Abdominal Pain in Children (Paediatrics)
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Abdominal pain (also known as a stomach ache, or a tummy ache) is one of the most common symptoms and reasons for parents to take children to their doctor or the hospital emergency department. However, it is a symptom associated with both non-serious and serious medical issues that might require urgent medical attention. About 10-15% of school-aged children (more often girls) suffer from recurrent abdominal pain and 90-95% of them do not have specific organic diseases.
Among the warning signs that might indicate the origin of the pain and may further lead to a better understanding of the disorder and a precise differential diagnosis are: abdominal pain in children under the age of 4, can be localised everywhere but around the navel, manifestation of pain, it interferes with sleep - causing insomnia, weight loss, noticeable change in development, vomiting, fever etc.
Types of Abdominal Pain
- according to the course:
- acute - severe, persistent abdominal pain of sudden onset (usually develops within a couple of hours or days)
- acute appendicitis, cholecystitis, intestinal obstruction...
- chronic - pain that is present for more than 3 months. It may be present all the time or come and go (recurring incidentally or might be linked to a certain activity or irritation by food)
- celiac disease, gastoesophageal reflux disease, Crohn's disease...
- acute - severe, persistent abdominal pain of sudden onset (usually develops within a couple of hours or days)
- according to the origin/cause:
- organic - lactose intolerance, gastroduodenal ulcers
- functional – dyspepsia, irritable bowel
- according to characteristics:
- visceral (diffuse, blunt, difficult to localize);
- parietal (sharp, localized pain) when the peritoneal lining is irritated, pain makes breathing difficult; also might be of a vertebrogenic or a metabolic ethiology - diabetic ketoacidosis (pseudoperitonitis diabetica), lead intoxication etc.
- psychogenic (pain that is caused, increased, or prolonged by mental, emotional, or behavioral factors - this diagnosis can be determined only after excluding other causes and evaluating the child by a psychologist)
Health Assessment Questions:
- intensity of pain (on a scale 1→10, we can also evaluate from indirect signs such as the child's position and the intensity of crying),
- duration
- localization (younger children cannot usually point to a specific area, older children locate it in the periumbilical area),
- possible triggers (food, position of a body, particular part of a day, stress),
- associated symptoms (fever, nausea, vomiting, constipation, diarrhea, stool abnormalities, dysuria),
- time context (especially in case of psychogenic pain – for example in the morning of a school day, right before a dentist appointment)
Infantile Colic
- hardly defined problems in early stages of infancy, affecting about 1 in 10 infants (it is most common around six weeks of age and gets better by six months of age)
- equally common in both bottle and breast-fed infants
Clinical evidence: episodes of severe irritability and abdominal pain typically alongside with lifting of the legs
- they are associated with the food consumption, they appear in the second half of the feeding, and stop after the meal
- gradually worse in the afternoon and in the evening
- they are accompanied by borborygmi ("tummy rumble") and flatulence
Examination: exclusion of other causes (hunger, thirst, urinary tract infections, otitis)
- sometimes the cause is solely intolerance to cow's milk or lactose
Therapy: in breastfed children, mothers might be advised to change their diet - avoid dairy products (need to supplement calcium)
- hospital care - only for prolonged or severe difficulties, physiological development issues - poor weight gain, in case of very persuasive and anxious parents
Differential Diagnostics: severe pain may suggest intussusception (invagination) -
- intussusception linked trias: 1. colic-like pain, 2. intussusception tumor in the abdomen, 3. stool in the form of mucus usually coloured by blood (in only about 20% of diagnosed children)
Functional Recurrent Abdominal Pain
definition: at least 3 cases of abdominal pain in a period of 3 months
it is a functional disease that has a paroxysmal character
Pain limits the child's natural activity are observed in about 10-15% of children, more often in girls they most often affect children aged 4-16, they usually start at 5-8 years mental and physical stress, genetic predisposition, anxiety, impenetrability, low self-confidence contribute to the emergence…
- it is a functional disorder with episodes of incidental pain
- pain limits child's physiological activities
- observed in 10-15% of children, more likely girls
- often affect children aged 4-16 with the usual onset at around the age of 5
- it might develop due to mental and physical stress, genetic predisposition, anxiety (such as social anxiety from meeting new people in different environment), low self-confidence, etc.
Clinical Evidence
- children locate pain in the periumbilical area, or the mid-epigastric area
- the pain does not project anywhere, it has a paroxysmal character
- it is not associated with food, defecation and child's activity
- does not occur at night
Diagnosis
- diagnosis is primarily based on precise personal and family health history assessment, clinical evidence, physical examination (including per rectum examination), laboratory test results and additional examinations - need to distinguish whether it is an organic or a functional cause
- lab. tests: blood (CBC, FW, urea, creatinine, bilirubine, aminotransferases, amylase, glycemia, IgA - transglutaminase and endomysium antibodies, lipids, ANCA, ASCA), urine (chemical properties, sedimentation, quantitative bacteriuria, porhyrins screening), stool (occult gastrointestinal bleeding, antigen test for H. pylori, parasitology tests, calprotectin levels)
- abdominal and renal ultrasound examination
- further gynecologic examination might be suggested (girls)
- lactose malabsorption in anamnesis, or additional tests (such as the hydrogen breath test)
Diferenciální diagnóza
- proti této diagnóze svědčí následující symptomy – velmi dobře lokalizovaná bolest jinde než kolem pupku, vyzařování, bolest probouzející dítě v noci, ztráta hmotnosti, zpomalení růstu, zvracení, dále průjmy nebo zácpy a systémové příznaky jako jsou teploty, artralgie, exantémy, chudokrevnost…
Terapie
- léčba je dlouhodobá a vyžaduje dobrou spolupráci lékaře s dítětem a s rodiči
- základem léčby je pohovor s rodiči – nutné je zdůraznit, že bolesti jsou reálné, že jsou dané pouze motorickou aktivitou trávicího traktu při zvýšené vnímavosti na normální či stresové podněty
- ujistíme je, že nebyla prokázána žádná organická porucha
- upozorníme, že musejí rodiče podporovat dítě, nikoli bolest
- pravidelná návštěva školy je nutná!
- někdy je vhodná pomoc psychologa či psychiatra
- účinek farmak není prokázán! – podáváním „ujišťujeme pacienta v nemoci“
- prognóza: u 30–50 % obtíže zmizí, u 30–50 % přetrvají do dospělosti (bolesti hlavy, menstruační potíže, bolesti v zádech)
Recidivující bolesti břicha spojené s funkční dyspepsií
- neboli tzv. dyspepsie horního typu, zvláštní forma funkčních bolestí břicha
- klinický obraz: nauzea, nadýmání, říhání, škroukání v žaludku, škytavka, regurgitace žaludečního obsahu, pálení za sternem
- dif. dg: vždy musíme vyloučit organickou příčinu (hlavně peptický vřed, jícnový reflux, gastritidu Helicobacter pylori)
Recidivující bolesti břicha spojené s projevy dráždivého tračníku
- neboli tzv. dyspepsie dolního typu
- častější u adolescentů
- klinický obraz: střídání zácpy a průjmu, bolesti břicha (ustupují po defekaci), hlen ve stolici, urgence, nadýmání, pocit nedokonalého vyprázdnění
- dif. dg: především idiopatické střevní záněty; při pozitivním okultním krvácení vždy indikujeme koloskopii
Pankreatitida
Iron
