Pediatric emergency medicine trisk 1052 1052
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Abdominal pain and pallor can occur rarely in a child with malignancy, as with
bleeding into an abdominal Wilms tumor, hepatoma, or neuroblastoma. The
presence of pallor and pain also raises the possibility of vaso-occlusive crisis in a
patient with sickle cell disease; splenic sequestration should also be considered.
Jaundice may be observed in the child with hemolysis or with hepatitis. At times,
an intra-abdominal vasculitis that causes pain may precede the rash of Henoch–
Schönlein purpura or be a prominent finding with Kawasaki disease.
Chronic abdominal pain in the adolescents may be due to inflammatory bowel
disease. In these children, inflammatory markers such as erythrocyte
sedimentation rate and C-reactive protein levels are commonly elevated. In
postpubertal females, dysmenorrhea, endometriosis, chronic PID, chronic UTI, or
gallbladder disease can be associated with chronic or recurrent abdominal pain.
Functional abdominal pain may be considered only after exclusion of other
conditions; the presence of focal tenderness, rebound, guarding, or fever should
prompt consideration of alternative diagnoses.
Additional Considerations in the Postpubertal Female With
Acute Abdominal Pain
Among postpubertal females, pregnancy and complications of pregnancy must be
considered ( Fig. 53.2 ). A menstrual history and ascertainment of sexual activity
are essential, and a urine β-hCG sample should be obtained in all females in
whom pregnancy is a possibility.
The diagnosis of ectopic pregnancy must be considered among females with
lower abdominal pain occurring within the first trimester of pregnancy (see
Chapter 92 Gynecology Emergencies ). Vaginal bleeding occurs in most patients
with ectopic pregnancy but is not always present. A transvaginal or
transabdominal ultrasound should be obtained. The diagnosis of ectopic
pregnancy is not usually confirmed by ultrasound; however, the presence of an
intrauterine gestational sac is reassuring and argues against the diagnosis of
ectopic pregnancy. A quantitative serum β-hCG sample should be obtained; it
may need to be repeated within 48 to 72 hours if the diagnosis remains uncertain.
In addition, RhoD immune globulin (RhoGAM) should be administered to Rhnegative women. Although the diagnosis of ectopic pregnancy should be
considered in all pregnant women, crampy lower abdominal pain is commonly
reported among women with intrauterine pregnancy.
Rupture of an ovarian cyst is the most common cause of lower abdominal pain
in postpubertal women; however, the diagnosis can be made only after the
exclusion of more serious conditions. An ultrasound should be obtained if focal
