Abdominal pain is a common and recurring problem in paediatric emergency departments

Diagnostic Yield of Abdominal Radiographs in the Pediatric Emergency Department

BACKGROUND AND OBJECTIVES

Abdominal radiographs (ARs) are commonly used in the pediatric emergency department (PED). Their low diagnostic accuracy leads to overuse, excess radiation exposure, and increased resource usage. This study aims to assess the diagnostic yield of ARs in the evaluation of intraabdominal pathology in the PED.

METHODS

Retrospective, cross-sectional study of patients aged 0 to 18 years with an AR who visited the PED between 2017 and 2019. Diagnostic yield was analyzed with sensitivity, specificity, positive predictive value, negative predictive value (NPV), and likelihood ratio.

RESULTS

A total of 4288 ARs were identified, with a rate of 6%. The overall abnormal AR rate was 31%. The incidences of an abnormal AR in abdominal pain, vomiting, and constipation were 26%, 37%, and 50%, respectively. There was a 13% rate of clinically significant diagnoses. The AR diagnostic yield showed 44% sensitivity, 70% specificity, 17% positive predictive value, and 90% NPV ( P < 0.05). Unadjusted odds ratio analysis of positive AR and abdominal pain, vomiting, and constipation revealed an odds ratio of 0.68 (95% confidence interval [CI], 0.63-0.75), 1.22 (95% CI, 1.06-1.39), and 1.72 (95% CI, 1.54-1.91), respectively.

CONCLUSIONS

There is a low rate of intraabdominal pathologic processes that an AR can identify. A normal AR does not change patient management, nor does it reduce the need for further radiologic imaging. Despite a good NPV, the AR is not a useful diagnostic tool in the PED because of its limited ability to rule in or rule out clinically significant diagnoses.

Determining clinical predictors to identify non-specific abdominal pain and the added value of laboratory examinations: A prospective derivation study in a paediatric emergency department

AIM

To develop a model to discriminate non-specific abdominal pain (NSAP) from organic pain in the paediatric emergency department (PED) and evaluate the added value of laboratory markers.

METHODS

Prospective cohort study in an urban French PED including all patients aged ≥4 years with abdominal pain between November 2020 and May 2021. The outcome was the discrimination between NSAP (patients coded to have only "pain" or "constipation") and organic pain (all other diagnoses) using stepwise backward multivariate logistic regression method with bootstrap resampling.

RESULTS

The study enrolled 246 patients. Overall, 163 patients (66.2%) had NSAP. Four variables associated with organic pain: pain in the epigastric region (OR 0.48 [0.23-0.99]), worsening pain (0.57 [0.32-0.99]), pain migration (0.42 [0.17-0.99]) and vomiting (0.47 [0.26-0.84]) were integrated in a clinical model. To discriminate NSAP with a probability of 65%, model sensitivity was 71.8% (64.9-78.7), specificity was 53.0% (42.3-63.7), and the Net Benefit (NB) was 15.4%. White Blood Count and C-reactive protein results improved discriminative capacity of the model (AUC 0.708 [0.643-0.773] vs. 0.654 [0.585-0.723], p = 0.01) with a supplementary NB of 12%. Patient follow-up showed 95% diagnostic accuracy.

CONCLUSION

This study reveals a four-clinical predictor model with a NB of 15% in predicting NSAP. Validation studies are necessary.

Salpingitis in an Adolescent Female With Constipation and Abdominal Pain

Abdominal pain is one of the most common presenting complaints in the emergency room for pediatric patients. While constipation is one of the most common causes for abdominal pain in pediatrics, serious intra-abdominal pathology must always be excluded. We report a pre-coital post-menarchal adolescent female who presented with severe abdominal pain and constipation and had radiographic findings of salpingitis. It was suspected that uterine and adnexal changes seen on imaging resulted from the fecal mass compressing the genitourinary tract leading to fluid collection manifesting as radiographic evidence of salpingitis. This mechanism is similar to bladder outlet obstruction resulting from compression by intestinal stool burden, leading to urinary stasis, bacteriuria, and ascending urinary tract infection. This case demonstrates how a common pediatric problem, constipation, can lead to a condition rarely found in the pre-coital adolescent population.

Comparing the Evaluation of Abdominal Pain in Adolescent Females at a Pediatric vs General Emergency Department

BACKGROUND

The objective of this study was to determine the rates at which gynecologic history and related exams are performed among adolescent females presenting with abdominal pain and whether the rates differ between patients seeking care at a pediatric compared with a general emergency department (ED).

METHODS

We conducted a retrospective cohort study of female patients aged 12-21 years who presented to the ED for a chief complaint of abdominal pain at either a single academic children's ED or a single general academic ED during 2016. We examined differences in the rates of gynecologic history and related exams between institutions, before and after adjustment with inverse probability weights.

RESULTS

A total of 837 females met the inclusion criteria for this study, and 627 patients were included in the adjusted analyses. Outcomes more commonly performed at the pediatric institution included documentation of contraception (28% at the general ED vs 43% at the pediatric ED, P < .001), sexually transmitted infection testing (32% at the general ED vs 42% at the pediatric ED, P = .04), and radiologic imaging (46% at the general ED vs 70% at the pediatric ED, P < .001). Outcomes that were more commonly performed at the general ED were pelvic exam (26% at the general ED vs 10% at the pediatric ED, P < .001) and complete blood count draw (67% at the general ED vs 39% at the pediatric ED, P < .001). No differences were observed between institutions in the documentation of menarche or sexual activity, the performance of a pregnancy test or CT scan, or the rate of subsequent ED/urgent care visits in the following year.

CONCLUSION

The rates at which gynecologic history and pelvic examination were performed in adolescent females presenting for abdominal pain at both a general ED and a pediatric ED were low and inconsistent. Providers should have a low threshold for testing for sexually transmitted infections and pregnancy. Pelvic examination and diagnostic lab testing should be performed when indicated in the setting of a clinically appropriate history. These efforts would ensure adequate evaluation of adolescent women and reduce unnecessary health resource utilization.

Risk Factors for Recurrent Abdominal Pain in Children with Nonorganic Acute Abdominal Pain

PURPOSE

The purpose of this study was to identify the risk factors for recurrent abdominal pain (RAP) in children who presented with nonorganic acute abdominal pain.

METHODS

A retrospective, single study was conducted on 2-15-year-old children diagnosed with nonorganic acute abdominal pain at the pediatric outpatient department of Vajira Hospital, Nawamindradhiraj University, between January 2015 and December 2019. The potential risk factors were analyzed using univariate and multivariate analyses.

RESULTS

Of the 367 patients with nonorganic acute abdominal pain, 94 (25.6%) experienced RAP within three months. In this group with RAP, 76 patients (80.8%) were diagnosed with functional gastrointestinal disorders, including functional dyspepsia, irritable bowel syndrome, functional abdominal pain-not otherwise specified, and functional constipation. History of gastrointestinal infection (p=0.011), mental health problems (p=0.022), abdominal pain lasting ≥7 days (p<0.001), and change in stool frequency (p=0.001) were the independent risk factors associated with RAP in children with nonorganic acute abdominal pain; their odds ratios and 95% confidence intervals were 3.364 (1.314-8.162), 3.052 (1.172-7.949), 3.706 (1.847-7.435), and 2.649 (1.477-4.750), respectively.

CONCLUSION

RAP is a common problem among children who first present with nonorganic acute abdominal pain. The identification of risk factors may provide proper management, especially follow-up plans for this group in the future.

Utility of biomarkers in predicting complicated appendicitis: can immature granulocyte percentage and C-reactive protein be used?

BACKGROUND

Acute appendicitis is the most common reason for abdominal surgery in children. The aim of this study was to evaluate the utility of biomarkers in predicting complicated appendicitis (CA).

METHODS

Patients having a diagnosis of acute appendicitis who underwent operations were retrospectively determined, and the utility of biomarkers in predicting CA was evaluated.

RESULTS

A total of 251 patients were included in the study. The mean age was 130.9 ± 48.8 months, 148 of the cases (59%) were simple appendicitis, and 103 (41%) were CA. The C-reactive protein (CRP) levels, immature granulocyte (IG) percentage, white blood cell counts, and absolute neutrophil counts were significantly higher in the CA patients. The bilirubin levels and neutrophil to lymphocyte ratios were not useful for predicting CA. The best area under the curve (AUC) values to predict CA were with the IG percentage and CRP level (0.82), the IG percentage [odds ratio (OR) 9.36, 95% CI (4.94-17.75), p < 0.001] and CRP [OR 8.42, 95% CI (4.72-15.02), p < 0.001] were the best marker in predicting CA. The sensitivity of the IG percentage and CRP level were higher than other markers.

CONCLUSION

To predict CA, the best AUC values were associated with the IG percentage and the CRP level. Because it is easy, fast to measure, does not require taking extra blood, and does not lead to additional costs, IG percentage may be preferred in the diagnosis of patients with CA.