Clerking abdominal pain in children

History

Clerking abdominal pain in paediatric patients may be challenging due to the peculiar nature of children. However, the approach below will help to gather enough information to aid in making an informed diagnosis. The steps are as follows:

Obtain the patient’s biodata, taking note of the age especially.

With the mnemonic ‘SOCRATES’ as a guide, ask about the following to characterise the pain:

  • Site of the pain; whether the pain is localised or diffuse
  • Onset of the pain; whether sudden or gradual
  • Character of the pain: dull, burning, sharp or stabbing
  • Whether the pain Radiates or migrates between areas of the abdomen
  • Associated symptoms like constipation, diarrhoea, fever
  • Timing of the pain; whether worse at any time, continuously present, or intermittently with pain-free periods in between.
  • Exacerbating and relieving factors, such as movement, food, or medication
  • Severity of the pain, usually using a pain scale

More specific questions may then be asked as follows depending on the possible differentials already generated after characterising the pain. 

Common differentials:

  • Constipation: 

poor diet and fluid intake; hx of developmental delay, 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), faecal incontinence; medication with known constipating agents (e.g., iron supplements); obesity, low birth weight 

  • Acute appendicitis:

hx of sharp or stabbing periumbilical pain that migrates to the RLQ; anorexia, fever, vomiting, and/or diarrhoea may be present; occurs in all age groups but is rare in infants

  • Gastroenteritis:

vague abdominal pain with nausea and vomiting; diarrhoea 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 non-infectious cause; fever, chills, myalgia, rhinorrhoea, upper respiratory symptoms

  • UTI:

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

  • Abdominal trauma:

hx of trauma; abdominal pain may be out of proportion to examination findings; may have multiple complaints; hx may suggest child abuse or non-accidental trauma (e.g., inconsistent or changing history)

  • Cholelithiasis/cholecystitis:

recurrent, episodic 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)

  • Primary dysmenorrhoea:

hx of recurrent crampy abdominal pain associated with menstruation

  • Pneumonia:

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

  • Functional abdominal pain:

hx 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; FHx of functional disorders common (e.g., irritable bowel syndrome, anxiety, psychiatric disorders, and migraine)

Uncommon

  • Intussusception:

usually infants between 3 months and 12 months of age; colicky abdominal pain, flexing of the legs, fever, lethargy, and vomiting; vague abdominal complaints; severe, cramp-like abdominal pain; with or without inconsolable cry

  • Meckel’s diverticulum:

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

  • Mesenteric adenitis:

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

  • Hirschsprung’s disease:

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

  • Ulcerative colitis:

positive FHx, bloody diarrhoea, cramping abdominal pain, anorexia, weight loss, fever, rash

  • Crohn’s disease:

crampy abdominal pain, intermittent diarrhoea, bloody diarrhoea if colitis a feature (blood less common in Crohn’s disease (CD) than in ulcerative colitis), weight loss, fatigue, FHx of inflammatory bowel disease

  • Small bowel obstruction:

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

  • Volvulus:

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

  • Large bowel obstruction:

hx of risk factors: mental illness, inflammatory bowel disease, diabetes, poor diet, previous colorectal resection, laxative abuse, megacolon, or previous abdominal surgery; change in bowel habit with partial or complete obstruction, or change in calibre 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

  • Necrotising enterocolitis:

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

  • Peptic ulcer disease:

FHx 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; melaena and/or haematemesis if blood vessel perforated

  • 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, diarrhoea, headache, anorexia, dark urine, pale stool, abdominal pain; late disease: weight loss, easy bruising and bleeding tendencies

  • Biliary dyskinesia:

hx of previous negative work-up for cholelithiasis common; recurrent RUQ pain; nausea and vomiting; symptoms may or may not be associated with eating

  • Acute pancreatitis:

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

  • Splenic infarction/cysts:

varied; may be hx 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)

  • Nephrolithiasis:

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

  • Testicular torsion:

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

  • Ovarian torsion:

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

  • Ruptured ovarian cyst:

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

  • Pelvic inflammatory disease:

sexually active; multiple partners; hx 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

  • Pregnancy complications:

hx of previous ectopic pregnancy or miscarriage, fallopian tube or pelvic surgery, pelvic inflammatory disease (PID); lower abdominal pain, amenorrhoea, and vaginal bleeding

  • Empyema:

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)

Past medical history focusing on previous operations, medication use, immunisations, allergies, and current comorbidities.

Dietary history: for new or unusual food intake, and presence of fibre

Family history

Social and psychiatric history including family dynamics

Sexual history in females of reproductive age

Physical examination

A general physical examination will be relevant first to make a general assessment of the child, as some causes of the abdominal pain may be originating from areas outside the abdomen.

An abdominal examination may then follow suit with particular attention to the organ system suspected to be primarily involved. This is guided by clues from a good history.

  • Constipation:

examination findings may be minimal (mild abdominal tenderness, stool in rectum); abdominal distension in severe cases or in small children; faecal mass palpable on abdominal or rectal examination; 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, haemorrhoids (rare in children; may be mistaken for skin tags from Crohn’s disease); imperforate anus or anal stenosis; evidence of depression, abuse, autism, ADHD, or oppositional disorder

  • Accute appendicitis:

patient lies still, tries not to move (especially in severe cases with significant peritoneal irritation); positive McBurney’s 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’s 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

  • Gastroenteritis:

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)

  • Urinary tract infection:

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

  • Abdominal trauma:

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

  • Cholelithiasis/Cholecystitis:

right subcostal region tenderness; positive Murphy’s 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

  • Primary dysmenorrhoea:

lower abdominal tenderness; normal pelvic examination

  • Pneumonia:

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

  • Functional abdominal pain:

periumbilical tenderness, abdomen is soft, non-distended, no guarding or rebound tenderness; examination of other systems normal

  • Intussusception:

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

  • Meckel’s diverticulum:

dark red, maroon, or ‘red currant jelly ‘ stools; abdominal tenderness with guarding and rebound (may suggest diverticulitis); palpable abdominal mass (may suggest intussusception)

  • Mesenteric adenitis:

fever, abdominal tenderness not localised to RLQ, rhinorrhoea, hyperaemic pharynx or oropharynx (pharyngitis), and/or associated extramesenteric lymphadenopathy (usually cervical)

  • Hirschsprung’s disease:

abdominal distension, fullness in LLQ; palpable faecal mass on abdomen examination; absence of peritonitis (no guarding or rebound tenderness); small rectum and absence of stool on rectal examination; dysmorphic features of Down’s syndrome may be present

  • Ulcerative colitis:

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

  • Crohn’s disease:

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

  • Small bowel obstruction:

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, ischaemia, and peritonitis; hyperactive bowel sounds (early finding), hypoactive or absent bowel sounds (late finding); incarcerated femoral, obturator, umbilical or ventral hernia may be present

  • Voluvulus:

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

  • Large bowel obstruction:

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

  • Necrotising enterocolitis:

abdominal distension, tenderness, abdominal wall erythema, haematochezia, bradycardia

  • Peptic ulcer disease:

unremarkable or epigastric tenderness; melaena may be present on rectal examination or occult bleeding on stool haemoccult test

  • Viral hepatitis:

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

  • Biliary dyskinesia:

may be equivocal; RUQ tenderness

  • Acute pancreatitis:

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

  • Splenic infarction/cysts:

may be vague LUQ tenderness

  • Nephrolithiasis:

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

  • Testicular torsion:

tender, oedematous testicle; affected testicle may appear higher than unaffected testicle with horizontal lie; associated scrotal erythema and oedema; absent cremasteric reflex; usually no pain relief with elevation of the scrotum

  • Ovarian torsion:

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

  • Ruptured ovarian cyst:

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

  • PID:

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

  • Pregnancy complications:

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

  • Empyema:

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

Appropriate lab investigations may then be requested to strengthen clinical impression made at the end of history and examination.