A Study of Abdomenal Pain in Children

Pain abdomen is a common pediatric complaint that brings patient to the hospital in Nepal. Knowledge about its etiology and frequency helps in its evaluation and management. The present study was undertaken to find out the causes and their frequency of pain abdomen in Nepali children. Children with pain abdomen presenting at the emergency room and pediatric outpatient department of Kathmandu Medical College, Kathmandu from January, 2006 to December 2007 were clinically evaluated and investigated to find out the causes and frequency of their pain abdomen. The outcomes were tabulated and analyzed for interpretation. Of 444 patients attended, 356 completed investigations and came for follow up. Cause of pain abdomen was apparent in 117 (32.9%) only. 91.5% were medical causes, comprising predominantly of diarrheal diseases (28.3%), infantile colic (9.4%), urinary tract infection (7.7%) and acid peptic disease (6.8%). 8.5% causes were related to surgical conditions, which needed operative management. Secondary or extra-abdominal causes were found in 20 cases (17.1%). Pneumonia (2), functional (5), vulvovaginitis (2) and infantile colic (11) were predominant causes. Our study showed that the causes of pain abdomen in children were predominantly medical. Gastroenteritis was the most frequent cause. Secondary causes, including functional and emotional causes were infrequent. Small percentage needing surgical management formed a diagnostic challenge.


INtRODUCtION
Pain abdomen is one of the most common and frequent complaint in children. 1 About 10% of all children attending the emergency room have complaints referable to the abdomen. 2 The cause of pain abdomen may be a trivial and self limiting condition or it may herald a medical or surgical emergency.Differentiating abdominal pain because of benign conditions from those that require prompt medical or surgical intervention is an enormous problem. 3 Knowledge about the various etiologies of abdominal pain and their frequency helps to provide a clinical guideline for evaluation of a child with abdominal pain and to identify patients who will not improve without medical or surgical intervention.Published reports on abdominal pain in Nepali Children are scarce and those about its causes and frequency are almost non-existent. 4So, the present study was undertaken to list the various causes of pain abdomen in Nepali children and to find out their frequency of occurrence.

MAtERIAL AND MEtHODS
This is a prospective, observational study conducted in the children with pain abdomen presenting at the emergency room and the pediatric outpatient department of Kathmandu Medical College, Kathmandu from January 2006 to December 2007 were included in the study.Inclusion criteria was age below 15 years and site of pain below costal margins and above inguinal ligaments.Case exclusion criteria were considered met when pain was vague and inconsistent or not present at the time of clinical examination and following subsequent observation.Clinical examination was done in each case followed by routine stool, urine and blood investigations.Urine culture and sensitivity, abdominal ultrasonogram, radiological investigations and endoscopic examinations were done according to case merit.Treatment and observations were done and follow up visits arranged on response basis.All apparent causes of pain abdomen were recorded, tabulated and analyzed for interpretation by using appropriate statistical values.

RESULtS
A total of 444 children attended with complaints of pain abdomen during the study period.88 patients were lost to follow up.Of 356 children investigated identifiable causes for pain abdomen were found in 117 (32.9%) cases.The demographic profile of those patients with identifiable cause have shown male predominance (Table 1).Male children (62.53%) slightly outnumbered the females with a male female ratio of 1.1:1.The age distribution shows preponderance of 6-10 year olds (53%) with mean age 8.7 years (Table 1).
Maximum number of causes of pain abdomen (59.1%) were from gastrointestinal system which together with Hepatobiliary (6.8%) and genitourinary causes (12%) constituted three fourth (76.9%) of all causes (Table 2).Secondary causes (Pneumonia 2, functional 5, vulvovaginitis 2, infantile colic 11) were observed in 20 (17.1%) cases, in whom the causes were considered extra-abdominal.According to the system wise, pain abdomen comprises medical (91.5%) and surgical (8.5%), gastoenteritis being the most common and frequent cause of pain abdomen (Table 3, 4).On the other hand, a case of lymphoma of mesenteric lymph nodes, a rare case, was also seen.Surgical causes (10, 8.5%) were responsible in less than one tenth cases of abdominal pain in our study (Table 5).All those cases needed operative treatment.

DISCUSSION
Causes of pain abdomen can be many and varied.Parents tend to be complacent as pain subsides and refuse investigations to find out the etiology of pain.
In the present study 88 cases (19.8%) were lost to follow up.Moreover, it is difficult to find a specific cause for every pain abdomen 2 and the diagnostic yield may be small, even with the invasive procedures 5 .In the present study, only in one third cases (32.9%) recognizable causes for pain abdomen were found.Many cases of acute abdominal pain resolve spontaneously before a cause could be found and such a situation is disturbing to parents as well as the physician. 6mong the identifiable causes 91.5% were due to medical conditions comparable to other studies.This preponderance of medical causes for pain abdomen is documented. 7Less than a quarter of total cases (17.1%) were found to be due to secondary or extra-abdominal causes and unsuspected pneumonia was revealed in two cases (1.7%), which corresponded with reports by others. 8,9Pneumonia(15 out of 51 cases) was the most frequent extra-abdominal cause of pain abdomen found in another study. 10Infantile colic (9.5%) observed in our study is considered to be due to psychosocial factors, a failure of parent infant interaction and milk allergy. 11,12iarrheal diseases, urinary tract infection and acute peptic disease observed in our study as frequent causes of pain abdomen in children are also well documented in other literature. 7,13Distinguishing features of acute gastrointestinal tract pain in children has also been described. 14Helminthiasis (5.1%) although considered a common cause of pain abdomen in Nepali children was found less frequently in our study.It may be due to the fact that this study was carried in urban population.Furthermore, only severe helminthiais only become symptomatic. 15[18][19] Surgical conditions were found responsible for pain abdomen in less than one tenth cases (8.5%), although they needing rapid diagnosis for preventing morbidity.
Early exclusion of surgical cause has been emphasized, which holds true, as all our surgical cases needed operative treatment.In our experience, trans-abdominal ultrasound examination was helpful for early diagnosis.1][22] It has been estimated that less than 5% of children with pain abdomen will ultimately require abdominal exploration. 23owever, differentiating abdominal pain that require prompt surgical intervention from pain because of nonsurgical conditions often is challenging. 24No case of congenital abnormality, intussusceptions or intestinal obstruction causing pain abdomen was observed in the present study, which may be due to lack of pediatric surgical unit in our hospital.
Periodic appraisal and re-evaluation of causes and their frequency helps in planning investigations and forming clinical guidelines for management of children with abdominal pain. 6,24

CONCLUSION
Pain abdomen in children was most commonly due to medical causes.Gastroenteritis was observed as the most frequent cause.Secondary or extra-abdominal causes comprised less than one quarter of all causes.Surgical conditions needed early exclusion and their differentiation from medical causes were challenging.They were responsible in about one tenth cases only.Knowing causes and frequency helps in focused investigation and clinical management of abdominal pain in children.