Pediatrics International (2008) 50, 315–318
doi: 10.1111/j.1442-200X.2008.02578.x
Original Article
Acute abdomen in children due to extra-abdominal causes Aggelos Tsalkidis,1 Stefanos Gardikis,2 Dimitrios Cassimos,1 Katerina Kambouri,2 Evanthia Tsalkidou,1 Savas Deftereos3 and Athanasios Chatzimichael1 Departments of 1Pediatrics, 2Pediatric Surgery and 3Radiology, University Hospital of Alexandroupolis, Democritus University of Thrace-Medical School, Alexandroupolis, Greece Abstract
Background: Acute abdominal pain in children is a common cause for referral to the emergency room and for subsequent hospitalization to pediatric medical or surgical departments. There are rare occasions when the abdominal pain is derived from extra-abdominal organs or systems. The aim of the present study was to establish the most common extra-abdominal causes of acute abdominal pain. Methods: The notes of all children (1 month–14 years of age) examined for acute abdominal pain in the Accident and Emergency (A&E) Department of Alexandroupolis District University Hospital in January 2001–December 2005 were analyzed retrospectively. Demographic data, clinical signs and symptoms, and laboratory findings were recorded, as well as the final diagnosis and outcome. Results: Of a total number of 28 124 children who were brought to the A&E department, in 1731 the main complaint was acute abdominal pain. In 51 children their symptoms had an extra-abdominal cause, the most frequent being pneumonia (n ⫽ 15), tonsillitis (n ⫽ 10), otitis media (n ⫽ 9), and acute leukemia (n ⫽ 5). Conclusion: Both abdominal and extra-abdominal causes should be considered by a pediatrician who is confronted with a child with acute abdominal pain.
Key words
abdominal pain, acute abdomen, children, extra abdominal, pain.
Acute abdominal pain (AAP) is a common health problem in children. The possible causes are numerous and varied, some of which are self-limiting and others life-threatening for young patients. The diagnosis and subsequent therapeutic approach to the problem of AAP in children remains a challenge for the clinician. The clinical symptoms and signs in an acute abdomen may be not typical in many cases, and although occurring infrequently, could be due to extra-abdominal organs and systems.1,2 A delay in the diagnosis could be catastrophic, resulting in irreversible damage to the child’s health. Here we present the experience of the Pediatric and Pediatric Surgery departments of Democritus University of Thrace in Alexandroupolis, with the intention of showing that the diagnosis should not be limited to the abdominal cavity in the case of an AAP.
Methods The study population consisted of all children (1 month–14 years of age) who were brought to the Accident and Emergency (A&E) Department of Alexandroupolis District University Hospital between January 2001 and December 2005, whose main complaint was AAP. A questionnaire was completed for each patient,
Correspondence: Aggelos Tsalkidis, MD PhD, Department of Pediatrics, University Hospital of Alexandroupolis, Dragana, 68100 Alexandroupolis, Greece. Email:
[email protected] Received 25 September 2006; revised 12 December 2006; accepted 2 April 2007.
© 2008 Japan Pediatric Society
requesting information regarding demographic data as well as personal and family medical history. The following characteristics of the abdominal pain were recorded: intensity, frequency, localization, duration, radiation, relation to meals, and inhibition of physical activity. Other related symptoms were recorded, such as fever, vomiting, cough, arthralgia, dermatic rash, headache, sore throat, rhinorrhea, hematuria, malaise, and dyspnea. Laboratory investigations included full blood count, biochemistry, blood and urine culture, throat swab, lumbar puncture, nasal swab, and specific antibodies, as appropriate depending upon the clinical findings. Abdominal X-ray, chest X-ray, and abdominal ultrasound were performed in 23, 21, and 40 patients, respectively. An electroencephalogram was part of the diagnostic work-up in two children. Written informed consent was obtained from all parents and the Regional ethical committee approved the study.
Results Between January 2001 and December 2005 (5 year period), 1731 children with AAP were brought to the A&E Department of Alexandroupolis District University Hospital. This represents 6.15% of the 28 124 young patients who were examined at the A&E Department during that period. Of the 1731 children, 812 (46.90%) were boys and 919 (53.10%) were girls. The two most common causes of AAP were acute non-specific abdominal pain (ANSAP; 1026 patients, 59.3%) and acute appendicitis (529 patients, 30.6%), followed by urinary tract infection (30 patients, 1.7%) and others (mesenteric adenitis,
316 A Tsalkidis et al. constipation, Meckel’s diverticulitis, gastroenteritis, omental disease, ovarian pathology, and viral hepatitis: 95 patients, 5.5%). The patients with ANSAP were kept under surveillance and no etiology (e.g. extra-abdominal causes) for the pain was found. All of these patients were excluded from further analyses. Extra-abdominal causes of abdominal pain were identified in 51 patients, 35 of whom had been transported from the other three hospitals in the area. These children represent a percentage of 2.9% of the present patients with AAP who had an extraabdominal etiology for their pain. Of these 51 children, 32 (62.7%) were boys and 19 (37.2%) were girls, and they had a mean age of 6.2 ± 3.2 years (£3 years, n ⫽ 26; >3 years, n ⫽ 25). The presenting symptom of all of these patients was AAP. The most common related symptoms in the study group with extraabdominal pain were fever (39 patients; 76.4%), loss of appetite (26 patients; 50.9%), cough (15 patients; 29.4%), vomiting (15 patients; 29.4%), and rash (two patients; 3.9%). The parents of preverbal pediatric patients requested medical advice also because of irritability or intense crying. Furthermore, some of them noted discomfort in their child while touching his/her abdomen. The clinical examination of the abdomen indicated tenderness. Respiratory-tract infections were the most major cause of extra-abdominal pain and occurred more frequently in children up to 3 years of age (22/51) than in those older than 3 years (12/51; Table 1). The duration of symptoms was £1 day in 25 patients, 2–3 days in 13, and ⱖ3 days in the remaining 13. Physical activity was reduced for the majority of these patients (29/51). The diagnosis of the underlying cause of symptoms was made at the A&E Department in 25 patients, of which 17 (33.3%) were discharged home with the diagnosis of upper respiratory tract infections (otitis media in eight and tonsillitis in nine). These patients were reviewed at the outpatient clinic before the completion of treatment. The patients who continued to attend the pediatric outpatient clinic (n ⫽ 11) were those with long-standing health problems: Table 1 Extra-abdominal causes of acute abdominal pain according to sex and age Disease
Pneumonia Tonsillitis Otitis media Leukemia Diabetes Henoch-Schönlein Purpura Migraine Meningitis Hemolytic uremic syndrome Rheumatic fever Leishmaniasis Familial Mediterranean fever Total
Boys
Girls
£3
>3
9 6 6 2 1 2
6 4 3 3 2 0
10 6 6 1 1 0
5 4 3 4 2 2
15 10 9 5 3 2
1 1 1
1 0 0
0 0 0
2 1 1
2 1 1
1 1 1
0 0 0
0 1 1
1 0 0
1 1 1
32
19
26
25
51
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Age (years)
Total
diabetes mellitus (n ⫽ 3), leukemia (n ⫽ 5), familial Mediterranean fever (n ⫽ 1), rheumatic fever (n ⫽ 1), migraine (n ⫽ 2), and leishmaniasis (n ⫽ 1). One of the children with acute leukemia succumbed to his disease 2 years after the diagnosis.
Discussion The medical term ‘acute abdomen’ includes all diseases for which the main symptom is AAP. Although the majority of causes are localized to the abdomen (intra- and extraperitoneal), there are many diseases and conditions outside the abdominal cavity that can induce AAP (Table 2).3 According to Scholer et al., upper respiratory tract infections – especially otitis media and tonsillitis – are frequent causes of extra-abdominal pain (18% and 16.6%, respectively).1 Vendargon et al. consider basal pneumonia to be a possible cause of AAP.4 Moustaki et al. consider that pneumonia often coexists with mesenteric adenitis, which is causative of AAP; this should not be surprising, perhaps, because the peritoneal and vertebral nerves share a common origin.5 In the present study the underlying cause of AAP in 34 out of 51 patients (66.6%) was pneumonia, tonsillitis, or otitis media. Furthermore, of the 51 children (26 under the age of 3 years) with AAP of extra-abdominal origin, 15 had basal pneumonia; 10 of these were under 3 years of age (Table 1). Conversely, the cause of extra-abdominal pain was basal pneumonia in only five out of 25 children >3 years. These results indicate that the main cause of extra-abdominal pain in children aged £3 years is basal pneumonia,6 and concur with the suggestion of Storby that chest X-ray is indicated in patients with AAP in order to exclude basal pneumonia.7 In the present series five children with leukemia (acute lymphogenic leukemia, n ⫽ 3; acute non lymphogenic leukemia, n ⫽ 2) presented with AAP. Kurtz et al. reported eight cases of children with acute or recurrent leukemia, who presented with AAP, and they described this situation as pseudo-acute abdomen.8 In a large retrospective study in Greece from 938 children with acute leukemia 79 (8.4%) presented with AAP.9 Other diseases of the blood, lymphatic system, and connective tissue that can present with AAP are cyclic neutropenia,10 non-Hodgkin lymphoma,11 idiopathic thrombopenic purpura,3 juvenile dermatomyositis,3 Henoch–Schönlein purpura (HSP),12,13 sickle cell anemia,14–16 hemolytic uremic syndrome,17 rheumatic autoimmune diseases,18 and familial Mediterranean fever.19–21 In the present study there was one child diagnosed as having familial Mediterranean fever who presented with AAP and fever. The diagnosis was established with the identification of K695R10 in the exon of the gene MEF. According to Ertekin et al., AAP is a common symptom in familial Mediterranean fever; they found that 96.2% of patients with this condition presented with AAP.20 According to Trapani et al., AAP is the initial and main symptom in 12% of patients with HSP.12 The presentation of HSP with AAP can be confusing, leading the clinical physician to inappropriate investigation or even to harmful procedures/operations, as reported by Van der Boon and Groeneweg.13 In Alexandroupolis University Hospital, 11 children were admitted with HSP during the period January 2001–December 2005, two of whom (boys) presented initially with only AAP.
Extra-abdominal pain in children Table 2 Extra-abdominal causes of acute abdominal pain (in prevalence order) Pneumonia–Pleuritis Upper respiratory tract infection Diabetic ketoacidosis Henoch-Schönlein purpura Leukemia Meningitis Abdominal migraine Hemolytic uremic syndrome Acute rheumatic fever Kala-azar (Leishmaniasis) Familial Mediterranean fever Viral disease (coxsackie B1–B5, measles) Sickle cell crisis Juvenile dermatomyositis Non-Hodgkin lymphoma Cyclic hematopoiesis: neutropenia Disk protrusion: diskitis Acute porphyria Psoas abscess Aortitis syndrome Spontaneous esophageal perforation (Boerhaave’s syndrome) Slipping rib syndrome
There was also one case of a 10-year-old boy who was transferred from a different district hospital for AAP and in whom hemolytic uremic syndrome was eventually diagnosed. In diabetic ketoacidosis (DCA) the sole presenting symptom can be AAP.22 In the present study there were three patients with newly diagnosed DCA, one girl and two boys. In the literature many case of DCA have been reported that presented with AAP, some of which were wrongly diagnosed as acute appendicitis and underwent appendicectomy.23 Migraine and epilepsy can have a similar clinical picture. In the present study population there were two patients whose symptoms were attributed to migraine after a thorough clinical examination and an extended diagnostic work-up. The impressive improvement in their condition after treatment confirmed the diagnosis. In the literature there are many reported cases of abdominal migraine as a cause of abdominal pain, so the pediatrician should keep in mind that AAP could be caused by migraine.24,25 A common cause of AAP is ANSAP, defined as abdominal pain of short duration with no identifiable cause.26 This descriptive term, although not a diagnosis in itself, is used to include those patients who do not have a convincing, acceptable, alternative explanation. The precise pathophysiology of ANSAP is unknown. Various theories from viral origin to bowel motility disorder have been proposed. The typical scenario of ANSAP is a gradual onset of pain localized in the center of the abdomen without radiation and no deterioration with movements or coughing. The pain usually lasts for 12–24 h. The child has a peaceful night’s sleep and wakes up in the morning without any abdominal or other complaint.27 The diagnosis is often retrospective but can be made prospectively if the possibility is considered carefully. Children with ANSAP should be admitted to the hospital for active observation. Explanation to and reassurance of parents and children is a vital part of their management.
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In conclusion, AAP is a common health problem in children that presents a challenge to physicians. Pediatricians confronted with a child with AAP should take into consideration not only causes of abdominal origin, but also of extra-abdominal origin. A careful approach, consisting of a detailed personal history, a thorough clinical examination, and appropriate laboratory investigations, is the hallmark of achieving a correct diagnosis.
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