What is colicky abdominal pain and how to elicit history from a pediatric patient?

Colicky Abdominal Pain in Pediatric Patients

Definition of Colicky Abdominal Pain

Colicky abdominal pain is characterized by intermittent, cramping pain that comes in waves, typically lasting more than 1 hour per episode, with periods of relief between attacks. 1 This pain pattern differs from constant pain and is often associated with intestinal obstruction, intussusception, or functional gastrointestinal disorders. 2

• The pain typically has a waxing and waning quality with variable intensity between episodes 1
• In young children, particularly those under 5 years, colicky pain with intermittent episodes, vomiting, and potentially bloody stools strongly suggests intussusception as the primary differential diagnosis 2
• Colicky pain is distinct from the progressive, constant pain that characterizes appendicitis, where pain typically precedes vomiting 3

History-Taking Approach in Pediatric Patients

Age-Specific Considerations

Age is the single most critical factor in evaluating abdominal pain, as the incidence and symptom presentation of different conditions vary dramatically across the pediatric age spectrum. 3

• Children under 5 years, especially around age 4, present with atypical symptoms significantly more frequently than older children, making clinical diagnosis particularly unreliable in this age group 2
• First-decade pediatric patients with inflammatory bowel disease are more likely to have colonic involvement and upper gastrointestinal involvement compared to adults 4
• Very young children may have less architectural distortion and inflammation on examination, with unusual patterns including patchiness and rectal sparing 4

Pain Characteristics to Elicit

Document the temporal relationship between pain and vomiting, as this distinguishes surgical from medical causes: pain preceding vomiting suggests a surgical abdomen, while vomiting preceding pain suggests a medical condition. 3

• Duration: Determine if pain has lasted days, weeks, or months—47.3% of children with chronic issues have pain lasting several months 1
• Frequency: Ask if pain occurs daily, multiple times weekly, or intermittently—65.9% of children with significant pathology experience pain daily or several times per week 1
• Location: Document if pain is periumbilical, right lower quadrant, or diffuse—77.7% of children describe intra-abdominal pain, though 61.5% report changeably located pain 1
• Character: Distinguish between colicky (intermittent cramping), constant, or sharp pain—59.3% of children describe variable character 1
• Intensity: Quantify severity and whether it increases over time, as severe, localized pain that increases in intensity indicates surgical referral 5

Associated Symptoms

Specifically ask about the sequence of symptoms: bilious vomiting, hematochezia, fever, and diarrhea are red flags requiring urgent evaluation. 5

• Vomiting: Bilious vomiting suggests obstruction and requires immediate surgical consultation 5
• Bowel movements: Diarrhea suggests gastroenteritis or food poisoning, while bloody stools suggest intussusception in young children 2, 3
• Fever: The presence of fever increases the likelihood of appendicitis 3.4 times and is the most useful single clinical sign 2
• Urinary symptoms: Essential to exclude urinary tract infection, as symptoms may mimic appendicitis 2

Dietary and Lifestyle Factors

Inquire about specific dietary habits, as 96% of children with chronic abdominal pain consume foods that may provoke symptoms, particularly sweets (42%), chips (23.9%), and sweetened fizzy drinks (20.8%). 1

• Food relationship: Ask if pain is connected with food intake—this occurs in 20.8% of cases 1
• Constipation: A frequent cause of abdominal pain in young children that can localize to the right lower quadrant 2

Psychosocial Factors

Document stress-related triggers, as stress provokes abdominal pain in 35% of children, and characterological features that influence mental reactions are noted in 47.4% of patients. 1

• Functional disorders account for 32.3% of children presenting with abdominal pain, with dyspepsia affecting 22.1% 1
• The Rome criteria for IBS require abdominal pain associated with changes in stool frequency or form, specifically presuming the absence of structural explanations 6

Physical Examination Red Flags

Signs indicating acute surgical abdomen and requiring immediate surgical consultation include involuntary guarding or rigidity, marked abdominal distention, marked tenderness, and rebound tenderness. 3

• Decreased or absent bowel sounds, psoas sign, obturator sign, Rovsing sign, and right lower quadrant rebound tenderness suggest acute appendicitis 5
• Repeated physical examination by the same physician is often useful when the diagnosis is not clear after initial evaluation 3

Common Pitfalls to Avoid

• Do not dismiss appendicitis in very young children despite atypical presentations, as delayed diagnosis leads to higher perforation rates 2
• Do not rely solely on clinical scoring systems like the Pediatric Appendicitis Score for diagnosis or exclusion, as imaging remains essential in young children 2
• Do not assume periappendiceal inflammation indicates Crohn's disease, as this is frequently seen in ulcerative colitis without significant cecal involvement 2
• Do not overlook inflammatory bowel disease in young children with aberrant presentations, as it should always be considered in the differential diagnosis 4, 2