A Case of Back to The Future: Paediatric Abdominal Pain. Thorough History, Examination And Senior Clinician Involvement Remain Imperative For Successful Management

Abstract

INTRODUCTION: The inherent variability of the history and exam in paediatrics make acute abdominal pain a diagnostic challenge. Investigations such as white-cell-count (WCC), C-reactive-protein and radiological studies have been advocated to help objectify management. Whilst Computed Tomography is accurate, the amount of radiation involved renders it unacceptable and thus many view ultrasonographyas an acceptable alternative. But do these tests add value? METHODS: Retrospective review between 2002–2012. Data was collected for children under sixteen with acute abdominal pain undergoing investigation with ultrasound and haematological testing. For 2005,a retrospective review was conducted for children presenting with abdominal pain to obtain data on demographics, history and examination findings. Analysis for diagnostic accuracy was undertaken. RESULTS: 5000 records were reviewed, and 1744 records included. 6% of children developed appendicitis. Findings of worsening pain, associated with nausea or vomiting yielded moderate sensitivities and specificities (combined values over 70%). Fever was non-specific. Localised tenderness is the most sensitive exam finding and rebound tenderness is the most specific, both having values over 90%. WCC and CRP offer similar sensitivities and specificities, both producing results under 80%. Only 30% of ultrasounds visualised the appendix, significantly dampening the sensitivity below 75%. The incidence of appendicitis in the non-visualised group was 8%. Conclusion No test is useful for ruling out appendicitis. Given that the incidence of appendicitis is higher in the non-visualised group, this is especially so with ultrasonography. Clinical examination with senior input is the most sensible strategy for managing children with acute abdominal pain.