseling
Dietary modification
Conclusion
History and PE
Focused diagnostic workups
Modification of environmental,
dietary factors predisposing to
symptoms
Counsel the patient and their
caregivers