John E. Monaco, MD
It is well known amongst those who care for children, that one of the more vexing diagnostic challenges is the child, particularly the little girl, with belly pain. There is no research to support the observation that girls are more challenging... this is a purely anecdotal observation!
If the complaint is clear-cut, the diagnosis is easier. For example, if the child has fever, sudden onset of right lower abdominal pain along with nausea and vomiting, there is a good chance this complaint might be due to appendicitis. If the pain is in the upper abdomen, not associated with fever and either improves or worsens with eating, the pain could indicate gastritis or possible reflux disease. If it is associated with vomiting, fever and diarrhea, pain could be due to an intestinal infection. If the diarrhea is bloody, a more severe infection, like E. coli might be considered. However, understand that all the above diagnostic scenarios have exceptions. In other words, appendicitis could present with any of the symptoms listed above, and acute gastroenteritis may present without diarrhea.
The key to an accurate diagnosis is a good history, because even the physical exam may sometimes fool the doctor. For example, there's been more than one child whose appendix was removed only to find out later that he actually suffered from lower lobe pneumonia. What is the reason for this seemingly glaring error? The pain can feel exactly the same in both situations.
Recently I cared for a seven-year-old girl who came to the emergency room with abdominal pain. She described it as central ("around my belly button" were her words). It was not associated with diarrhea. There had been fever the day before, and every time she tried to drink something, she vomited. She did not appear terribly distressed, but she did not hesitate to tell me, each time I went to check on her, that her stomach hurt. In the emergency room, when she was admitted, a CT scan was done to rule out appendicitis. Nearly every child with a suspicion of appendicitis these days gets a CT scan. Most scans, it turns out, are negative. But for children who are difficult to diagnosis, this technology has been a godsend, and undoubtedly saved lives, and prevented many complications due to more timely surgery. This young lady's CT scan was negative for appendicitis.
Her diagnosis was confirmed by her lab work. It was noted early in the course of her work-up that her pancreatic enzymes, amylase and lipase, were markedly elevated. From this we were able to conclude that she was suffering from pacnreatitis. There are multiple causes for this disorder. It can be as a result of trauma. A common scenario is a child falling off her bike, with handlebars hitting the mid/upper abdomen. In this case the pancreas becomes inflamed directly as a result of the impact. Pancreatitis can also be caused by certain drugs or viral infections. Almost one quarter of the time the cause is unknown.
Since our little patient had experienced fever, and her lab work pointed to an infectious etiology, we concluded, along with help from our gastroenterologist, that her pancreatitis was most likely caused by a viral infection. This meant, of course, that there wasn't anything specific we could treat. We would have to let the viral infection "run its course" as we like to say. Since there is no specific treatment for pancreatitis anyway, other than bowel rest, IV hydration and pain medications, it sometimes appears to families that we aren't doing anything other than watching and waiting. In actuality, this is true!
The "bowel rest" aspect of the treatment regimen can be very frustrating for both the patient and her parents. Bowel rest means that the child must not be fed or given anything to drink. It always interests me how many times parents "cheat" when given the order that their child must not eat or drink anything until further notice. It is counterintuitive, and against all parental instinct, to deny their child food and fluids when she is sick... or anytime for that matter. In pancreatitis, however, when children take so much as a sip of water, they can almost immediately begin to vomit and complain of severe pain. So it is very difficult to cheat without getting caught.
Our little patient got better, with time, but it took several days. And each morning, during rounds, I would ask her if her belly hurt, and up until the last day, she said "yes," knowing this would mean, once again, that she wouldn't be allowed to eat. On the final day, however, she smiled when I walked into her room, as if she had anticipated my question. And when I asked what had become my routine morning question, she gave a resounding "no" and then asked, "Can I eat today?" After palpating her belly and realizing that indeed it was pain-free, it was with great pleasure and relief that I answered her question in the affirmative.
John E. Monaco, M.D., is board certified in both Pediatrics and Pediatric Critical Care. His new book, Moondance to Eternity, is now available. He lives and works in Tampa, Florida. He welcomes your comments, suggestions, and thoughts on his observations.
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Pediatric Abdominal Pain - It is Appendicitis?
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