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pericarditis) Metabolic acidosis due to inborn errors of metabolism Toxic overdose Hemolytic uremic syndrome Diabetic Sepsis ketoacidosis Sepsis Myocarditis, pericarditis Sepsis Diabetes mellitus (infection or ketoacidosis) Diabetic Drug ketoacidosis abuse/overdose Collagen vascular disease Hemolytic uremic syndrome a Alcohol, amphetamines, aspirin, insecticide, iron, lead, phencyclidine, plants, etc Functional abdominal pain should be considered among children with recurrent abdominal pain, but should be a diagnosis of exclusion The pain rarely occurs during sleep and has no particular associations with eating, exercise, or other activities The child typically has normal growth and development, and the abdominal examination is unremarkable; occasionally, mild midabdominal tenderness, without involuntary guarding, is elicited Among postmenarchal females, life-threatening conditions within the reproductive tract that can cause abdominal pain include pelvic inflammatory disease (PID) with tubo-ovarian abscess and ruptured ectopic pregnancy Although intrauterine pregnancy may be associated with lower abdominal pain, ectopic pregnancy should always be considered EVALUATION AND DECISION The first priority is the stabilization of the seriously ill or injured child Attention to airway, breathing, and circulation is critical because cardiorespiratory disease and shock may present with abdominal pain as the major complaint and abdominal emergencies left untreated or with deterioration can lead to cardiorespiratory failure The next priority is to identify the child who requires immediate or potential surgical intervention, whether for a traumatic injury, appendicitis, intussusception, or other congenital or acquired lesions Third, an effort is directed to diagnose any of the medical illnesses from among a large group of acute and chronic abdominal and extra-abdominal inflammatory disorders that require emergency nonoperative management Table 53.2 lists lifethreatening causes of abdominal pain by age groups Finally, the physician should consider those self-limiting or nonspecific causes of abdominal pain The algorithm presented in this chapter for the approach to abdominal pain is shown in Figure 53.1 Abdominal Pain in the Setting of Trauma In the setting of major trauma, the physician should perform a rapid physical examination to distinguish superficial injury (e.g., soft tissue or muscle contusion) from significant intra-abdominal trauma (e.g., splenic hematoma or rupture, liver injury, or hollow viscus perforation) (see Chapter 103 Abdominal Trauma ) Children with localized and/or acute pain after blunt trauma may appear surprisingly well yet have significant solid organ or hollow viscus trauma When significant intra-abdominal injury is suspected in a stable patient, an urgent computed tomography (CT) scan should be obtained to evaluate for solid organ injury Lacerations of the liver and spleen are the most common intra-abdominal injuries seen in children Bedside ultrasound (f ocused a ssessment with s onography in t rauma [FAST]) may be used to evaluate for hemoperitoneum The sensitivity of ultrasound for the detection of solid organ injury is low, and some children with liver and splenic lacerations have minimal intra-abdominal fluid Given the low sensitivity of the FAST exam for detecting solid organ injury and hemoperitoneum, it should not be used as the sole diagnostic test to exclude intraabdominal injury in children FIGURE 53.1 Acute abdominal pain (males and premenarchal females) UTI, urinary tract infection Considerations Among Children With Abdominal Distention or Prior Abdominal Surgery A child who has had prior abdominal surgery presenting with abdominal pain and vomiting should have abdominal radiographs, including flat and upright views, obtained to evaluate for obstruction Bowel obstruction may result from adhesions in this population Ileus, manifesting clinically with distention and absent bowel sounds, often accompanies surgical conditions, such as volvulus and intussusception, but may also be observed among children with sepsis, infectious enterocolitis, or pneumonia Obstruction may present with isolated vomiting A low-grade fever suggests an inflammatory process, including peritonitis A patient with episodic colicky pain with interposed quiet intervals, even in the absence of a “currant jelly” stool, should raise suspicion for intussusception or midgut volvulus An incarcerated hernia is a common cause of bowel obstruction in infants and young children Inguinal hernias may incidentally incarcerate during acute illnesses in young, crying infants and may be a cause of abdominal obstruction Signs of partial or complete obstruction with peritonitis indicate a perforated viscus from intussusception, volvulus, or, occasionally, appendicitis or Hirschsprung disease An upper GI radiographic series should be performed if malrotation is suspected Abdominal Pain Associated With Peritoneal Signs Rebound tenderness (including tenderness to percussion) or guarding suggests peritoneal inflammation Children with peritonitis will often avoid motion and keep their hips flexed to relieve tension on the abdominal musculature The abdomen may be distended, with decreased or absent bowel sounds In neonates and young infants, abdominal tenderness, which is associated with peritoneal findings or abdominal distention with or without emesis, should raise suspicion for necrotizing enterocolitis Systemic signs such as temperature instability, apnea, and lethargy may be present The presentation of a child with appendicitis may vary widely, and the clinical signs and symptoms depend upon the stage of disease Early in the course of illness children will most often complain of diffuse, nonspecific, periumbilical abdominal pain, nausea, and anorexia As disease progresses, vomiting, fever, and migration of pain to the right lower abdomen are common findings Ultrasound can be used to confirm the diagnosis of appendicitis, but the diagnosis cannot be excluded if the appendix is not well visualized, particularly early in the disease process CT imaging has excellent test characteristics in the diagnosis of appendicitis; however, the risk of radiation must be considered MRI has similar test characteristics to CT for the evaluation of appendicitis without the risk of radiation Various scoring systems, such as Alvarado Score and the Pediatric Appendicitis Score utilize historical factors, physical examination findings, and laboratory results such as peripheral white blood cell count to risk stratify patients for imaging or surgery (see Chapter 116 Abdominal Emergencies ) Peritonitis in a child with nephrotic syndrome or liver failure may be due to spontaneous bacterial peritonitis Pain localized to the epigastrium can be due to gastritis; however, the presence of peritonitis should raise suspicion for a perforated ulcer Cholecystitis and pancreatitis may also produce peritonitis, with ... appendicitis without the risk of radiation Various scoring systems, such as Alvarado Score and the Pediatric Appendicitis Score utilize historical factors, physical examination findings, and laboratory