Peds - Acute Tummyache Differentials and Workup!

When should you call your senior, if there is one..

Acute Abdominal Pain by Age
Common to Uncommon

Age	Neonate	2 m- 2yrs	2 m - 5 yrs	>5 yrs
ER	Volvulus	Trauma	Trauma	Appendicitis
	NEC	Incarcerated hernia	Appendicitis	Trauma
	Adhesions	Intussusception	Intussusception	DKA
		Foreign body ingestion	Foreign body ingestion	PPU
		Hirschsprung disease	Adhesions	Adhesions
		Adhesions	HUS	HUS
		HUS	Primary bacterial peritonitis	Myocarditis/pericarditis
				Primary bacterial peritonitis
Common/ER	Colic	AGE	AGE	AGE
		Viral illness	Viral illness	Viral illness
			Pharyngitis	Constipation
			Constipation	Pharyngitis

Acute Abdomen
1. Trauma
    A. Motor vehicle collisions, falls, child abuse
2. Appendicitis
    A. Most predictive: RLQ pain, abd. wall rigidity, and migration of periumbilical pain to the RLQ
    B. Pediatric Appendicitis Score (PAS)
        1. For 1-17 y/o, total 10 pts
        2. Point System:
            a. 2 pts: cough/percussion/hopping tenderness; RLQ tenderness;
            b. 1 point: fever > 38° C, anorexia, N/V, migration of pain, WBC >10 000 cells/mm3 , and PMN >7500 cells/mm3
        3. Score
            PAS≧ 7: dx of appendicitis
            PAS 3-6: Need image studies
            PAS≦ 2: exclusion
       (Reference: Journal of Pediatrics 153.2 (2008): 278-282)
    C. Perforation rarely occurs within the first 24 hrs
3. Intussusception
    A. 2 months - 2 yrs, peak at 6 months
    B. Triad (<15%): 
        1. Intermittent, colicky pain (88%)
        2. Palpable sausage-shaped abd. mass (48%)
        3. Currant-jelly stool (25%)
        Others: Inconsolable crying, drawing legs towards abd., bilious emesis. 15-20 min intervals. Progressive
    C. Dx: Ultrasound
        1. Target sign/coiled spring sign
        2. Most common: ileocolic (95%)
    D. Tx:
        1. Hydrostatic (ex. Barium) /pneumatic enema under Ultrasound guidance <48 hrs of onset
        2. Surgery (esp. small bowel)
4. Malrotation with midgut volvulus
        1. S/S: Bilious/Non-bilious vomiting + abd. pain
5. Incarcerated inguinal hernia
        1. S/S:  irritable and crying, vomiting, abdominal distention,  palpation of a firm inguinal mass that may extend to scrotum/labia majora in the groin
6. Adhesions with intestinal obstruction
        1. Hx of abd. surgery + abd. pain
7. Necrotizing enterocolitis
        1. S/S: vomiting, abd. distention, and tenderness
        2. Prematurity, congenital heart diseases more common
8. Peptic ulcer disease
        1. >10 yrs: Meds (ex. NSAIDs)/Stress
        2. H.pylori less common
9. Ectopic pregnancy 
        1. Postmenarchal girls
        2. S/S: abd. pain, amenorrhea, vaginal bleeding

Less Common
1. DKA
2. Hirschsprung associated enterocolitis (HAEC)
3. Hemolytic uremic syndrome (HUS)
4. Primary bacterial peritonitis, usually caused by Streptococcus pneumoniae or E. coli
5. Myocarditis

Surgical indications:
1. Vascular compromise
     A. Malrotation/volvulus
     B. Ischemic bowel obstruction
     C. Intussusception, nonreduced
     D. Incarcerated hernia
     E. Torsed ovary/testis
2. Perforated organ
3. Intra-abdominal bleeding, uncontrolled

Common DDx of Abd. Pain:
1. Constipation
    A. Likely if ≥2
        1. <3 stools wk      
        2. Fecal incontinence (usu. related to encopresis)
        3. Can palpate large stools in rectum/through abdominal wall
        4. Retentive posturing
        5. Painful defecation
2. Gastrointestinal infection
    A.  fever, severe cramping abd. pain, and diffuse abd. tenderness before diarrhea begins
3. Other infections
    A. Urinary tract infections
        1. 2-5 yrs old - Abd. pain, fever, N/V, poor appetite, most common
        2. >5 yrs old - dysuria, frequency, and/or flank discomfort
    B. Streptococcal pharyngitis
        1.  Abd pain, fever, exudative pharyngitis
    C. Pneumonia
        1. Lower lobe pneumonia
    D. Viral illnesses
        1. Fever/cough/sore throat, and/or rhinorrhea
    E. PID
        1. Lower abd. pain begins during/after menses, vaginal discharge in sexually-active girls
    F. Mesenteric lymphadenitis
        1. RLQ
        2. Ultrasound: Abd. LN > 10 mm + normal appendix
        3. Viral infection most common
4. Ruptured ovarian cyst
    A. Acute, severe, focal abd. pain
5. Foreign body ingestion
    A. Sharp/>5 cm in length/multiple magnets/batteries --> Emergent eval. for obstruction/perforation
6. Colic
    A. Hypertonia
        1. face flushed, occasional circumoral pallor
        2. Abd. distended + tense
        3. Legs drawn up on abd. + feet cold
        4. Fingers clenched
        5. Arms stiff, tight, extended
        6. Back arched

Others:
    A. GI
        1. IBD (esp. Crohn's)
            a. Pediatric Crohn’s Disease Activity Index (PCDAI) 
        2. Cholecystitis (esp. w/ hemolytic anemia/cystic fibrosis/older adolescents)
        3. Pancreatitis
        4. Dietary protein allergy (usu. neonates/infants)
        5. Malabsorption
        6. Intraabdominal abscess from perforated appenditis
    B. Extraintestinal:
        1. HSP
            a. Triad: Abd. pain, arthritis, purpura
        2.  Ovarian torsion/Testicular torsion
        3.  Urolithiasis
        4. Malignancy
        5. Toxins (lead/iron)
        6.  vasoocclusive crisis (VOC) for children with sickle cell disease

What to do? Approach and Algorithms
1. Boys/Premenarchal girls

2. Postmenarchal girls


(Reference: Uptodate/NTUH Pediatrics Handbook)