From the Guidelines
The diagnostic workup for a 4-year-old child presenting with abdominal pain and nausea/vomiting for 4 days should begin with a thorough history and physical examination, followed by initial laboratory tests and imaging studies to evaluate for potential causes such as appendicitis, intussusception, or other structural abnormalities. Key history elements include pain characteristics (location, severity, timing), associated symptoms, recent illnesses, dietary changes, and bowel/bladder patterns 1. Initial laboratory tests should include complete blood count to assess for infection or inflammation, comprehensive metabolic panel to evaluate electrolytes and liver/kidney function, urinalysis to rule out urinary tract infection, and C-reactive protein or erythrocyte sedimentation rate to gauge inflammation. Imaging studies may include an abdominal X-ray to check for obstruction or constipation, and an abdominal ultrasound to evaluate for appendicitis, intussusception, or other structural abnormalities 1.
Some potential causes of abdominal pain in children include:
- Gastroenteritis
- Constipation
- Urinary tract infection
- Appendicitis
- Intussusception
- Other structural abnormalities
If symptoms are severe or concerning features are present (such as high fever, bilious vomiting, or significant abdominal tenderness), surgical consultation may be warranted 1. Stool studies including culture, ova and parasites, and tests for Clostridioides difficile should be considered if diarrhea is present 1. Depending on the clinical presentation, additional specialized tests might include abdominal CT scan, upper GI series, or endoscopy. Throughout the evaluation, maintaining adequate hydration is essential, potentially requiring intravenous fluids if oral intake is poor or vomiting is persistent 1. Antinausea and antiemetic medications, such as ondansetron, may be given to facilitate tolerance of oral rehydration in children >4 years of age and in adolescents with acute gastroenteritis associated with vomiting 1.
It is also important to consider the diagnosis of irritable bowel syndrome (IBS) in children with abdominal pain, although this diagnosis is typically made after other potential causes have been ruled out 1. The Rome II Diagnostic Criteria For Irritable Bowel Syndrome may be used to support the diagnosis of IBS, which includes symptoms such as abdominal discomfort or pain, relieved with defecation, and/or onset associated with a change in frequency or form of stool 1. However, in the case of a 4-year-old child with acute abdominal pain and nausea/vomiting, the focus should be on ruling out more serious causes of abdominal pain, such as appendicitis or intussusception, before considering a diagnosis of IBS.
From the Research
Diagnostic Approach
The diagnostic workup for a 4-year-old child presenting with abdominal pain and nausea/vomiting for 4 days involves a meticulous history taking and physical examination, as these are the best tools for diagnosis 2. The emergency physician should consider various etiologies, including surgical and non-surgical causes, and extra-abdominal conditions that may present as abdominal pain 3.
Possible Causes
Some possible causes of abdominal pain in children include:
- Acute gastro-enteritis
- Constipation
- Functional abdominal pain
- Intestinal obstruction
- Perforation peritonitis
- Urachal cysts 4
- Intestinal duplication cysts 5
Diagnostic Evaluation
The diagnostic evaluation may involve:
- Detailed history from a parent or caregiver
- Careful physical examination
- Laboratory tests and imaging studies, such as ultrasound, barium examination, and colonoscopy, which may be useful in certain cases, such as intestinal duplication cysts 5
- Consideration of the child's age and presentation to narrow the differential diagnosis 3
Important Considerations
It is essential to distinguish between diagnoses requiring immediate attention and self-limiting processes 3, 6. The emergency physician should be aware of rare but significant conditions, such as urachal cysts and intestinal duplication cysts, which can present with abdominal pain and may require prompt diagnosis and treatment 4, 5.