Pediatric emergency medicine trisk 1037 1037

tolerance. Individual variation exists such that some children with an appendiceal
abscess will appear to have minimal pain, whereas other children with a
functional etiology of their abdominal pain will appear quite distressed.
A number of illnesses that present with abdominal pain including conditions
such as tonsillitis with high fever, viral syndromes, and streptococcal pharyngitis
cannot be readily explained neurophysiologically as the triggers of abdominal
pain. Despite the appearance of localized abdominal pain, clinicians need to
perform a thorough physical examination that should include the assessment of
the oropharynx, lung, skin, and genitourinary system. The principal causes of
abdominal pain in children and adolescents are summarized in Table 53.1 . Table
53.2 highlights the life-threatening disorders.

DIFFERENTIAL DIAGNOSIS
Intra-abdominal injuries can be life-threatening (such as hemorrhage from solid
organ laceration or fluid loss and infection from perforated hollow viscus) and
rarely may occur after minor trauma. An accurate history may not always be
provided and, thus, clinicians must specifically inquire about a history of trauma
in a child presenting with acute abdominal pain. Typical mechanisms include
motor vehicle crashes, falls, and child abuse (see Chapter 103 Abdominal Trauma
).
Bowel obstruction may occur as a result of adhesions in a child with previous
abdominal surgery. Malrotation with volvulus, and necrotizing enterocolitis,
should be considered in neonates with bilious emesis. Intussusception typically
occurs among children 2 months to 2 years of age. Colicky abdominal pain is a
typical feature of intussusception. The presence of blood in the stool, or “currant
jelly stool,” is a relatively late finding among children with intussusception.
Among children of all ages, appendicitis can cause peritoneal irritation and
focal tenderness. It occurs most commonly in children older than 5 years. The
classic history of diffuse abdominal pain that later migrates to the right lower
abdomen is not always elicited. The diagnosis of appendicitis in younger children
can be more difficult and is often made later in the course of disease; as such, the

rate of perforation in younger children is higher (see Chapter 116 Abdominal
Emergencies for further information). Primary bacterial peritonitis is an
uncommon cause of abdominal pain among children, but should be considered
among children with nephrotic syndrome or liver failure.
Common conditions that are associated with acute abdominal pain include viral
gastroenteritis, systemic viral illness, streptococcal pharyngitis, lobar pneumonia,
and UTIs. Frequent causes of chronic or recurrent abdominal pain include colic