Evaluation of abdominal pain in children

Overview 
Theory 
Emergencies 
Diagnosis 
Resources 

Common

Constipation

History

poor diet and fluid intake; history of cerebral palsy, learning difficulties, or spinal cord problems; psychological factors (e.g., depression, abuse, ADHD, autism, oppositional disorder), weaning, toilet training, start of schooling or other causes of stress may be present; vague abdominal pain, painful defecation (infants may extend their legs and squeeze anal and buttock muscles to prevent stooling; toddlers often rise up on their toes, shift back and forth, and stiffen their legs and buttocks), fecal incontinence; medication with known constipating agents (e.g., iron supplements); obesity, low birth weight

Exam

exam findings may be minimal (mild abdominal tenderness, stool in rectum); abdominal distension in severe cases or in small children; fecal mass palpable on abdominal exam; absence of peritonitis (guarding or rebound tenderness); sacral dimples or pits and/or tags/tufts indicative of spinal cord abnormality (i.e., spina bifida); anal fissure, hemorrhoids (rare in children; may be mistaken for skin tags from Crohn disease); imperforate anus or anal stenosis

1st investigation

none:
clinical diagnosis
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Other investigations

abdominal x-ray:
stool visible throughout colon
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radiopaque marker colonic transit study:
slow colonic transit, as measured by delay in marker movement, confirms constipation

Constipation in children

Acute appendicitis

History

history of sharp or stabbing periumbilical pain that migrates to the right lower quadrant (RLQ); anorexia, fever, vomiting, and/or diarrhea may be present; occurs in all age groups but is rare in infants

Exam

patient lies still, tries not to move (especially in severe cases with significant peritoneal irritation); positive McBurney sign (RLQ pain and tenderness to palpation at a point two-thirds along a line from the umbilicus to the anterior superior iliac spine); positive Rovsing sign (pain in the RLQ in response to left-sided palpation, suggesting peritoneal irritation); positive psoas sign (pain in the RLQ when child placed on left side and right hip gently hyperextended, suggesting irritation to the psoas fascia and muscle); positive obturator sign (RLQ pain on internal rotation of the flexed right thigh); rectal tenderness and/or palpable abscess in RLQ

1st investigation

CBC:
normal or elevated WBC
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C-reactive protein (CRP):
likely to be elevated
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urinalysis:
normal
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urine pregnancy test:
negative
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Other investigations

abdominal ultrasound:
dilated appendix, free fluid; appendicolith may be present
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Ultrasound is the preferred method of assessment.[76] In children, specificity of ultrasound is similar to that of CT (0.92 vs. 0.94).[78] It may elicit a sonographic McBurney sign (pain on compression of the appendix that is visualized on ultrasound). A negative ultrasound does not necessarily rule out appendicitis as a cause of abdominal pain. Subsequent investigations for pediatric patients with an equivocal ultrasound include CT or MRI.[78][129]
CT scan abdomen and pelvis:
dilated appendix, free fluid, mesenteric stranding, or appendicolith; abscess or phlegmon consistent with perforated appendicitis
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Useful when body habitus of patient makes ultrasound difficult or when ultrasound and/or clinical evaluation are inconclusive. CT has greater sensitivity than ultrasound (0.93 vs. 0.90).[78] Radiation exposure and contrast burden should be considered.[128][133] However, use of IV contrast, when feasible, is recommended for patients undergoing CT scan.[129] Sedation or general anesthesia may be required in some children.
[Figure caption and citation for the preceding image starts]: CT scan demonstrating fecalith (white arrow) outside the lumen of the appendix consistent with perforated appendixFrom the collection of Dr KuoJen Tsao; used with permission [Citation ends].[Figure caption and citation for the preceding image starts]: CT scan demonstrating intra-abdominal abscess consistent with perforated appendixFrom the collection of Dr KuoJen Tsao; used with permission [Citation ends].
MRI scan abdomen and pelvis:
dilated appendix; hyperintensity of the luminal contents of the appendix, periappendiceal tissue and thickened wall
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In children, MRI has excellent sensitivity and specificity (0.97); however, there are fewer studies evaluating its test characteristics.[78][131][143] It is increasingly used due to the potential hazards of ionizing radiation from CT.

Acute appendicitis

Gastroenteritis

History

vague abdominal pain with nausea and vomiting; diarrhea with or without mucus in stool; recent travel or contact with sick individual(s) or ingestion of suspected food and drink; >10 days suggests parasitic or noninfectious cause; fever, chills, myalgia, rhinorrhea, upper respiratory symptoms

Exam

diffuse abdominal pain without evidence of peritonitis (no guarding or rebound tenderness); abdominal distension; hyperactive bowel sounds; mucus in stool (bacterial or parasitic); signs of volume depletion (tachycardia, hypotension, dry mucous membranes, poor capillary refill, sunken fontanelle in infants); low-grade fever, lethargy and/or irritability, reduced response to noxious stimuli, abnormal temperature (elevated or low)

1st investigation

none:
clinical diagnosis

Other investigations

serum electrolytes:
normal or low sodium and potassium
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BUN and creatinine:
normal; may have evidence of renal failure in patients with hemolytic uremic syndrome
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stool microscopy and culture:
fecal leukocytes; ova or parasites; culture positive for infectious agent in bacterial gastroenteritis
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Fecal leukocytes and stool culture may be helpful in children presenting with dysentery and to demonstrate invasive pathogens such as Clostridium difficile. Ova and parasite studies are useful if history suggests camping, travel to other countries, or long-term disease.
In patients who have taken previous antibiotics or have contact with an individual with C difficile diarrhea, it is important to test for C difficile toxin. Untreated C difficile-related diarrhea can have serious consequences (e.g., toxic megacolon).
urine dipstick:
may detect presence of albumin or blood in hemolytic uremic syndrome
CBC:
variable
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blood culture:
may be positive for infectious agent in presence of sepsis
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Important to order if concern for sepsis. Guidelines recommend blood cultures: in children with infectious diarrhea who are <3 months of age or who are immunocompromised; when enteric fever is suspected (including travel to an enteric fever-endemic area, or contact with travelers from enteric fever-endemic areas who have a febrile illness of unknown etiology); when there are systemic manifestations of infection; and with high-risk conditions such as hemolytic anemia.[117][118]
endoscopy with biopsy:
variable
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Indicated only when eosinophilic gastroenteritis is a concern (condition affecting the gastrointestinal tract with eosinophil-rich inflammation without a known cause of the eosinophilia).[17]

Viral gastroenteritis in children

Urinary tract infection

History

neonates and infants: fever, vomiting, lethargy, irritability, and poor feeding; older children: dysuria, urinary frequency and urgency, back pain if pyelonephritis

Exam

variable; fever >102.2°F (>39°C); suprapubic and/or costovertebral angle tenderness; irritability; foul-smelling urine; gross hematuria

1st investigation

urine dipstick:
positive leukocyte esterase and/or positive nitrite
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Urinalysis should be performed within 1-2 hours of obtaining specimen.[144] First morning voids may be best for yielding a positive nitrite test.
Positive leukocyte esterase alone: sensitivity 84%, specificity 77%, likelihood ratio (LR)+ 5:5, LR- 0:26.[145][146]
Positive nitrite alone: sensitivity 58%, specificity 99%, LR+ 15:9, LR- 0:51.[145][146] This test has a high positive predictive value.
Positive for either leukocyte esterase or nitrite: sensitivity 92%, LR- 0:2.[145][146] This test is best at ruling out disease.
Positive for leukocyte esterase and nitrite: LR+ 28:2.[146] This test is best at ruling in disease.
urine microscopy:
>4 WBC per high-power field or any bacteria
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Microscopic analysis is more accurate; however, a urine dipstick analysis may suffice.
Pyuria (the presence of WBC): sensitivity 78%, specificity 87%; LR- 0:27.[145][146] Bacteriuria: sensitivity 88%, specificity 93% LR+ 14:7, LR- 0:19.[145][146]
Centrifugation reduces the specificity of these tests.
urine culture:
suprapubic aspirate: >1000 colony-forming units (CFU)/mL; catheter: >10,000 CFU/mL; clean-catch midstream: >100,000 CFU/mL
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Other investigations

renal ultrasound:
abnormalities may be present such as dilatation of the renal pelvis or ureters, or distension of thick-walled bladder; renal abscess: area of radiolucency to the renal parenchyma with local hypoperfusion on color Doppler; perinephric abscess: hypoechoic fluid
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voiding cystourethrogram (VCUG):
if vesicoureteral reflux is present: contrast seen ascending out of the bladder into the upper urinary tract
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The American Academy of Pediatrics (AAP) recommends a VCUG in children between 2 and 24 months of age following an initial urinary tract infection (UTI) if renal and bladder ultrasonography reveals hydronephrosis, scarring, or other findings that would suggest either high-grade vesicoureteral reflux or obstructive uropathy, as well as in other atypical or complex clinical circumstances.[137] Further evaluation is required if there is a recurrence of febrile UTI.[137][138][139]

Urinary tract infections in children

Abdominal trauma (blunt or penetrating)

History

history of trauma; may have multiple complaints; history may suggest child abuse or nonaccidental trauma (e.g., inconsistent or changing history, history not consistent with injuries/exam)

Exam

abdominal tenderness; skin marks reflecting mechanism of injury (e.g., seat belt mark); referred left shoulder pain (due to splenic injury); blood at the urethral meatus, or hematuria (indicate urinary tract or kidney injury); signs of nonaccidental trauma may be present (e.g., cigarette burns, subdural hemorrhages in an infant/young toddler)

1st investigation

CBC:
may be normal or show decreased hematocrit and hemoglobin
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abdominal CT scan with intravenous contrast:
variable
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This is the diagnostic test of choice for the identification of solid organ injuries, especially to liver, kidney, and/or spleen.
In abdominal trauma, results from one retrospective study suggest that LFTs may be used as a screening tool to determine need for CT scan; in a hemodynamically normal patient with normal AST/ALT, it may be possible to avoid CT scan.[113]

Other investigations

chest x-ray:
may be normal or show compatible thoracic injury (e.g., pulmonary contusion, pneumothorax); free air under diaphragm (suggests perforation)
abdominal ultrasound:
variable; may show free fluid in abdominal cavity
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Focused abdominal sonography for trauma (FAST) may be useful in patients with blunt abdominal trauma who are hemodynamically unstable.[125] Presence of large amounts of free fluid indicates need for immediate operative intervention. FAST in hemodynamically stable patients with blunt abdominal trauma has a less certain impact as a negative scan does not preclude injury.[126]
full skeletal x-rays:
variable
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Evaluation of abdominal trauma

Cholelithiasis/cholecystitis

History

recurrent, episodic right upper quadrant (RUQ) pain, may radiate to the back and is classically colicky in nature; often occurs after eating, particularly fatty foods; nausea, vomiting, and anorexia may be present; persistent pain and fever may signify acute cholecystitis; referred pain to right shoulder can occur; presence of risk factors (e.g., sickle cell disease, cystic fibrosis)

Exam

right subcostal region tenderness; positive Murphy sign (during palpation, deep inspiration causes pain to suddenly become worse and produces inspiratory arrest); palpable distended, tender gallbladder; fever suggests acute cholecystitis; jaundice rare and suggests common bile duct obstruction

1st investigation

RUQ ultrasound:
gallstones; ductal dilation, thickened gallbladder wall (>4 mm); pericholecystic fluid; may also see ultrasonographic Murphy sign
liver tests:
may see elevated alk phos, bilirubin, and aminotransferase
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CBC:
normal WBC (suggests cholelithiasis) or leukocytosis (suggests acute cholecystitis)
C-reactive protein:
normal (suggests cholelithiasis) or elevated (suggests acute cholecystitis)

Other investigations

abdominal x-ray:
opacities in RUQ consistent with gallstones
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hepatobiliary iminodiacetic acid (HIDA) scan:
nonfilling gallbladder
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Cholecystitis

Primary dysmenorrhea

History

history of recurrent crampy abdominal pain associated with menstruation

Exam

lower abdominal tenderness; normal pelvic exam

1st investigation

none:
diagnosis is clinical

Other investigations

abdominal/pelvic ultrasound:
normal; however, useful to rule out other diagnoses

Evaluation of dysmenorrhea

Pneumonia

History

cough; purulent sputum production; upper respiratory tract symptoms (rhinorrhea, sore throat, nasal congestion), shortness of breath, fever, and chills; splinting secondary to pain; vomiting, diarrhea, anorexia

Exam

tachypnea, cyanosis, decreased breath sounds, crackles/rales on auscultation, dullness on percussion; abdominal tenderness and distension without guarding or rebound

1st investigation

CBC:
variable
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chest x-ray:
infiltration, consolidation, effusion
sputum culture:
growth of infecting organism

Other investigations

chest ultrasound:
localized fluid collection
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CT scan chest with intravenous contrast:
consolidation of lung parenchyma; extraparenchymal fluid with loculations suggests empyema
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Overview of pneumonia

Functional abdominal pain

History

history may be acute, chronic, or cyclic (frequently girls ages 8-12 years), complaint of vague, persistent, central abdominal pain common, may be associated nausea and vomiting, particularly in chronic cases; family history of functional disorders common (e.g., irritable bowel syndrome, anxiety, psychiatric disorders, and migraine); Rome IV criteria use symptoms for diagnosis

Exam

periumbilical tenderness, abdomen is soft, undistended, no guarding or rebound tenderness; exam of other systems normal

1st investigation

none:
diagnosis is clinical after exclusion of possible organic causes

Other investigations

CBC:
normal
erythrocyte sedimentation rate:
normal
urinalysis:
normal
stool microscopy:
normal

Irritable bowel syndrome

Infantile colic

History

paroxysms of uncontrollable crying in otherwise healthy and well-fed infant age <5 months; duration of crying is >3 hours per day, and >3 days per week, for at least 3 weeks; sibling(s) may have history of infantile colic

Exam

exam findings may be minimal; infant typically well and thriving

1st investigation

none:
clinical diagnosis
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Other investigations

urinalysis:
normal
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urine culture:
normal
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Infantile colic

Uncommon

Intussusception

History

usually infant between 3 and 12 months of age presenting with colicky abdominal pain, flexing of the legs, fever, lethargy, and vomiting; Henoch-Schonlein purpura (HSP) may be initiating factor in an older child (usually <11 years of age); vague abdominal complaints; severe, cramp-like abdominal pain; child may be inconsolable

Exam

may see gross or occult blood that may be mixed with mucus and have red-brick-colored jelly-like appearance, abdominal tenderness, and palpable abdominal mass; signs of HSP may be present in older child (rash of palpable purpura, blood in the stools)

1st investigation

abdominal ultrasound:
tubular mass in longitudinal view; and a doughnut or target lesion in transverse view
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Point-of-care ultrasound may be useful for detecting intussusception at an early stage.[123][124] Ultrasound can also be used to monitor success of treatment with enema, or if recurrence suspected after reduction.
diagnostic enema:
meniscus sign; coiled spring sign
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Contraindicated if peritonitis, shock, perforation, or an unstable clinical condition is present.
Should perforation ensue, the use of barium would lead to barium peritonitis; therefore, it would be problematic.
Contrast enema (air or contrast reagent) is the long-standing most specific and sensitive diagnostic test. [Figure caption and citation for the preceding image starts]: Contrast enema demonstrating ileocolic intussusception (black arrow)From the collection of Dr KuoJen Tsao; used with permission [Citation ends].

Other investigations

CT scan abdomen and pelvis:
target lesion: intraluminal soft-tissue density mass with an eccentrically placed fatty area; reniform mass: high attenuation peripherally and lower attenuation centrally; sausage-shaped mass: alternating areas of low and high attenuation representing closely spaced bowel wall, mesenteric fat and/or intestinal fluid and gas
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CT scan should include intravenous and oral contrast for best yield and be performed only in cases in which peritonitis is not present. In general, for investigation of abdominal pain in children, CT scan of the abdomen and pelvis, with or without contrast, may provide a high yield of information, but radiation exposure should be considered.[133] Sedation or general anesthesia may be required in some children.
CBC:
may show elevated WBC (suggests intestinal ischemia)
fecal occult blood test:
positive test can support suspicion of intussusception
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Intussusception

Meckel diverticulum

History

typically age <2 years; may present with abdominal pain (may be intermittent or mimic acute appendicitis), and/or painless passage of bright red blood per rectum (hematochezia); often asymptomatic

Exam

painless dark red, maroon, or red-brick-colored jelly-like stools; abdominal tenderness with guarding and rebound (may suggest diverticulitis); palpable abdominal mass (may suggest intussusception)

1st investigation

abdominal ultrasound:
tubular mass in longitudinal views and a doughnut or target appearance in transverse views suggests intussusception
More
Good initial test if there is concern for intussusception. Point-of-care ultrasound may be useful for detecting intussusception at an early stage.[123] Sensitivity is user-dependent.
technetium-99m pertechnetate scan:
positive
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Identifies ectopic gastric mucosa as tracer is taken up by mucin-secreting cells. A positive scan shows immediate tracer localization in the stomach and in the right lower quadrant; an area of 1.8 cm² of ectopic gastric mucosa in a Meckel diverticulum is required to produce a positive result.
In the pediatric population, the specificity has been reported to be 95%, with an accuracy of 90%.[147]

Other investigations

CT scan abdomen and pelvis:
may show intussusception, Meckel diverticulitis, and/or dilated bowel consistent with bowel obstruction
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Meckel diverticulum

Mesenteric adenitis

History

diffuse abdominal pain; history of recent or current upper respiratory tract infection

Exam

fever, abdominal tenderness not localized to right lower quadrant, rhinorrhea, hyperemic pharynx or oropharynx (pharyngitis), and/or associated extramesenteric lymphadenopathy (usually cervical)

1st investigation

abdominal ultrasound:
enlarged mesenteric lymph nodes
More

Other investigations

CT scan abdomen and pelvis:
enlarged mesenteric lymph nodes
More
Demonstrates number and size of mesenteric lymph nodes. Can evaluate entire abdomen in a single scan. In general, for investigation of abdominal pain in children, CT scan of the abdomen and pelvis, with or without contrast, may provide a high yield of information, but radiation exposure should be considered.[133] Sedation or general anesthesia may be required in some children.

Hirschsprung disease

History

males affected more commonly, mainly presents in early infancy (prior to 6 months); failure to pass meconium in first 36 hours of life strongly suggestive; increased incidence in Down syndrome

Exam

abdominal distension, fullness in left lower quadrant; palpable fecal mass on abdomen exam; absence of peritonitis (no guarding or rebound tenderness); small rectum and absence of stool on rectal exam (should be performed by clinician able to interpret features of Hirschsprung disease); dysmorphic features of Down syndrome may be present

1st investigation

abdominal x-ray:
stool visible throughout colon, decreased air in rectum; air-fluid levels may be present
More
Stool throughout the colon does not rule out other etiologies of abdominal pain. [Figure caption and citation for the preceding image starts]: Abdominal x-ray of a neonate with abnormal stooling pattern and constipation. The dilated transverse and descending colon is suggestive of Hirschsprung diseaseFrom the collection of Dr KuoJen Tsao; used with permission [Citation ends].
It is very difficult to differentiate between a distended colon and the small bowel; it is a nonspecific investigation.
contrast enema:
proximal dilation with narrowing of the distal colon, with a funnel-shaped transition zone
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Other investigations

rectal biopsy:
required for a definitive diagnosis; absence of ganglion cells and the presence of an excess of nonmyelinated nerves; presence of increased acetylcholinesterase
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anorectal manometry:
absent reflex
More

Hirschsprung disease

Ulcerative colitis

History

positive family history, bloody diarrhea, cramping abdominal pain, anorexia, weight loss, fever, rash

Exam

evidence of weight loss, pallor, abdominal tenderness, abdominal mass, iritis (inflamed irritated eyes), arthritis, sacroiliitis, erythema nodosum, pyoderma gangrenosum

1st investigation

fecal calprotectin:
elevated
More
Increasingly used to distinguish between inflammatory bowel disease and noninflammatory bowel disease, with a sensitivity of up to 90% and a specificity of up to 80%.[116][148]
CBC:
leukocytosis, anemia, thrombocytosis
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colonoscopy with biopsy:
continuous uniform rectal involvement, loss of vascular marking, diffuse erythema, mucosal granularity and friability, mucosal edema ulcers, fistulas (rarely seen), normal terminal ileum (or mild backwash ileitis in pancolitis)
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erythrocyte sedimentation rate:
elevated
More
C-reactive protein:
elevated
More

Other investigations

plain abdominal x-rays:
dilated loops with air-fluid level secondary to ileus; free air is consistent with perforation; in toxic megacolon, the transverse colon is dilated to 6 cm or more in diameter
More
CT scan abdomen:
thickened inflamed bowel mucosa, thumbprinting, intestinal dilation or evidence of stricture; inflamed mesentery; intra-abdominal abscesses
More
Ordered when complications or other diagnoses are being considered. In general, for investigation of abdominal pain in children, CT scan of the abdomen and pelvis, with or without contrast, may provide a high yield of information, but radiation exposure should be considered.[133] Sedation or general anesthesia may be required in some children.
serologic markers: perinuclear antineutrophil cytoplasmic antibody (pANCA) and anti-Saccharomyces cerevisiae antibody (ASCA):
positive pANCA
More
Require special laboratories and are expensive but may be particularly useful for differentiating between Crohn disease and ulcerative colitis in the pediatric population; about 70% of patients with ulcerative colitis have positive pANCA; about 70% of patients with Crohn disease have positive ASCA.[122]

Ulcerative colitis

Crohn disease

History

crampy abdominal pain, intermittent diarrhea, bloody diarrhea if colitis a feature (blood less common in Crohn disease than in ulcerative colitis, weight loss, fatigue, family history of inflammatory bowel disease

Exam

aphthous ulcers, evidence of weight loss, pallor, abdominal tenderness, abdominal mass, perianal fistula, perirectal abscess, anal fissure, perianal skin tags; extraintestinal manifestations including iritis, arthritis, sacroiliitis, erythema nodosum, pyoderma gangrenosum

1st investigation

fecal calprotectin:
may be elevated
More
Increasingly used to distinguish between inflammatory bowel disease and noninflammatory bowel disease, with a sensitivity of up to 90% and a specificity of up to 80%.[116][148]
CBC:
leukocytosis, anemia, thrombocytosis
More
C-reactive protein:
elevated
More
erythrocyte sedimentation rate:
elevated
More
colonoscopy with biopsy:
may demonstrate inflammation, friability, ulcer formation, and edema
More
MR enterography:
skip lesions, bowel wall thickening, surrounding inflammation, abscess, fistulas

Other investigations

plain abdominal x-rays:
small bowel or colonic dilation; calcification; intra-abdominal abscesses
More
upper gastrointestinal series with small bowel follow-through:
edema and ulceration of the mucosa with luminal narrowing and strictures
More
CT scan abdomen and pelvis:
skip lesions, bowel wall thickening, surrounding inflammation, abscess, fistulas
More
Ordered when complications or other diagnoses are being considered. In general, for investigation of abdominal pain in children, CT scan of the abdomen and pelvis, with or without contrast, may provide a high yield of information, but radiation exposure should be considered.[133] Sedation or general anesthesia may be required in some children.
serologic markers: perinuclear antineutrophil cytoplasmic antibody (pANCA) and anti-Saccharomyces cerevisiae antibody (ASCA):
positive ASCA
More
Require special laboratories and are expensive, but may be particularly useful for differentiating between Crohn disease and ulcerative colitis in the pediatric population; about 70% of patients with ulcerative colitis have positive pANCA; about 70% of patients with Crohn disease have positive ASCA.[122]

Crohn disease

Small bowel obstruction

History

intolerant of feeding, with nausea and/or bilious vomiting; abdominal pain may or may not be a feature; history of previous abdominal surgery; history of cystic fibrosis may be present

Exam

limited abdominal distension (with proximal obstructions in the duodenum or early jejunum); abdominal tenderness may or may not be present; rebound tenderness and guarding may occur if perforation, ischemia, and peritonitis; hyperactive bowel sounds (early finding), hypoactive or absent bowel sounds (late finding); incarcerated femoral, obturator, umbilical or ventral hernia may be present

1st investigation

abdominal x-ray:
dilated small bowel loops, air-fluid levels throughout abdomen
More
Supine and upright films may reveal characteristic pattern of gas in bowel. In duodenal atresia may see double bubble sign. [Figure caption and citation for the preceding image starts]: Abdominal x-ray demonstrating double bubble gas pattern consistent with duodenal atresiaFrom the collection of Dr KuoJen Tsao; used with permission [Citation ends]. Jejunal atresia shows dilated proximal small bowel with decompressed nonair-filled bowel distally.

Other investigations

abdominal ultrasound:
may demonstrate focal area causing obstruction
More
Can be used to diagnose intussusception; may be of particular value when diagnosing intussusception secondary to Henoch-Schonlein purpura, as it is typically ileoileal instead of ileocolic.[22] Point-of-care ultrasound may be useful for detecting intussusception at an early stage.[123]
Ultrasound with Doppler blood flow evaluation may assist in the diagnosis of midgut volvulus associated with malrotation. In addition, it may be useful in the diagnosis of omental and duplication cysts.
upper gastrointestinal contrast study:
dilated small intestine; may demonstrate a transition zone of obstruction
More
Critical to rule out acute midgut volvulus and/or malrotation; water-soluble contrast challenge can be both diagnostic and therapeutic.[149] [Figure caption and citation for the preceding image starts]: Upper GI contrast study demonstrating malrotation with volvulus. The duodenum fails to develop the normal anatomic C-loop. There is failure of contrast to pass, resulting in a characteristic bird beak consistent with acute midgut volvulusFrom the collection of Dr KuoJen Tsao; used with permission [Citation ends].
lower gastrointestinal contrast study:
dilated small intestine; may demonstrate a transition zone of obstruction
More
CT scan abdomen:
dilated small intestine; may demonstrate a transition zone of obstruction, mass, tumor, abscess
More
Helps to determine diagnosis of underlying cause, extent, and location of the obstruction when x-rays are inconclusive.[150] CT scan should include intravenous and oral contrast for best yield and be performed only in cases in which peritonitis is not present.

Small bowel obstruction

Volvulus

History

infant age group; history of bilious vomiting; pain usually manifests as notable transition to an inconsolable state

Exam

often diffuse abdominal distension and tenderness; faint or no bowel sounds, rigid abdomen, guarding, rebound tenderness, fever, or hematochezia

1st investigation

upper gastrointestinal contrast study:
bird beak sign of stricture at the site of the volvulus
More
Standard diagnostic test for malrotation. Should be performed with anteroposterior and lateral projections if there is any history of bilious vomiting without previous abdominal surgery.
Not necessary if diagnosis is strongly indicated from plain x-rays or there is evidence of bowel necrosis. [Figure caption and citation for the preceding image starts]: Upper GI contrast study demonstrating malrotation with volvulus. The duodenum fails to develop the normal anatomic C-loop. There is failure of contrast to pass, resulting in a characteristic bird beak consistent with acute midgut volvulusFrom the collection of Dr KuoJen Tsao; used with permission [Citation ends].
abdominal x-ray:
partial or complete obstruction; dilated bowel loops; air-fluid levels; abdominal free air with perforation
More
CBC:
elevated WBC (suggests intestinal ischemia)

Other investigations

CT scan abdomen:
bowel obstruction with whirl pattern of mesentery
More

Intestinal malrotation

Large bowel obstruction

History

history of risk factors: neurodevelopmental problems, inflammatory bowel disease, diabetes, poor diet, previous colorectal resection, laxative misuse, megacolon, or previous abdominal surgery; change in bowel habit with partial or complete obstruction, or change in caliber of stool; colicky abdominal pain becoming more constant and worse with movement, coughing or deep breathing as bowel approaches perforation; intolerant of feeding, with nausea or vomiting

Exam

tympanic, distended abdomen; hyperactive bowel sounds that become absent in advanced stages; abdominal rebound, guarding, and/or rigidity if perforation or close to perforation; empty rectum; incarcerated femoral, obturator, umbilical, or ventral hernia may be present

1st investigation

abdominal x-ray:
gaseous distension of large bowel; volvulus suggested by kidney-bean-shape bowel loop
More

Other investigations

abdominal ultrasound:
may demonstrate focal area causing obstruction (e.g., intussusception)
More
Point-of-care ultrasound may be useful for detecting intussusception at an early stage.[123]
lower gastrointestinal (GI) contrast study:
may indicate site of obstruction
More
CT scan abdomen and pelvis:
gaseous distension of large bowel; may demonstrate a transition zone of obstruction
More
May also reveal underlying cause and provide more diagnostic information than contrast enema.
Intravenous and oral contrast should be used for best diagnostic yield. Radiation exposure should be considered.[133] Sedation or general anesthesia may be required in some children.
flexible/rigid sigmoidoscopy:
flood of stool and mucus upon passing and decompressing apex of volvulus
More

Large bowel obstruction

Necrotizing enterocolitis

History

premature neonate weighing less than 1500 g; feeding intolerance, apnea, lethargy, bloody stools

Exam

abdominal distension, tenderness, abdominal wall erythema, hematochezia, bradycardia

1st investigation

CBC:
leukocytosis or leukopenia, anemia, thrombocytopenia
More
Decreased WBC count may be more ominous than leukocytosis. Thrombocytopenia develops in 50% to 95% of all infants with necrotizing enterocolitis within 24-72 hours of receiving the diagnosis.[151] Anemia may result with significant hematochezia.
blood culture:
negative
More
serum electrolyte panel:
hyponatremia
abdominal x-ray:
dilated loops of bowel, pneumatosis intestinalis, portal venous gas, free air, fixed loop of bowel, lack of normal intestinal gas pattern
More

Other investigations

abdominal ultrasound:
fluid collections, ascites
More
Useful for diagnosing fluid collections that may represent perforation or abscess. A few centers use abdominal ultrasound for early diagnosis and serial follow-up; very sensitive but still not widely used.[152]

Sepsis in children

Peptic ulcer disease

History

nonsteroidal anti-inflammatory drug use; family history of peptic ulcer disease; weight loss, vomiting, anorexia, and intermittent epigastric pain, usually related to eating meals; pain often nocturnal and usually relieved by antacids; melena and/or hematemesis if erosion into blood vessel

Exam

unremarkable or epigastric tenderness, melena, or occult bleeding on stool hemoccult test

1st investigation

CBC:
normal or leukocytosis; anemia present if sustained blood loss
erect chest x-ray:
usually normal
More
upper gastrointestinal series with water-soluble contrast:
mucosal defect(s) consistent with ulcer or free intraperitoneal contrast consistent with perforation
More
upper gastrointestinal endoscopy:
mucosal inflammation, ulceration, and hemorrhage
More

Other investigations

Helicobacter pylori breath test or stool antigen test:
positive result if Helicobacter pylori present
More
Generally not necessary if endoscopy and biopsy are being performed; however, in places where endoscopy is not readily available, and peptic ulcer disease is suspected, H pylori breath test or stool antigen test may be helpful, and may also be performed 4 weeks after starting treatment, to assess treatment success.[119][120] A blood test for H pylori is not useful in children.

Peptic ulcer disease

Celiac disease

History

recurrent abdominal pain, cramping, or distension; bloating and diarrhea; dermatitis herpetiformis, an intensely pruritic papulovesicular rash that affects the extensor limb surfaces, almost universally occurs in association with celiac disease; may be a history of immunoglobulin A deficiency, type 1 diabetes, autoimmune thyroid disease, Down syndrome, Sjogren syndrome, inflammatory bowel disease, or primary biliary cholangitis; may be a family history of celiac disease

Exam

generalized abdominal pain or bloating; underweight or failing to thrive; aphthous stomatitis; dermatitis herpetiformis

1st investigation

immunoglobulin A-tissue transglutaminase (IgA-tTG):
titer above normal range for laboratory
More
IgA anti-tissue transglutaminase antibody is the preferred single test for detection of celiac disease in individuals over the age of 2 years.[153] When screening children <2 years of age for celiac disease, the IgA-tTG test should be combined with deamidated gliadin peptide (IgA and IgG).[153]
quantitative immunoglobulin A (IgA):
titer normal or below normal range for laboratory
More
In patients with low total IgA concentrations, an IgG-based test (e.g., deamidated gliadin peptide) should be performed.[154]
CBC:
may show iron deficiency anemia
endoscopy and small bowel biopsy:
presence of intraepithelial lymphocytes, villous atrophy, and crypt hyperplasia
More
Small-bowel histology is essential and the gold-standard test to confirm the diagnosis.
Two biopsies of the bulb and at least four biopsies of the distal duodenum should be submitted for histologic analysis.
Pediatric patients with symptoms consistent with celiac disease and a high IgA-tTG titer (≥10 times the upper limit of normal) may go on to have confirmatory EMA and HLA-DQ2/-DQ8 testing. If both of these are positive, celiac disease may be considered confirmed without a small intestinal biopsy.[154] Children with lower IgA-tTG titers (<10 times upper limit of normal) should undergo biopsies to decrease the risk of false positive diagnosis.[154]

Other investigations

endomysial antibody (EMA):
elevated titer
More
human leukocyte antigen (HLA) typing:
positive HLA-DQ2 or HLA-DQ8
More
This genetic test is useful to rule out celiac disease in patients already on a gluten-free diet or in patients with an idiopathic celiac-like enteropathy.[46]
Pediatric patients with symptoms consistent with celiac disease and a high IgA-tTG titer (≥10 times the upper limit of normal) may go on to have confirmatory EMA and HLA-DQ2/-DQ8 testing. If both of these are positive, celiac disease may be considered confirmed without a small intestinal biopsy.[154] Children with lower IgA-tTG titers (<10 times upper limit of normal) should undergo biopsies to decrease the risk of false positive diagnosis.[154]

Celiac disease

Viral hepatitis

History

birth or residence in endemic area, prenatal exposure, family history of chronic viral hepatitis, multiple sexual partners, sexual intercourse with infected individuals (hepatitis B and/or C), travel to developing countries, pregnant (hepatitis E); early disease: malaise, muscle and joint aches, fever, nausea, vomiting, diarrhea, headache, anorexia, dark urine, pale stool, abdominal pain; late disease: weight loss, easy bruising and bleeding tendencies

Exam

jaundice; early disease: tender hepatosplenomegaly, lymphadenopathy; late disease: generalized wasting, cachexia, gynecomastia, ascites, altered sensorium, asterixis, or decreased deep tendon reflexes, caput medusa, ascites, hepatosplenomegaly, congestion secondary to right heart failure

1st investigation

serum LFTs:
high direct bilirubin, AST, ALT, alk phos and gamma-GT
More
serum IgM anti-HAV:
positive if acute hepatitis A infection
serum hepatitis B surface antigen (HBsAg):
positive if hepatitis B infection
More
serum hepatitis B core antigen (HBcAg):
positive if hepatitis B infection
More
serum hepatitis B e antigen (HBeAg):
positive if hepatitis B infection
More
serum HCV RNA:
positive if hepatitis C infection
More
serum total (IgM and IgG) anti-HDV antibodies:
positive if hepatitis D infection
More
serum anti-HEV IgM antibodies:
positive if acute hepatitis E infection

Other investigations

CBC:
low or normal platelet count
More
coagulation profile (prothrombin time [PT], INR):
May be elevated or normal
More

Hepatitis B

Biliary dyskinesia

History

history of previous negative workup for cholelithiasis common; recurrent right upper quadrant (RUQ) pain; nausea and vomiting; symptoms may or may not be associated with eating

Exam

may be equivocal; RUQ tenderness

1st investigation

LFTs:
normal aspartate aminotransferase, alanine aminotransferase, alk phos, and bilirubin
RUQ ultrasound:
normal
More

Other investigations

hepatobiliary iminodiacetic acid (HIDA) scan:
decreased (<35%) gallbladder ejection fraction
More

Acute pancreatitis

History

nausea, vomiting, epigastric pain radiating to back; acute-onset abdominal pain

Exam

epigastric or upper abdominal tenderness; tachycardia and hypotension in severe cases; discoloration around the umbilicus (positive Cullen sign) or flanks (positive Grey-Turner sign) in cases of hemorrhagic pancreatitis; small children may demonstrate increased irritability and abdominal distension only

1st investigation

lipase:
at least 3 times upper limit of normal range; can be elevated if amylase normal
More
Use serum lipase in preference to serum amylase, if available.[114] Serum lipase levels remain elevated for longer (up to 14 days after symptom onset vs. 5 days for amylase), providing a higher likelihood of picking up the diagnosis in patients with a delayed presentation.[155]
amylase:
at least 3 times upper limit of normal range
More
Use serum lipase in preference to serum amylase, if available.[114] Serum lipase levels remain elevated for longer (up to 14 days after symptom onset vs. 5 days for amylase), providing a higher likelihood of picking up the diagnosis in patients with a delayed presentation.[155]
bilirubin:
normal or elevated
More

Other investigations

abdominal ultrasound:
may appear normal early in disease course; enlargement of the pancreas; peripancreatic edema; dilated pancreatic duct; may show underlying biliary disease
More
CT scan abdomen with intravenous contrast:
peripancreatic inflammation (fat stranding); may show gallstones
More
Although this involves exposure to radiation, it is an excellent tool in the diagnosis of early pancreatitis. Ordered if patient is not improving with standard treatment or if complicated disease is suspected. Should not be ordered for uncomplicated cases of pancreatitis in which the patient is improving.
Allows better assessment of potential pancreatic necrosis (which would indicate more serious disease) and peripancreatic inflammation than is achievable with ultrasound. [Figure caption and citation for the preceding image starts]: CT scan of teenage girl presenting with mid-epigastric abdominal pain as a result of gallstone pancreatitis. The large fluid collection in the pancreatic bed (white arrow) and lack of pancreatic enhancement suggest liquefactive necrosis of the pancreasFrom the collection of Dr KuoJen Tsao; used with permission [Citation ends].

Acute pancreatitis

Splenic infarction/cysts

History

varied; may be history of trauma; cysts either asymptomatic or dull, left-sided abdominal pain; infarction typically causes fever as well as pain, but occasionally asymptomatic; left-sided shoulder and/or chest pain; presence of risk factors for splenic infarction (sickle cell disease, high altitude)

Exam

may be vague left upper quadrant tenderness

1st investigation

Doppler ultrasound:
infarction or cyst on spleen
More

Other investigations

CT scan abdomen with intravenous contrast:
infarction or cyst on spleen
More

Nephrolithiasis

History

family history of nephrolithiasis and/or gout; intermittent, severe, colicky flank and/or abdominal pain; nausea and vomiting; gross or microscopic hematuria; urinary frequency/urgency; atypical presentation common in younger children

Exam

ipsilateral costovertebral angle and flank tenderness; tachycardia and hypotension in pain-controlled patient may suggest concurrent urosepsis

1st investigation

ultrasound of the urinary tract:
calcification seen within urinary tract; possible dilated proximal ureter and hydronephrosis
More
urinalysis:
may be normal or dipstick-positive for leukocytes, nitrites, blood; microscopic analysis positive for WBCs, red blood cells, or bacteria
More

Other investigations

abdominal x-ray:
radioopaque stones
More
noncontrast CT scan abdomen and pelvis:
calcification seen in renal collecting system or ureter; possible dilated proximal ureter and hydronephrosis
More

Nephrolithiasis

Sepsis

History

may be history of decreased activity, caregiver concern that child is not behaving as normal; may not wake or may be difficult to rouse

Exam

fever may be present (although core temperature may also be normal or low), tachycardia, elevated respiratory rate, may be delayed capillary refill time, oxygen saturations may be <92% in air, altered mental state, petechiae or purpura may be present

1st investigation

CBC:
WBC variable; may be thrombocytopenia
More
Abnormal WBC count (i.e., above or below normal range for age or >10% immature white cells) is one of the core diagnostic criteria for systemic inflammatory response syndrome.[156] However, elevated or depressed WBC count is not specific for the diagnosis of sepsis.
blood glucose:
may be hypo- or hyperglycemia
serum electrolytes:
deranged
blood lactate:
elevated
More
arterial blood gas:
hypoxemia and/or hypercarbia; large base deficit
coagulation studies:
may be abnormal
LFTs:
may be abnormal
blood culture:
may be growth of bacteria identifying pathogen
chest x-ray:
may reveal evidence of pneumonia
urinalysis:
may be positive for nitrites and leukocytes if urinary tract infection present
urine culture:
may be positive if urinary tract infection present

Other investigations

lumbar puncture:
positive culture may reveal bacterial meningitis as infective source
procalcitonin:
elevated
More
Elevated procalcitonin levels may be better than traditional laboratory screening tests for detecting serious bacterial infections in febrile infants and young children without obvious sources of infection.[157][158][159]
CT scan of the chest and/or abdomen and pelvis:
may reveal focus of infection
More
abdominal ultrasound scan:
may reveal focus of infection
More

Sepsis in children

Testicular torsion

History

acute-onset testicular pain; nausea, and vomiting; history of recurrent episodes suggests repeated episodes of testicular torsion followed by spontaneous detorsion; history of trauma may be present

Exam

tender, edematous testicle; affected testicle may appear higher than unaffected testicle with horizontal lie; associated scrotal erythema and edema; absent cremasteric reflex; usually no pain relief with elevation of the scrotum; thin skin of the scrotum sometimes allows visualization of the torsed appendage ("blue dot or black dot sign")

1st investigation

Testicular Workup for Ischemia and Suspected Torsion (TWIST) score:
low risk (score 0 to 2), intermediate risk (3 to 4), or high risk (5 to 7)
More
Sensitivity 98.4% in low-risk patients and specificity 97.5% in high-risk patients.[160]
duplex Doppler ultrasound of scrotum:
presence of fluid and the whirlpool sign (the swirling appearance of the spermatic cord from torsion as the ultrasound probe scans downward perpendicular to the spermatic cord); absent or decreased blood flow in the affected testicle; decreased flow velocity in the intratesticular arteries, increased resistive indices in the intratesticular arteries
More
Definitive test for torsion and should be obtained unless the test would unnecessarily delay intervention in a child for whom there is a high index of suspicion. Diagnostic studies should not preclude operative intervention.[94][95]
Duplex Doppler ultrasound includes gray scale, color Doppler, and spectral Doppler ultrasound. Power Doppler can be used as well as or instead of color Doppler. Power Doppler is more sensitive for evaluating areas of low blood flow such as the prepubertal testis.[161]

Other investigations

urinalysis:
usually normal, but can be abnormal in some cases
More

Testicular torsion

Ovarian torsion

History

acute onset of one-sided lower abdominal or pelvic pain; nausea and vomiting common; history of frequent, similar episodes; fever rare

Exam

tender pelvic mass (adnexal); in patients old enough to undergo pelvic exam, cervical motion tenderness may be elicited; typically no vaginal discharge, but may be some mild to moderate vaginal bleeding

1st investigation

pelvic ultrasound:
solid appearance of the ovary, unilateral ovarian enlargement, ovarian peripheral cystic structures, marked stromal edema, fluid in the pouch of Douglas

Other investigations

color Doppler ultrasound:
reduced or absent intraovarian blood flow
More
Suggestive of ovarian torsion. Can help determine whether the flow in the ovary is impaired. Doppler ultrasound is of only variable reliability in the diagnosis of ovarian torsion.[87][88]
CT scan abdomen and pelvis:
enlarged, edematous ovary with or without vascular enhancement; free fluid in pelvis
More
CT scans can demonstrate adnexal masses and ischemia of the ovary. Typically, ovarian torsion diagnosed by CT scan is a serendipitous finding during an attempt to identify other sources of abdominal pain. [Figure caption and citation for the preceding image starts]: CT scan of a young girl presenting with ovarian torsion. The large pelvic cystic lesion contains calcifications (white arrow) consistent with a teratoma or dermoid cystFrom the collection of Dr KuoJen Tsao; used with permission [Citation ends].
In general, for investigation of abdominal pain in children, CT scan of the abdomen and pelvis, with or without contrast, may provide a high yield of information, but radiation exposure should be considered.[133] Sedation or general anesthesia may be required in some children.

Ovarian torsion

Ruptured ovarian cyst

History

rupture usually spontaneous, can follow history of trauma or sexual intercourse; mild chronic lower abdominal discomfort may suddenly intensify; may occur in conjunction with torsion

Exam

adnexal tenderness; adnexal size unremarkable due to collapsed cyst; peritonism may be present in lower abdomen and pelvis

1st investigation

pelvic ultrasound:
complex mass appearance; fluid in the pouch of Douglas
More

Other investigations

Ovarian cysts

Pelvic inflammatory disease (PID)

History

sexually active; multiple partners; history may be suggestive of sexual abuse (particularly if young child); pain worse with sexual intercourse; dull, aching lower abdominal pain with or without dysuria; vaginal discharge, low-grade fever

Exam

temperature >101°F (38.3°C); cervical motion tenderness, adnexal or uterine tenderness, vaginal or cervical mucopurulent discharge

1st investigation

wet mount of vaginal secretions:
polymorphonuclear leukocytes (PMNs) seen
More
nucleic acid amplification test or culture of vaginal secretions for Neisseria gonorrhoeae and Chlamydia trachomatis:
positive result indicates presence of organism
More

Other investigations

pelvic ultrasound:
normal or may demonstrate endometritis, hydrosalpinx, pyosalpinx, tubo-ovarian abscess
More
HIV serology:
positive or negative
More
hepatitis studies:
positive or negative
More
rapid plasma reagin (RPR):
positive or negative
More
CBC:
leukocytosis
More
C-reactive protein or erythrocyte sedimentation rate:
elevated
More
laparoscopy:
normal or may demonstrate endometritis, hydrosalpinx, pyosalpinx, tubo-ovarian abscess
More

Pelvic inflammatory disease

Pregnancy complications

History

history of previous ectopic pregnancy or miscarriage, fallopian tube or pelvic surgery, pelvic inflammatory disease; lower abdominal pain, amenorrhea, and vaginal bleeding

Exam

minimal abdominal tenderness and/or vaginal bleeding; pelvic exam may reveal a mass, eliciting cervical motion tenderness if hemoperitoneum is present; tubal rupture can cause hemodynamic instability

1st investigation

urine pregnancy test:
positive
More
quantitative serum beta-hCG:
positive
More
A normal intrauterine pregnancy is typically visualized at serum human chorionic gonadotropin (beta-hCG) levels between 1500 and 2500 mIU/mL. If not, the likely differential diagnosis is ectopic pregnancy or miscarriage.
Serial beta-hCG measurement is usually used when the ultrasound is inconclusive and the initial beta-hCG is below the discriminatory zone (1500-2000 mIU/mL). An increase of at least 66% in 2 measurements over 48 hours is suggestive of a viable intrauterine pregnancy. An increase of <66% is suggestive of an ectopic pregnancy. A rapid and steady decline is indicative of a miscarriage.
A single serum measurement cannot exclude ectopic pregnancy or predict the risk of rupture unless it is <5 mIU/mL.
pelvic ultrasound:
demonstrates free fluid in the pelvis and/or a periovarian mass
More
With trained personnel, bedside pelvic ultrasound is a fast, reliable method to evaluate for ectopic pregnancy. Transvaginal ultrasound may be used to evaluate for intrauterine pregnancy.
An ectopic pregnancy may be characterized by an echogenic, cyst-like structure outside the uterus. Several ultrasonographic findings may be associated with early ectopic pregnancy such as tubal ring, extrauterine mass, extrauterine empty gestational sac, and hemosalpinx.
In an unstable patient, it is important not to delay treatment while waiting for an ultrasound. A quick and focused bedside ultrasonographic exam to assess for the presence of free fluid or blood may be helpful when ruptured ectopic pregnancy is suspected.
transvaginal ultrasound:
presence or absence of intrauterine pregnancy
More

Other investigations

blood type and screen:
variable
More

Overview of pregnancy complications

Empyema

History

recent pneumonia, fever, cough, chest pain; malaise, anorexia, weight loss, or fatigue may occur; presence of risk factors (immunocompromise, comorbidities predisposing to the development of pneumonia, pre-existing lung disease, iatrogenic interventions in the pleural space, male sex)

Exam

febrile, toxic patient, dullness on percussion, absence of breath sounds over affected area; abdominal tenderness and distension without guarding or rebound

1st investigation

CBC:
elevated WBC count
chest x-ray:
blunting of costophrenic angle or effusion on affected side, possible consolidation, pleurally based "D" shape in empyema
More
thoracentesis:
frank pus in empyema, serous or cloudy in complicated parapneumonic effusions
More

Other investigations

blood culture:
positive for specific pathogens
More
chest ultrasound:
localized fluid collection
More
CT scan chest with intravenous contrast:
consolidation of lung parenchyma; extraparenchymal fluid with loculations suggests empyema
More

Empyema

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Evaluation of abdominal pain in children

Differentials

Common

Constipation

History

Exam

1st investigation

Other investigations

Acute appendicitis

History

Exam

1st investigation

Other investigations

Gastroenteritis

History

Exam

1st investigation

Other investigations

Urinary tract infection

History

Exam

1st investigation

Other investigations

Abdominal trauma (blunt or penetrating)

History

Exam

1st investigation

Other investigations

Cholelithiasis/cholecystitis

History

Exam

1st investigation

Other investigations

Primary dysmenorrhea

History

Exam

1st investigation

Other investigations

Pneumonia

History

Exam

1st investigation

Other investigations

Functional abdominal pain

History

Exam

1st investigation

Other investigations

Infantile colic

History

Exam

1st investigation

Other investigations

Uncommon

Intussusception

History

Exam

1st investigation

Other investigations

Meckel diverticulum

History

Exam

1st investigation

Other investigations

Mesenteric adenitis

History

Exam

1st investigation

Other investigations

Hirschsprung disease

History

Exam

1st investigation

Other investigations

Ulcerative colitis

History

Exam

1st investigation

Other investigations

Crohn disease