PEDIATRIC ABDOMINAL PAIN
Pediatric Abdominal Pain
Abdominal pain is one of the most common complaints that leads to EMS activation, there are several etiologies of abdominal pain that are more prevalent in a pediatric population as well as some unique treatment considerations that will be reviewed in this unit.
The majority of abdominal pain cases are vague symptoms associated with self-limited conditions like gastroenteritis, constipation, and viral infections. However, life-threatening conditions such as appendicitis or bowel obstruction can also occur. The fact that a child is unreliable as a historian often makes it challenging for the EMS responder to make the distinction between these two.
Chronic Abdominal Pain
Chronic abdominal pain in children and adolescents is either organic or functional.
ORGANIC DISORDERS: can be explained via anatomical or physiologic causes and include,
- peptic ulcers
- gaseous distention
- reflux esophagitis
- lactose intolerance
- celiac disease (malabsorption)
- musculoskeletal disorders (including a hernia)
- inflammatory bowel disease
- endometriosis and dysmenorrhea (in adolescent girls)
FUNCTIONAL DISORDERS: cannot be explained via anatomical or physiologic causes and most commonly include,
- irritable bowel syndrome
- abdominal migraine
- functional constipation
Whether organic or functional, there are "alarm findings" which indicate that a severe life-threatening condition may exist.
- Weight loss
- Significant vomiting
- Chronic, severe diarrhea
- Urinary symptoms
- Bloody diarrhea or dark, tarry stools (melena)
Acute Abdominal Pain
TRAUMA: intra-abdominal injuries from trauma--organ laceration or perforated intestines from car/pedestrian accidents, sports, falls, and abuse. Blood is especially irritating to the internal abdomen and spillage of digestive enzymes or feces evokes an inflammatory immune response.
APPENDICITIS: the most predictive clinical features of appendicitis are
- peri-umbilical pain that migrates to the RLQ over 12 hours or more,
- vomiting, and
- guarding. [SEE BELOW]
CAVEAT: Any abdominal pain + vomiting should include appendicitis for consideration.
INTUSSUSCEPTION: a "telescoping" portion of the intestine onto itself. Intussusception most commonly occurs between two months and two years of age.
- The pain is sudden, then intermittent (the child usually behaves between episodes but with inconsolable crying during). Pain will cause the child to draw up the knees toward the abdomen.
- Vomiting may occur.
INCARCERATED HERNIA: trapped intestinal tissue risks ischemia and bowel death. The umbilicus and inguinal areas are the most frequent sites.
INTESTINAL OBSTRUCTION: everything backs up, and the GI tract distends above the site of obstruction. The lining over the bowel and colon is covered with the peritoneum, which is exquisitely sensitive to distension.
CONSTIPATION: causes colicky pain from both distention and hyperactive (cramping) peristalsis that attempts to move feces along.
- GI infection: fever, cramping, diffuse tenderness, and diarrhea.
- Foreign body ingestion and obstruction.
The Appendix: called the "vermiform appendix," or "worm-like," is a worm- or finger-shaped narrow pouch projecting from the cecum (beginning of the large intestines/ascending colon) in the RLQ of the abdomen. It is an organ of immunity, but due to the redundancy of immune organs in the human body (tonsils, spleen, thymus, lymph nodes, etc.), its contribution is not crucial when it needs to come out--as in appendicitis, where removal is curative.
Because it is narrow, and because it is a blind, one-way dead-end street, it can collect debris such as fecaliths (hardened stool) and even corn husks, etc. This can cause infection, abscess formation, and rupture, which in turn causes peritonitis.
Appendicitis: defined as painful inflammation of the appendix.
It will occur in 1 of every 10 people over their lifetimes.
In the field, the presence of RLQ pain is enough to initiate transport where more sophisticated diagnostics can be used to differentiate it from colic, constipation, inflammatory bowel disease, etc.
Treatment of appendicitis is surgical removal, either laparoscopically or by a small incision in the RLQ. If it is treated with antibiotics, it will usually respond unless it's perforated, which is the end-point of appendicitis, causing peritonitis.
Signs and Symptoms:
- Usually begins with pain around the navel which migrates to the RLQ over 12-24 hours. It can also just begin in the RLQ.
- It is almost always accompanied by nausea.
- It is made worse with coughing, walking, or other jarring movements and can present with rebound tenderness, especially if its ruptured.
Common complaints include:
- nausea and vomiting,
- loss of appetite,
- low-grade fever that worsens as inflammation progresses,
- constipation or diarrhea, and
CALL TO ACTION: TRANSPORT ALL RLQ PAIN. RLQ pain is a surgical emergency till proven otherwise and always indicates a need for transport. (The downside without transport is too devastating.)
Prehospital management should focus on
- strict attention to BSI and PPE,
- airway and circulatory support including IV fluid replacement and medication administration, as well as
- rapid transport to definitive care.
Assessment of Abdominal Pain in Pediatric Patients
Assessment should include a
- a thorough history, including a history of constipation, diarrhea or vomiting.
Physical findings should center on
- RLQ pain, or any pin-point pain other than vague;
- any blood in vomit or stool.
The first goal in evaluating children with acute abdominal pain is to determine whether there is a life-threatening condition.
Any vomiting/diarrhea in children can quickly lead to dehydration, electrolyte imbalance, hypovolemia, cardiovascular collapse/shock, and death. If not correctly and quickly diagnosed and treated, morbidity and mortality associated with abdominal and gastrointestinal disorders are high in pediatric patients.
There are many anatomic and physiologic differences in children that affect the pathophysiology associated with acute abdominal conditions.
The GI tract develops in the embryo and can be abnormal from birth with pediatric GI abnormalities that cause increased vomiting (usually projectile) and electrolyte imbalances due to gastroenteritis and pyloric stenosis, and GI bleeding.
Congenital diaphragmatic hernias and pyloric stenosis can result in vomiting from obstruction.
Age of Viability and the Extra Problems that Prematurity Survival Present
As the "age of viability" (the gestational age at which a baby is deemed salvageable) keeps moving down, due to advances in neonatology, there are additional considerations for evaluations of newborns for the EMS responders. Recently discharged infants from NICUs may exhibit apnea (sounding of the apnea alarm) and difficulty breathing from bronchopulmonary dysplasia (lung immaturity).
But in the abdomen, there may be abdominal pain from feeding disorders accompanied by vomiting or gastrostomy tube complications. Extremely premature infants are at risk for neonatal jaundice.
Call to Action: TRANSPORT
There can never be an overreaction to signs of dehydration, abdominal pain with or without fever, or persistent diarrhea or vomiting, with or without blood. Deterioration in children is along an exponential curve compared to adults, so your threshold for transport should be very low. You simply cannot go wrong in transporting.