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COPYRIGHT 2004 A Thomson Healthcare Company
Part I: Pediatric Patients
Authors: Larissa I. Velez, MD, Assistant Professor, Assistant Director of Emergency Medicine Residency Program, University of Texas Southwestern Medical Center, Dallas; Fernando L. Benitez, MD, Assistant Professor, Emergency Medicine, University of Texas Southwestern Medical Center, Dallas; and Salvador E. Villanueva, MD, Assistant Professor, Emergency Medicine, University of Puerto Rico.
Peer Reviewers: J. Stephan Stapczynski, MD, Chair, Emergency Medicine Department, Maricopa Medical Center, Phoenix, AZ; and O. John Ma, MD, Professor and Vice Chair of Emergency Medicine, Truman Medical Center, University of Missouri--Kansas City School of Medicine.
Acute abdominal pain, defined in this article as any non-traumatic cause of abdominal pain of less than one week duration, can be one of the most challenging complaints in the emergency department (ED). (1) It is estimated that 5-10% of ED visits are due to abdominal pain. (2,3) The final etiologic diagnoses range from a simple problem to a complicated, life-threatening disease. Even with our current diagnostic abilities, up to 40% of the patients are discharged from the EDs with a diagnosis of "undifferentiated abdominal pain." (4)
When evaluating a patient with acute abdominal pain, obtain a pertinent history (duration, character, severity, and radiation of the pain, associated symptoms) and perform a thorough, yet focused, physical examination. Keep in mind the common diagnoses for each patient population and patterns of pain that are typical for some diagnoses. Finally, judiciously use laboratory and radiologic studies to exclude or confirm the presence of life-threatening conditions.
While the diagnosis of abdominal pain of uncertain etiology is an acceptable discharge diagnosis, care must be taken to ensure adequate follow up of these patients. Appropriate discharge instructions always must be provided, and follow up should be arranged. (3) All of these precautions will ensure that the patient understands and is satisfied with ED care.
A comprehensive review of abdominal pain is beyond the scope of this discussion. Table 1 lists some of the most common causes of acute abdominal pain. This article instead will focus on specific populations presenting with abdominal pain to the ED and their specific or unique diagnoses. The pediatric, elderly, pregnant, and immunocompromised patients are special populations that pose a particular challenge to clinicians. These high-risk groups often present atypically, and serious conditions can be missed or misdiagnosed. Finally, this article will discuss unusual diagnoses that often present with abdominal pain as one of the main symptoms.
Part I of this article will discuss pediatric patients, and part II will cover elderly, pregnant and immunocompromised patients.--The Editor
Special Populations
This article will discuss abdominal pain in four special populations: pediatric patients, the elderly, the pregnant, and the immunocompromised. Each of these segments of the population has unique problems and very often has atypical and/or delayed presentations. Knowing the particularities helps focus the diagnostic workup and helps establish an accurate diagnosis. This segment will focus on pediatric patients.
Pediatric Patients
It is estimated that 10% of children in the ED have an abdominal complaint. (5) Still, missed diagnoses remain frequent in emergency medicine. Causes for these missed diagnoses include the child's inability to provide a good history, including the characterization of the pain. Pain localization also is poor in children. (6,7) The clinical signs of an abdominal emergency in pediatric patients include vomiting, abdominal pain, and fever. (6) Children may present with systemic and non-specific symptoms such as lethargy, poor feeding, weight loss, irritability, or malaise. (5) Signs and symptoms also are age-dependent, with the younger patients having the more atypical presentations.
The diagnostic etiologies are divided broadly by age (neonate, infant/toddler, and older children). Besides age, an attempt should be made to determine if the abdominal complaint is an acute or chronic problem, as chronic problems rarely are life-threatening.
When evaluating a pediatric patient, perform a systematic physical examination and leave the abdomen for last. This will help with the initial apprehension the patient has and also will allow for a more thorough examination before eliciting pain and possibly losing the patient's cooperation. When examining the abdomen, start with the least tender areas first and finish with the most tender area. Try to engage the child in distracting conversation while performing the examination and move slowly and non-threateningly.
Necrotizing Enterocolitis (NEC). NEC is the most common gastrointestinal (GI) emergency in the neonatal period. (8) It is an acute fulminant disease associated with focal and/or diffuse ulceration and necrosis of the distal small intestine and the colon. (9) Prematurity is the most important risk factor. NEC is a disease of neonates, having its usual onset in fewer than five days of life; however, it can present up to four weeks after birth.
Patients present...
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