Gastric trichobezoar: an important cause of abdominal pain presenting to the pediatric emergency department

Abdominal pain is a common presenting complaint of children seen in urgent care settings. It is the manifestation of a wide variety of disease processes ranging from benign to immediately life-threatening. Gastric bezoars are among the etiologies of chronic childhood abdominal pain that, when undiagnosed, may result acutely in serious complications, including gastric ulceration, bleeding and perforation, intussusception, and small bowel obstruction. To reinforce the importance of including this entity in the differential diagnosis of abdominal pain, we present the case of a 10-year-old girl with a history of chronic epigastric complaints who was ultimately presented with acute small bowel obstruction following fragmentation and distal migration of her gastric trichobezoar. Finally, we review and briefly summarize the current literature regarding the etiology, diagnosis, and management of this disorder in children.     

儿童腹痛的临床评估

摘要： 腹痛是儿科常见的临床问题,病因复杂,病情各异,预后不一。本文系统介绍了腹痛患者的临床诊断思路和处理原则。     

��ͯ��ʹ���ٴ�����

??Abdominal pain in a child is one of the most common presentations with both trivial and life-threatening etiologies?? ranging from functional pain to acute appendicitis. Diagnosing abdominal pain in children is also a challenging task?? and the differential diagnosis of abdominal pain is extensive. This paper systematically introduces the approach to and management of pediatric abdominal pain.     

Appendicitis and non-specific abdominal pain in childhood

Abdominal pain is a common experience during childhood and frequently presents to secondary healthcare facilities. Although non-specific abdominal pain and appendicitis are the most common causes, the clinician should also be aware of the diagnosis and management of all causes of abdominal pain in children. This article provides an overview of abdominal pain in children, including history and examination, initial management, diagnostic categories, modes of investigation, and definitive treatment.     

Prevalence and pattern of childhood abdominal pain in an Australian general practice

OBJECTIVE: Abdominal pain is a common problem in childhood and accounts for a significant workload in general practice. The aim of this study was assess the nature of abdominal pain in a sample of Australian children attending a Western Australian general practice for any reason, and to determine factors associated with the reporting of such pain. METHODOLOGY: A prospective study of children and their families attending a rural general practice was undertaken using a parental survey to assess the frequency and nature of abdominal pain, demographic features, physical and behavioural characteristics. RESULTS: Abdominal pain was common in this population; 44% (70 of 164) of parents reported that the index child had experienced abdominal pain in the past 12 months. The average age of children who experienced recent abdominal pain was 9 years and 9 months. Multivariate analysis suggested that children experiencing abdominal pain in the preceding 12 months were more likely to be anxious (odds ratio (OR) = 3.74, P = 0.01), to have a family history of similar problems in siblings (OR = 4.26, P = 0.01) and to experience sleep disturbance (OR = 3.90, P = 0.02) than children without abdominal pain. Consumption of three or more serves of wholemeal bread or cereals per day had a significant protective effect on reported abdominal pain in children (OR = 0.12, P = 0.03). The majority of families (66%) dealt with the pain without resorting to medical care. CONCLUSIONS: Abdominal pain remains a common problem of children attending an Australian general practice, and was associated with features suggesting that it is related to anxiety and coping ability. Abdominal pain is not usually associated with disease; most families recognize this and cope with abdominal pain without medical consultation.     

Abdominal migraine in children with neurofibromatosis type 1: a case series and review of gastrointestinal involvement in NF1

BACKGROUND: Symptomatic involvement of the gastrointestinal tract in children with neurofibromatosis type 1 (NF1) is rare. Most reported complications in adults are caused by the presence of neurofibromas in the stomach, small bowel, or mesentery. In contrast, abdominal pain in children with NF1 may be the result of nonanatomic causes, such as migraine. There are no previous reports of an association between abdominal migraine and NF1. METHODS: Children with abdominal migraine were identified from a group of children with NF1, all of whom had been followed up for a minimum of 3 years. Medical records of cases were reviewed independently by two authors. MEDLINE was searched via PubMed for all reports of children with NF1 and any associated gastrointestinal involvement. RESULTS: Six children with NF1 and intermittent, episodic, severe abdominal pain are reported. Investigations for obstructive or inflammatory causes of abdominal pain were negative. All patients had previously been diagnosed with migraine headaches by a neurologist. In five of the six patients, propranolol (10-15 mg three times daily) resulted in relief of their abdominal pain within days of starting therapy. Our review identified 24 children in the medical literature with gastrointestinal complications of NF1, mostly secondary to visceral neurofibromas. In almost all of these cases, clinical examination and simple radiologic investigations led to the definitive diagnosis. There were no reports of abdominal migraine complicating NF1. CONCLUSIONS: Abdominal pain secondary to migraine is an unrecognized cause of abdominal pain in children with NF1 and may be more common than anatomic causes of abdominal pain in children with NF1. In children with NF1 and severe recurrent abdominal pain in whom an evaluation for anatomic lesions is negative, a trial of migraine therapy may be indicated.     

Practical approach to the child presenting with back pain

Back pain may be the presenting symptom of many children attending to pediatric health care settings. As such, awareness to the common etiologies of back pain in this subgroup of patients remains essential as it guides appropriate diagnosis. Although several clues may be derived from the child’s history and physical examination, imaging techniques may be required to confirm the underlying diagnosis. This review summarizes the most commonly encountered causes of back pain in children and highlights diagnostic approaches that will ensure early diagnosis and intervention for a more favorable outcome.     

Approach to “Upset Stomach”

An “Upset stomach” is a common problem encountered by physicians involved in the care of children. It includes, diarrhea, vomiting or abdominal pain. Though often mild and self-limiting, at times there are uncommon life-threatening conditions that require urgent care. It is important for primary physicians to recognize “alarm signs” and make a referral to the specialist at the right time. At the same time it is important to recognize what is normal and re-assure the caregivers. A detailed history and a proper systemic examination are important at presentation, looking for any “red flags”. Investigations are seldom needed and the treatment is symptomatic. In acute diarrhea, adequate hydration is the cornerstone of management, which includes recognizing the degree of dehydration and treating with oral rehydration solution and Zinc. Dysentery i.e., bloody diarrhea needs treatment with antibiotics. In children with predominant vomiting and abdominal pain, it is vital to make sure one is not dealing with a “surgical “cause. If the child is not settling, a repeated examination is useful to look for the persistence or evolution of abdominal signs. Vomiting does not localize the problem to the gastro- intestinal (GI) tract and a complete systemic examination is needed to rule out an extra GI cause.     

Chronic Abdominal Pain In Children: a Technical Report of the American Academy of Pediatrics and the North American Society for Pediatric Gastroenterology, Hepatology and Nutrition

Chronic abdominal pain, defined as long-lasting intermittent or constant abdominal pain, is a common pediatric problem encountered by primary care physicians, medical subspecialists and surgical specialists. Chronic abdominal pain in children is usually functional-that is, without objective evidence of an underlying organic disorder. The Subcommittee on Chronic Abdominal Pain of the American Academy of Pediatrics and the North American Society for Pediatric Gastroenterology, Hepatology and Nutrition has prepared this report based on a comprehensive, systematic review and rating of the medical literature. This report accompanies a clinical report based on the literature review and expert opinion.The subcommittee examined the diagnostic and therapeutic value of a medical and psychologic history, diagnostic tests, and pharmacological and behavioral therapy. The presence of alarm symptoms or signs (such as weight loss, gastrointestinal bleeding, persistent fever, chronic severe diarrhea and significant vomiting) is associated with a higher prevalence of organic disease. There was insufficient evidence to state that the nature of the abdominal pain or the presence of associated symptoms (such as anorexia, nausea, headache and joint pain) can discriminate between functional and organic disorders. Although children with chronic abdominal pain and their parents are more often anxious or depressed, the presence of anxiety, depression, behavior problems or recent negative life events does not distinguish between functional and organic abdominal pain. Most children who are brought to the primary care physician's office for chronic abdominal pain are unlikely to require diagnostic testing. Pediatric studies of therapeutic interventions were examined and found to be limited or inconclusive.     

Child with Headache

Headache is a common complaint for which parents seek pediatrician’s consult. Headaches are seen in increasing frequency from 3 y of age onwards with peaks in older children and adolescents. In children, secondary headaches due to underlying etiologies are far more common than primary headaches due to migraine. Recognition of temporal pattern of headache along with focused neurological examination will help in narrowing down the etiology. The key goal in urgent care assessment is to identify children with underlying serious illnesses that require stabilization and urgent referral. For benign causes, symptomatic treatment with analgesics like paracetamol or ibuprofen would suffice initially, while identification of the underlying condition would lead to further appropriate management, particularly in primary headaches.     

Cholelithiasis in a toddler with sickle cell disease

Cholelithiasis is rarely seen in toddlers and school-aged children, even in the setting of sickle cell anemia. In addition to more common etiologies, such as gastroenteritis, constipation, and urinary tract infection, the differential diagnoses of acute abdominal pain in young children with sickle cell disease include vaso-occlusive pain crisis and splenic sequestration. We describe a case of a toddler with sickle cell disease initially presenting with abdominal pain who was found to have symptomatic cholelithiasis.     

The use of an emergency physician-directed bedside ultrasound examination to clarify a diagnosis in an 8-year-old boy with chronic abdominal pain

Abdominal pain is a common presenting complaint to the emergency department. Often, patients with chronic, intermittent histories of abdominal pain with multiple visits to medical providers find it difficult to be taken seriously. We describe a patient with a history of episodic abdominal pain who was found to have intermittent ureteropelvic junction obstruction after a timely ultrasound examination by the treating emergency physician.     

Omental infarction: an unusual cause of acute abdomen in children

Acute abdomen is caused by a wide variety of etiologies, many of which require surgical intervention. Two boys were hospitalized for acute abdominal pain and low-grade fever. Physical examination revealed epigastric and right upper abdominal fullness, and laboratory studies showed elevated erythrocyte sedimentation rates, with normal leukocyte counts and coagulation profiles. Abdominal ultrasound and computerized tomography revealed pseudotumor in both cases. Symptomatic treatment and cefazolin were administered, and pain and fever subsided after 6 to 10 days. Pseudotumor due to omental infarction can present as acute abdomen in children. A high index of suspicion and the use of both ultrasonography and computerized tomography will help avoid unnecessary surgical intervention in such cases.     

The management of recurrent abdominal pain

Recurrent abdominal pain is a common problem in school-aged children, and although many patients do not have an underlying identifiable pathology, it is important that those children with such conditions are diagnosed and treated promptly. This article sets out some of the common conditions presenting as recurrent abdominal pain in modern hospital-based practise, emphasizing features in the history and examination which point towards organic disease. Functional abdominal pain and irritable bowel syndrome are described. A scheme for appropriate use of investigations is suggested.     

以腹痛为首发表现的儿内科急危重症的临床特点和治疗

腹痛是儿科常见的一种症状,部分因急性腹痛而就诊.本文仅对以腹痛为首发表现的儿童暴发性心肌炎、过敏性紫癜、糖尿病酮症酸中毒的临床特点和治疗进行综述.     

Asthma and pneumonia

Chest pain remains a common complaint among children seeking care in the United States. Asthma and lower respiratory tract infections such as pneumonia can be significant causes of chest pain. Children with chest pain caused by either of these pulmonary etiologies generally present with associated respiratory symptoms, including cough, wheezing, tachypnea, respiratory distress, and/or fever. Although analgesic medications can improve chest pain associated with pulmonary pathologies, the mainstay of therapy is to treat the underlying etiology; this includes bronchodilator and/or steroid medications in children with asthma and appropriate antibacterial administration in children with suspicions of bacterial pneumonia. The chest pain generally resolves along with the resolution of other respiratory symptoms.     

Myocarditis presenting as gastritis in children

Vomiting and abdominal pain are common pediatric complaints encountered by emergency physicians. The differential diagnosis of abdominal pain is extensive. Herein, we report 2 cases with fatal myocarditis who initially presented with abdominal pain and vomiting. Both cases were presented with abdominal pain, vomiting, and loose stools. On arrival at our emergency department, hypotension, tachycardia, and cyanotic extremities were found. Their serum troponin-I levels were elevated. The echocardiogram demonstrated poor left ventricular performance and a decreased ejection fraction. In both cases, an arrhythmia and a coma developed within hours and were shortly followed by death. The clinical presentations of acute myocarditis are variable, ranging from an initial mild discomfort to acute progressive heart failure, and at times, even death. Abdominal pain may be a manifestation of systemic disease, an extra-abdominal lesion, or myocarditis. Although myocarditis associated with abdominal pain or vomiting remains a diagnostic challenge to physicians, it should be considered in the differential diagnosis of children with gastritis and hypotension or who are refractory to rehydration therapy.     

Chest pain in children and adolescents

The focus of this article is to explore chest pain in children and adolescents. Common causes of chest pain and the approach to its evaluation are reviewed. Special emphasis is given to the cardiac causes of pediatric chest pain and how it can be differentiated from more common benign etiologies.     

Clinical value of monitoring eosinophil activity in asthma

The prevalence and clinical features of migraine headache and abdominal migraine were studied in the well defined population of Aberdeen schoolchildren. Ten per cent of all children (2165) aged 5-15 years were given a questionnaire inquiring, among other symptoms, about the history of headache and abdominal pain over the past year. A total of 1754 children (81%) responded. Children with at least two episodes of severe headache and/or sever abdominal pain, attributed by the parents either to unknown causes or to migraine, were invited to attend for clinical interview and examination. After interview, 159 children fulfilled the International Headache Society's criteria for the diagnosis of migraine and 58 children had abdominal migraine giving estimated prevalence rates of 10.6% and 4.1% respectively. Children with abdominal migraine had demographic and social characteristics similar to those of children with migraine. They also had similar patterns of associated recurrent painful conditions, trigger and relieving factors, and associated symptoms during attacks. The similarities between the two conditions are so close as to suggest that they have a common pathogenesis.     

Acute abdomen in children due to extra-abdominal causes

Background: Acute abdominal pain in children is a common cause for referral to the emergency room and for subsequent hospitalization to pediatric medical or surgical departments. There are rare occasions when the abdominal pain is derived from extra-abdominal organs or systems. The aim of the present study was to establish the most common extra-abdominal causes of acute abdominal pain.
Methods: The notes of all children (1 month–14 years of age) examined for acute abdominal pain in the Accident and Emergency (A&E) Department of Alexandroupolis District University Hospital in January 2001–December 2005 were analyzed retrospectively. Demographic data, clinical signs and symptoms, and laboratory findings were recorded, as well as the final diagnosis and outcome.
Results: Of a total number of 28 124 children who were brought to the A&E department, in 1731 the main complaint was acute abdominal pain. In 51 children their symptoms had an extra-abdominal cause, the most frequent being pneumonia ( n  = 15), tonsillitis ( n  = 10), otitis media ( n  = 9), and acute leukemia ( n  = 5).
Conclusion: Both abdominal and extra-abdominal causes should be considered by a pediatrician who is confronted with a child with acute abdominal pain.