A

general assessment of hydration status is essential, as

decreased oral intake and vomiting often accompany

pediatric abdominal pain.

DIAGNOSTIC STUDIES

� Laboratory

General laboratory studies (complete blood count,

electrolytes) do not often add significant information in

the evaluation of children with abdominal pain. The total

white blood cell count in children with appendicitis is

often normal. With the correct clinical picture, an elevated

absolute neutrophil count is strongly supportive of the

condition. A prolonged case of pyloric stenosis will show

the stereotypical hypochloremic, hypokalemic, metabolic

alkalosis.

� Imaging

Flat and upright abdominal radiographs are useful to look

for obstruction, seen as a dilated stomach or bowel with

paucity of air distally. Free air under the diaphragm is seen

in the case of a ruptured viscus. In intussusception, a standard x-ray may reveal a paucity of bowel gas in the right

lower quadrant (Figure 50- 1).

Ultrasound is the preferred modality to diagnose

appendicitis in children, intussusception, and pyloric

stenosis. Classic ultrasound findings include target, hull's

eye, and pseudokidney signs (Figure 50-2). Reduction of

CHAPTER 50

.&. Figure 50-1 . Pa ucity of dista l bowel gas in child

with malrotation.

.&. Figure 50-2. U ltrasound showing classic target

sign in intussusception.

.&. Figure 50-3. Fl uoroscopy of malrotation with

corkscrew sign.

intussusception is routinely accomplished under fluoroscopy with air or barium. CT should be reserved for

equivocal cases of appendicitis or when the appendix is

not visualized on ultrasound. Upper GI series reveals

duodenal obstruction with an abnormal course and

"corkscrew" appearance in malrotation (Figure 50-3 ).

Meckel diverticulum with ectopic gastric tissue is diagnosed

with a technetium-99m pertechnetate study, commonly

referred to as a Meckel scan. It can also be visualized on

ultrasound or CT scan when it acts as a lead point in

intussusception.

MEDICAL DECISION MAKING

Age of patient, history, and physical exam are often sufficient

to narrow a differential diagnosis. Consider the following

extra abdominal causes of abdominal pain in the

investigation: urinary tract infection, inguinal hernia, testicular torsion, ovarian torsion and ovarian cysts, strep pharyngitis, and pneumonia. Children with bilious vomiting or

peritoneal findings require immediate surgical evaluation

(Figure 50-4).

ABDOMINAL PAIN

Abdominal pain/distress

or vomiting

Note vita l signs; observe chi ld's activity level

and interaction with parent(s)

Cobta in history to differentiat cute vs chronic condi�

Perform physica l exam. Note specifical ly presence of

· Mass

• Distention (obstruction)

• Periton itis

( Consider age of patient J

-...

La b studies and imaging (CT, ultrasound, upper

Gl, barium enema), as indicated

Surgical condition identified

Send appropriate pre-op labs

Consult pediatric surgery

Pursue identification of

medical diagnosis

Figure 50-4. Abdominal pain diagnostic algorithm.

TREATMENT

Pain control is essential in the care of patients. Analgesia

does not interfere with the examination; on the contrary,

it may even improve one's diagnostic accuracy by facilitating patient cooperation and removing less severe

aspects of the pain. The treatment of the distress should

proceed in parallel with the investigation of the etiology

of the pain. In addition, nausea and vomiting often

accompany abdominal pain and should be appropriately

managed.

Intussusception. For ileo-colic intussusception, emergent

radiologic reduction is necessary. In cases of unsuccessful

radiologic reduction and with ileo-ileal intussusceptions, surgical reduction is indicated to prevent bowel

necrosis.

CHAPTER 50

Pyloric stenosis. Correction of electrolytes is a prerequisite

for surgical repair. Pylorotomy is the treatment of cure.