ABDOMINAL PAIN
| EVALUATION OF PERIUMBILICAL ABDOMINAL PAIN —Kevin J. Kelly, MD, Philadelphia, Associate Professor,
Division of Gastroenterology, Temple University School of Medicine, Philadelphia
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| Categories of recurrent abdominal pain: peptic symptom complex; primary periumbilical paroxysmal pain; lower
abdominal pain associated with altered bowel patterns
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Peptic Symptom Complex
| Case 1 (Mary): history—girl 11 yr of age with history of pain in stomach from end of summer to October; speaker
asked, “What would you like me to do for you”? patient responded, “I’d like you to help me figure out how to get rid of
this stomachache”; pain present “lots of the time”; greatest slightly above umbilicus; nausea without vomiting; especially
severe in morning on awakening; worsens with hunger and improves with eating; patient falls asleep quickly, but often
awakened by pain during night; calcium carbonate (Tums) helpful; no missed days of school; no relationship between
bowel movements and pain; patient works hard in school, has many friends, likes to read and play soccer; argues sometimes
with younger sibling, but usually they play well together; physical examination—tenderness in epigastric region to
deep palpation; remainder of examination negative, including stool guaiac
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| Hallmarks of pain associated with acid injury: awakens patient from sleep (if pool of unbuffered acid present,
patient vulnerable to irritation in esophagus, stomach, or duodenum); presents in early morning hours upon awakening;
school avoidance also associated with complaint of pain in morning (but in peptic disease, pain worse when hungry and
improves with meals); improvement with antacids helpful but not diagnostic; nausea or vomiting; often, anemia with occult
blood-positive stool; family history of ulcer disease; endoscopy not always indicated
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| Treatment: acid-blocking medication, ie, H2 -blocker or proton pump inhibitor (PPI; lansoprazole [Prevacid]); follow-up
by telephone at 2 wk (in office, at 1 mo); if better, 2-mo course of medical therapy (>50% of time, child cured); treatment
failure—after few weeks off medication, with return of gastric acid secretions, symptoms recur (child deserves upper
endoscopy with biopsy); speaker does not deny procedure if family requests it
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| Endoscopic findings: evidence of linear erosions and edema typical of reflux esophagitis; duodenal ulceration; normal
gastric mucosa, antrum, and duodenum; slight thickening and edema of valvulae conniventes of second and third segments
of duodenum; linear erosions of gastritis in cardiac region
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| Helicobacter pylori-induced abdominal pain: problem of H pylori titer (issue whether active inflammation present);
symptoms recur after trial of PPI; on endoscopy, nodularity of antrum; biopsy gold standard for diagnosis of H pylori-induced
gastritis; presence of organism without gastritis controversial (speaker does not treat those cases)
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Primary Periumbilical Paroxysmal Pain
| Case 2 (Natalie): girl 11 yr of age presents with complaint of stomachache for several months; patient brought home
many times from summer camp because of inability to participate in activities due to abdominal pain; missed 15 days at
new school, but still maintained straight-A record; patient encircled abdomen to indicate site of pain (umbilicus point of
worst pain); pain present “all the time”; not greater when hungry and does not change with meals; keeps patient from falling
asleep at night, so parents allow her to watch television or listen to music in bedroom; child frequently enters parents’
bedroom at night with complaint of pain, but eventually sleeps well through night; no medications; blood and urine tests
negative; no weight loss; growing at 50th to 75th percentile for height and weight; no vomiting, diarrhea, or constipation;
abdominal examination unremarkable, but patient reported pain when physician touched her; examination inconsistent
(attention easily divertable); at parent’s insistence, speaker performed upper endoscopy with biopsy
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| Managing patients and parents: goal to make parent aware of alternative diagnoses, including functional abdominal
pain; critical to mention early in encounter that emotional triggers may be involved (otherwise, when endoscopy normal,
parent may conclude that physician unable to make diagnosis and not committed to helping patient); inform family that
purpose of endoscopic investigation to detect signs of inflammation and/or infection, celiac disease, or parasites; in this
case, endoscopy normal; show pictures to family (“we have abdominal pain here, we just do not have a cause that is obvious”);
abdominal computed tomography (CT)—speaker strives to avoid it; delivers large dose of radiation; meaningful
data requires intravenous (IV) and oral contrast; statistical yield extremely low; abdominal ultrasonography (US)—
helps address parental concerns without exposing child to needless radiation; important to acknowledge that pain genuine
(patient not malingering; much data in adult literature); clear genetic vulnerability (usually, parent has irritable bowel
syndrome [IBS]); internalizing behaviors also common; behavior pattern fostered (patient had no extracurricular activities;
expectation of high grades in school common)
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| Characteristic pain pattern: varies in intensity and frequency; pain vague (children have difficulty describing it);
does not happen at certain times; gradual onset; location periumbilical; interruption of normal activity; interaction with
physician vague; history—parent’s response to complaint of pain (typically, they pay more attention than when child
does not complain of pain); child expected to do well in school
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| Prognosis: organic disease rarely masked with this presentation; pain improves after labeling (diagnosis); placebo effect
of endoscopy (children have burden lifted when internal organs normal); most patients do well; children diagnosed with
functional pain often develop IBS as adults
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Lower Abdominal Pain With Altered Bowel Patterns
| Case 3 (Nicholas): boy 8 yr of age; described by triage nurse as rude and disinterested; mother reported that child having
abdominal pain; patient pointed to umbilicus and described cramping pain at start of meals (not present when hungry);
once patient starts eating and feels pain, he has urge for bowel movement (pain resolves after passage of stool);
stool pattern infrequent but fairly regular; important to ascertain from patients whether required to withhold urge to defecate
(frequent problem when child at school); delay causes alteration of bowel pattern; gastrocolic reflex typically induces
contraction of left colon at time when patient begins meal; management—may require stool softeners; patient may
have large, hard, and infrequent bowel movements (not always); write note to teacher and principal to allow child free access
to clean toilet whenever he or she needs to go; if needed, speak directly to school nurse or have school call physician;
being forced to withhold urge to defecate creates cascade of problems
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| History: pain related to urge to defecate; improves after passage of stool; clustered around eating or meals; differential
diagnosis—pain when hungry, better with eating (peptic syndrome); no pain when hungry, but pain with eating (constipation);
pain unrelated to meals (functional pain)
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| Clinical evaluation: history usually sufficient to make diagnosis; laboratory evaluation—urinalysis and urine cultures;
stool studies; possible blood studies; lactose breath hydrogen tests (often, children have cramping abdominal pain associated
with ingestion of lactose); speaker supports trial of acid-blocking medication and stool softeners; upper endoscopy with biopsy
(not automatically; never colonoscopy)
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| Red flags for Crohn’s disease: pain well localized away from umbilicus; intermittent episodes of pain that occur suddenly
and last variable periods; radiation of pain; weight loss or deceleration of growth; gastrointestinal bleeding; fever;
lethargy, malaise, or fatigue; on endoscopy—active inflammation in cecum; ulceration throughout colon
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| APPENDICITIS —Hanmin Lee, MD, Assistant Professor of Clinical Surgery, Pediatrics, Obstetrics, Gynecology, and Reproductive
Sciences, University of California, San Francisco, School of Medicine
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| Incidence: ≈7% of population affected (4% <18 yr of age); most common abdominal surgery in childhood; gradual increase
from birth; earliest onset 9 mo of age; peaks in late teens, with gradual decline; slight male predominance; less
common in countries with high-fiber diet
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| Natural history: occlusion of lumen of appendix followed by lymphatic obstruction, venous congestion, and arterial obstruction;
gangrene of appendix followed by necrosis; in perforated appendicitis, pus and abscess
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| Diagnosis: midepigastric pain from inflammation of visceral peritoneum; right lower quadrant pain when parietal peritoneum
becomes inflamed; anorexia, nausea, and vomiting; fever; tenderness at McBurney’s point; rebound tenderness; elevated
white blood cell (WBC) count with left shift; younger children more likely to have perforated appendix (>50% of
affected patients <4 yr of age present with perforation; important to diagnose early); variety of scoring systems; physical
examination—most important component; tenderness in right lower quadrant; rebound tenderness—younger patients
often apprehensive during palpation (if shake bed and patient grimaces, clear peritoneal sign of perforation); plain
films—rarely beneficial; chest x-ray more helpful to rule out right lower lobe pneumonia
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| Diagnostic accuracy and outcome: by midcentury, 1% overall mortality (6% mortality with perforation); current
mortality should approach 0% (mortalities associated with perforation and missed diagnosis); improved antibiotics, anesthesia,
surgical technique, and postoperative care; with reasonable clinical acumen, all deaths preventable; negative appendectomy
rate—expectation of 20% rate outdated; rate <5% achievable (early referral important); if diagnosis not
straightforward—admit and observe; imaging important adjunct; “salvage” rate after perforation excellent due to—
broad-spectrum antibiotics that have minimal toxicity; interventional radiology (IR) for draining abscesses; critical care
and anesthesia
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| Is imaging necessary? if diagnosis clear based on clinical findings, surgery indicated; if diagnosis unclear, US helpful;
if positive, diagnosis confirmed; if negative, talk to radiologist; if appendix not seen, results indeterminate (not negative;
appendicitis not ruled out)
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| CT compared to US: both highly accurate; institutional differences—CT more consistent between institutions (static;
easier for third party to read); US more variable; US dynamic (may detect problem not seen on CT); CT and US can be
complementary studies; patient differences—in younger, thinner patient, US better; in older, heavier patient, CT better
(hallmark of appendicitis stranding of fat around cecum); sonographer pushes right lower quadrant (if child complains of
pain, some interpret study as positive); if structure does not compress, study positive
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| Surgical technique: 3-mm diameter instruments through 3-mm port (healing almost scarless; speaker removes appendix
through umbilicus)
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| Timing of surgery: acute appendicitis—patient status nil per os (NPO; nothing by mouth); start IV fluids and antibiotics
immediately; treatment delay (study by Brender)—most likely factor to cause perforation (in study, delay days
not hours); in other papers, observation for 2 days did not change outcome or perforation rate in children with appendicitis,
because children NPO and given IV fluids and antibiotics; operating room (OR) or surgeon not immediately available;
bottom line—surgery timely if within 24 hr of hospitalization and patient NPO with IV fluids and antibiotics;
speaker tries to get patient to OR right away (at least within 6-8 hr); 24-hr wait possible, not ideal
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| Laparoscopic vs open surgery: speaker performs open surgery as often as laparoscopic surgery because incision so
small; not much data in children (in adult series, no significant differences); advantages of laparoscopic
appendectomy—3- to 5-mm incision; ability to view other organs; in adult literature, quicker return to activities; advantages
of open surgery—most surgeons have more experience with it; quicker; cheaper; total length of incisions smaller;
speaker’s approach—older heavier child (laparoscopic procedure); younger skinnier child (open procedure)
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| Perforated appendicitis: ≤3 days of onset of symptoms—treatment same as acute appendicitis; ≥4 days—antibiotics
several weeks, then interval appendectomy 2 mo later has some benefits (shorter total hospital stay; some believe fewer
complications [appendix less inflamed]); most recommend immediate appendectomy (avoids prolonged “sick” time; possible
decrease in complications overall); no good comparative studies; well-formed abscess present and patient appears
well—reasonable to have IR drain abscess; long-standing IV access; send patient home with IV antibiotics several
weeks, then perform appendectomy; diffuse process and patient sick (not able to eat)—immediate appendectomy indicated
with usual postoperative IV antibiotics; intraoperative cultures—not useful; treat with broad-spectrum antibiotics
based on clinical course (factors include pain, fever, and WBC count)
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| Antibiotic regimen: nonperforated and nongangrenous—one dose of first-generation cephalosporin preoperatively;
perforated or gangrenous—broad-spectrum coverage; historically, triple agent; if available, combination piperacillin
and tazobactam (Zosyn); if fever persists postoperatively—most likely cause gram-negative organism resistant to Zosyn
(speaker adds cephalosporin with gram-negative coverage or more commonly, aminoglycoside)
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| Wound closure: in adult literature, up to 40% rate of wound infection with perforated appendicitis; study by
Burnweit—only 11% of children with perforated appendix develop wound infection (children have less fat);
recommendation—close all wounds (small amount of pus easily managed)
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| Postoperative stay: nonperforated—patient usually sent home next day when patient PO and able to take oral pain
medication; perforated or gangrenous—IV antibiotics until afebrile with normal WBC count and patient PO; on discharge,
oral antibiotics 1 wk to 10 days
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Educational Objectives
| The goal of this program is to educate the listener about abdominal pain in children. After hearing and assimilating
this program, the clinician will be better able to:
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 | 1. Describe peptic symptom complex in children who present with recurrent abdominal pain.
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| 2. Diagnose primary periumbilical paroxysmal pain.
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| 3. Recognize lower abdominal pain with altered bowel patterns.
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| 4. Diagnose appendicitis in children.
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| 5. Choose appropriate therapy for children who present with appendicitis.
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Discussed on This Program
Calcium carbonate (several formulations and trade names)
Lansoprazole [Prevacid, Prevacid IV]
Piperacillin sodium and tazobactam sodium [Zosyn]
Suggested Reading
American Academy of Pediatrics Subcommittee on Chronic Abdominal Pain: Chronic abdominal pain
in children. Pediatrics 115:812, 2005; Bundy DG: Diagnostic accuracy in pediatric appendicitis. Pediatrics
114:514, 2004; Burnweit C et al: primary closure of contaminated wounds in perforated appendicitis. J Pediatr
Surg 26:1362, 1991; Di Lorenzo C et al: Chronic Abdominal Pain in Children: a Technical Report of the American
Academy of Pediatrics and the North American Society for Pediatric Gastroenterology, Hepatology and Nutrition.
J Pediatr Gastroenterol Nutr 40:249, 2005; Emil S: Perforated appendicitis in children: is there a best
treatment? J Pediatr Surg 39:1447, 2004; Heij HA, Offringa M: Effect of an imaging protocol on clinical outcomes
among pediatric patients with appendicitis. Pediatrics 113:626, 2004; Ikeda H et al: Laparoscopic versus
open appendectomy in children with uncomplicated appendicitis. J Pediatr Surg 39:1680, 2004; Kokoska ER et
al: Effect of pediatric surgical practice on the treatment of children with appendicitis. Pediatrics 107:1298, 2001;
Ponsky TA et al: Hospital- and patient-level characteristics and the risk of appendiceal rupture and negative appendectomy
in children. JAMA 292:1977, 2004; Samuel M: Pediatric appendicitis score. J Pediatr Surg 37:877, 2002;
Shipman SA, Forrest CB: Appendicitis-pediatric surgeons versus general surgeons. Pediatrics 109:988, 2002;
Stephen AE et al: The diagnosis of acute appendicitis in a pediatric population: to CT or not to CT. J Pediatr Surg
38:367, 2003; Walker LS et al: Recurrent abdominal pain: symptom subtypes based on the Rome II Criteria for
pediatric functional gastrointestinal disorders. J Pediatr Gastroenterol Nutr 38:187, 2004.
Faculty Disclosure
In adherence to ACCME guidelines, the Audio-Digest Foundation requests all lecturers to disclose any significant financial
relationship with the manufacturer or provider of any commercial product or service discussed. For this issue,
the faculty reported nothing to disclose.
Dr. Kelly was recorded at the Twenty-Fifth Annual Pediatric Novemberfest, presented November 3-4, 2005, in Atlantic
City, New Jersey, by Temple University School of Medicine; Dr. Lee was recorded at the 38th Annual Advances
and Controversies in Clinical Pediatrics, presented June 2-4, 2005, in San Francisco by the University of
California, San Francisco, School of Medicine, Department of Pediatrics; The Audio-Digest Foundation thanks Drs.
Kelly and Lee, and the sponsors, for their cooperation in the production of this program.
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