Paediatric Abdominal Pain: a case of trials and tribulations mixed with phantoms of the operating theatre? Or maybe just a case of going back to the future!

Abstract

Background: Paediatric abdominal pain has long been a diagnostic dilemma facing the emergency physician and surgeon alike. The majority of childhood abdominal complaints are benign. However, appendicitis represents the most common surgical emergency of childhood and if excessive delay in diagnosis and management occurs, serious complications and death can result. Expensive tests such as biochemical investigations and ultrasonography are often over-stated in their true value to the clinician.

Aim and Methods: This thesis hopes to enhance the management of paediatric abdominal pain in three ways: 1. By analyzing the epidemiology and presentation patterns in paediatric abdominal pain. This is discussed in chapter 3 and was conducted via a year’s review of paediatric abdominal pain for the calendar year 2005. 2. By investigating the role of biomarkers such as white cell count, neutrophil count, C-reactive protein and radiological investigations such as ultrasound in the management of paediatric abdominal pain. This study extrapolates some of the findings discussed in chapter 3 and examines them in greater detail. This is discussed in chapter 4 and was conducted through a ten year review of patients referred by Emergency physicians and surgeons for further work up of their abdominal pain between 1st of January 2002 and 31st December 2012. 3.By investigating the role of socioeconomic factors, heritable conditions and extra-abdominal conditions in paediatric abdominal pain. This is discussed in chapter 5 and was conducted via a prospective review conducted between 2012 and 2013. Results: 1) Appendicitis represented 6% of all presentations 2) Historical findings of most use included worsening pain, associated with nausea or vomiting which yielded moderate sensitivities and specificities (combined values over 70%). 3) Localised tenderness and percussion-tenderness were the only useful abdominal examination findings with sensitivities and specificities over 90%, respectively, when associated with moderate tenderness. 4) White Cell Count and CRP yielded sensitivities and specificities below 80% 5) Ultrasonography yielded high sensitivity (>95%) when only ultrasounds which visualise the appendix are analysed but, as the appendix is often not visualised, the actual sensitivity is only 70%. Ultrasound has a greater diagnostic yield for females than males. 6) Functional abdominal pain is the most common cause for presentation, followed by mesenteric adenitis and appendicitis. Children with Functional Abdominal Pain were more likely to have regular bowel habits and present in winter than those with other medical conditions. Of note, both groups had higher rates of parental smoking, atopic conditions and migraine than is usually seen in the general population. Conclusion: Paediatric abdominal pain is a common yet challenging scenario for clinicians. However, the most useful tools are an accurate history, thorough examination and sensible use of biomarkers and radiological investigations. Other factors affecting children should be taken into account, e.g. the family medical history, though they should not significantly alter the child’s workup. Biomarkers and radiological investigations should only be used where doubt exists as to the diagnosis, and we suggest ultrasonography only in those children in whom significant diagnostic uncertainty exists and where the clinical picture clashes with the prior mentioned investigations. Show more