Skip to 0 minutes and 1 secondHi my name is Damien Roland, I'm a Consultant and a Senior Honorary Lecturer at Leicester Hospitals and Leicester University. This portion of the MOOC is on abdominal pain. Abdominal pain is extremely common in young children. What this part of the MOOC aims to do is teach you about the things you can treat particularly easily or watch out for those really serious causes of abdominal pains that you don't want to miss.
Skip to 0 minutes and 27 secondsAs with all parts of the MOOC, what we need to think about is: is this child ill or relatively well? That's really important in abdominal pain because unlike fever and rash, you can be distressed with abdominal pain but not ill. So a key function of when your examining a child is working out whether they're in pain and look unwell because they're in pain or actually because they're seriously unwell because of the underlying pathology. A really good example of that is the way the children present. The child who is quiet, remains still, appears anxious is usually actually in a considerable amount of pain and probably has a serious underlying pathology.
Skip to 1 minute and 11 secondsThe child who is very verbose and is able to move around and explain what's wrong with them tends not to have such a severe underlying condition, And although these aren't absolute rules, they are a really good mark of what the problems are.
Welcome to Week 2: Let's begin with abdominal pain
Damien Roland, Consultant and a Senior Honorary Lecturer at Leicester Hospital and Leicester University introduces the next portion of the MOOC which is all about abdominal pain.
As suggested in Week 1, for all those non-medics out there, parts of this topic are quite technical. You may find it easier to first download the Parent Information Leaflet attached to the bottom of this page. This is written in plain English and avoids technical jargon.
Early on in the assessment of a child with abdominal pain, it is important to judge the degree of distress that child is in. The child who is quiet, who is pale, and who stays very still is more likely to have a underlying organic cause and is probably in a great deal of pain. The reluctance to move suggests that the peritoneum is irritated, pointing towards a possible surgical cause such as appendicitis.
Although this isn’t universally true, the child who is rolling around in the bed and then is able to be distracted by a question, and tell you in detail about the pain they are in, may not have an organic cause or may not be in as severe amount of pain as the child who is quiet. You also need to think and consider things like somatisation. This is where psychological symptoms such as stress manifest themselves as physical symptoms.
However, these are not hard and fast rules; regardless of the cause, it is always important to be compassionate and non-judgemental in your approach to a child with abdominal pain. Ultimately what you want to do is not disregard the child who has abdominal sepsis just because they’re quiet, and not overplay or over-treat the child who appears quite agitated because they’re telling you that they’re in a lot of pain. But also remember that not all children follow these rules. A rare situation such as volvulus (where the bowel twists) will initially cause severe abdominal pain that may lead the child to writhe in agony. The difference between this and a possible non-organic cause is that the child will appear to be in pain, look scared and not be distractible.
The idea of this module is to take you through a strategy to deal with a child with abdominal pain. One of the first things you need to do is look at the different causes of abdominal pain related to the child’s age. Have a look at the PDF attached to the bottom of this step for more guidance.
Having a frame of reference for the age of the child is important. What is the condition you want to make sure you are either ruling out or providing treatment for, and what is the most likely cause?
In most ages, appendicitis is a possibility and should always be considered (especially in the younger child in who may be harder to diagnose). Bowel obstruction is also a medical emergency and in both of these situations, the child will look very unwell with physiological derangement and some history of vomiting.
In infants less than 3 months old, obstruction or abdominal sepsis is an important consideration, but the diagnosis is much more likely to be colic. Colic is a cause of great anxiety for parents; the classic picture is one of inconsolable crying for hours on end. It is caused by abdominal spasm and is not a medical emergency, but of course for parents at home with the screaming child, it may seem like one. It is important to not dismiss all children of this age as having colic, but the history will often point to the diagnosis and the parents can be reassured that their child does not in fact have a serious problem.
Sometimes there will be a more serious cause. Parents’ anxieties – which mean that they’re high enough for them to phone an ambulance, especially in a child less than 3 months with abdominal pain – should always be taken seriously.
Abdominal pain in isolation is rare. Children are likely to have associated symptoms, and the most common is vomiting. Vomiting, abdominal pain and diarrhoea would point to a possible diagnosis of gastroenteritis, which is most often caused by a viral illness. But beware the child with vomiting and fever alone. In this group it is important to rule out a urine infection, a significant cause of sepsis particularly in babies.
Finally, all children who have abdominal pain should have a blood glucose test because diabetic ketoacidosis can present as abdominal pain. The history may help you here with a story of drinking a lot and weight loss but the important thing is to consider it in your differential diagnosis. Obviously if a child tells you they’ve taken a toxin, this needs to be considered and treated as well.
The 999 call.
Imagine the situation. A 999 call comes through from the parent of a 14-year-old female. The call handler hears a lot of distress on the line and is told that the teenager has been in agony for the last hour. Her pain is unbearable.
- Now, a paramedic team is dispatched. What do you think they need to start considering en route?
- What would their priorities be?
Discuss with other learners below.