Approach to acute abdominal pain (pediatrics): Clinical sciences

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A 17-year-old girl presents to the emergency department for evaluation of right sided lower abdominal painThe patient reports that she has felt pressure in her right lower abdomen over the last month but that the pain became intermittent and severe pain over the last 24 hours The patient reports nausea and two episodes of emesisThe patient reports urinary frequency but denies dysuria or hematuria. The patient is not sexually activeMenses began at age 13 yo and her Periods are regular. She has no history of dysmenorrhea or menorrhagiaLast menstrual period was two weeks ago. The patient has no new vaginal discharge or dysuria or frequency. Temperature is 37.2°C (99°F), pulse is 108/min, blood pressure is 111/66 mm Hg, respirations are 14/min, and oxygen saturation is 100% on room air. On physical examination, the patient is alert and appears uncomfortableCardiopulmonary examinations are within normal limitsThe abdomen is soft with tenderness to palpation in the right pelvic areaAdnexal tenderness on the right. No rebound or guarding are present. Psoas and obturator signs are negative. Which of the following is the best next step in management? 

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Acute abdominal pain is a common presenting concern in pediatric patients. While severe abdominal pain combined with abdominal rigidity, rebound, or guarding suggests a condition requiring urgent surgical intervention, most underlying causes of acute abdominal pain in children are transient and non-life-threatening. Acute abdominal pain can be caused by gastrointestinal, urinary, pelvic, and neurologic or musculoskeletal conditions.

When a pediatric patient presents with acute abdominal pain, you should first perform an ABCDE assessment to determine if they’re stable or unstable. If unstable, stabilize the airway, breathing, and circulation. Next, obtain IV access, begin fluid resuscitation, and continuously monitor vital signs. Provide supplemental oxygen if needed, ensure that the patient does not take anything by mouth, and consider placing a nasogastric tube. Finally, obtain an emergency surgical consultation and administer broad spectrum IV antibiotics.

Once you’ve initiated acute management, perform a focused history and physical examination. The history will reveal a sudden onset of severe abdominal pain, and the physical exam will often demonstrate abdominal tenderness, rebound, and guarding, possibly with abdominal distension and rigidity. These peritoneal signs indicate an acute “surgical” abdomen, which requires immediate surgical intervention.

Here’s a high-yield fact! Appendicitis is the most common cause of a surgical abdomen in childhood, but other significant causes include intussusception, intestinal malrotation with volvulus, and incarcerated inguinal hernia. Remember that blunt abdominal injury and nonaccidental trauma can cause intraperitoneal bleeding and visceral damage, both of which can present with acute abdominal pain in the absence of obvious external signs.

Now that we’ve discussed unstable patients, let’s move on to stable ones. First, perform a focused history and physical examination. The history will reveal an acute onset of pain; occasionally with nausea, vomiting, or fever; while the physical exam will demonstrate abdominal tenderness. Continue your evaluation by assessing your patient’s stooling pattern.

Sources

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  2. "Acute abdominal pain in children. " Pediatr Gastroenterol Hepatol Nutr. (2013;16(4):219-224. )
  3. "Nelson Textbook of Pediatrics. 21st ed. " Elsevier (2020. )
  4. "Pediatric Symptom-Based Diagnosis. 2nd ed." Elsevier (2023. )
  5. "Nelson Essentials of Pediatrics. 9th ed. " Elsevier (2023. )
  6. "Acute abdominal pain. " Pediatr Rev. (2010;31(4):135-144. )