Abdominal Pain in Children: An Emergency Practitioner's Guide

Sonographic Evaluation of the Child with Lower Abdominal or Pelvic Pain

At many centers, CT has become the primary imaging modality for children who have abdominal pain. CT, however, delivers a substantial radiation dose, which is of particular concern in the pediatric patient. In contrast, sonography does not expose the patient to ionizing radiation. Properly performed, sonography is capable of providing useful diagnostic information in the child who has lower abdominal or pelvic pain. In many children and with many disorders, sonography proves to be the only imaging modality that may be required. In this article, the usefulness of sonography in evaluating disorders producing lower abdominal or pelvic pain in a child is reviewed.

The evaluation of acute abdominal pain in children

The infant or child that presents with abdominal pain must be evaluated with a careful history, physical examination, and selective laboratory studies. There are a few diagnoses that the emergency physician should always consider as "life threatening." In the event of any uncertainty in the diagnosis of conditions like appendicitis, pyloric stenosis, or intussusception, the child or infant should be observed carefully over time with appropriate laboratory/radiologic studies ordered to further delineate pathology. Ultrasound evaluation of children with abdominal pain continues to be one of the most valuable tools to help diagnose different conditions.

Plain abdominal radiography in the detection of major disease in children: a prospective analysis

STUDY OBJECTIVE

To prospectively evaluate previously described high-yield clinical criteria for obtaining plain abdominal radiographs in the emergency evaluation of children.

DESIGN

Prospective, observational study.

SETTING

Emergency departments of a university medical center and an affiliated county hospital.

PARTICIPANTS

Three hundred fifty-four children 15 years old or younger who underwent plain abdominal radiography during a one-year period.

METHODS AND MEASUREMENTS

Physicians ordering plain abdominal radiographs completed data forms that included historical and physical examination information before viewing films. At a later date, records of all patients were reviewed for radiologist interpretation and final diagnosis. The data were analyzed to determine the sensitivity, specificity, and predictive values of previously described high-yield criteria (from a retrospective series) in detecting radiographs that were diagnostic or suggestive of "major" abdominal disease.

MAIN RESULTS

Sixty-one patients (17%) had major diseases potentially requiring procedural intervention (eg, appendicitis, ingested foreign bodies, and intussusception), whereas 296 patients (83%) had minor diseases not requiring procedural intervention (eg, gastroenteritis and nonabdominal diagnoses). The presence of any of the following features--prior abdominal surgery, foreign body ingestion, abnormal bowel sounds, abdominal distention, or peritoneal signs--was 93% sensitive and 40% specific in detecting diagnostic or suggestive radiographs in patients with major disease. Positive and negative predictive values were 11% and 99%, respectively. If only these criteria had been used to obtain radiographs, 38% of films would have been omitted (at an estimated savings of $20,000) with only two suggestive radiographs missed.

CONCLUSION

Our results suggest that restricting abdominal radiographs to patients with at least one of these five high-yield clinical features will detect most diagnostic and suggestive radiographs in children with major abdominal diseases.