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Pediatric Abdominal Pain Misdiagnosed
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Larry Mellick, MD, MS, FAAP, FACEP
Professor of Emergency Medicine
Medical College of Georgia
Pearl: Pneumonia can present as abdominal pain in children
Presentation: Twice within 24 hours an eleven-year-old
male presented with midepigastric pain, vomiting and a fever. At the first
early morning visit and despite the absence of diarrhea the discharge diagnosis
was gastroenteritis. At his second presentation his temperature was 38.2?
C and his abdominal pain was reported as 7/10 on a numeric descriptor scale.
Despite his history of asthma the patient's presentation included no signs
and symptoms associated with the respiratory system. Auscultation of the
patient's lungs demonstrated no evidence of rales or ronchi. His bowel sounds
were normal, but his midepigastric area was moderately tender to palpation.
His amylase and lipase were normal and his white count was 16,100 cells
per cubic mm. After scratching our heads (for just a few minutes), we ordered
an x-ray which demonstrated the patient's lower lobe pneumonia and the cause
of our patient's abdominal pain. (See Figure 1.) Subsequently, the patient's
father added that his wife, a radiologist at a neighboring hospital, had
mentioned the possibility of pneumonia. (Imagine the administrative flak
if the diagnosis had been overlooked a second time.)
Discussion: The most common typical bacterial pneumonia
in all children is pneumococcal pneumonia. In one retrospective review of
254 children and young adults (age <1 month to 26 years) with pneumococcal
pneumonia, the most common signs and symptoms were as follows1
| Fever: 90 percent, |
| Cough: 70 percent; productive cough: 10 percent |
| Tachypnea: 50 percent |
| Malaise/lethargy: 45 percent |
| Emesis: 43 percent |
| Hypoxemia (oxygen saturation 95 percent): 50 percent |
| Decreased breath sounds: 55 percent |
| Crackles: 40 percent |
On the other hand the presentation of pneumonia can be predominately abdominal
pain. The abdominal pain associated with pneumonia may be related to the
basilar location of the pneumonia and be referred through a shared dermatome
or mesenteric adenitis has been reported in these patients.2,3
So when you are evaluating abdominal pain have a practical differential
diagnoses list. Sure hyperthyroidism, lead poisoning, addison's disease,
pancreatitis, porphyria and abdominal migraine may be a cause of pediatric
abdominal pain, but when was the last time you diagnosed one of these conditions?
Here is my practical list of non surgical causes of abdominal pain in some
semblance of rank order for what children of this age range might come to
the emergency department.
| Acute Gastroenteritis |
| Constipation |
| Bacterial food poisoning |
| Functional or irritable bowel |
| Streptococcal pharyngitis |
| Urinary tract infections |
| Trauma |
| Sickle cell crisis |
| Pneumonia |
| Diabetic Ketoacidosis |
| Mesenteric adenitis |
References:
- Tan, TQ, Mason, EO Jr, Barson, WJ, et al. Clinical characteristics
and outcome of children with pneumonia attributable to penicillin-susceptible
and penicillin-nonsusceptible Streptococcus pneumoniae. Pediatrics
1998; 102:1369.
- Moustaki M, Zeis PM, Katsikari M, et al. Mesenteric lymphadenopathy
as a cause of abdominal pain in children with lobar or segmental pneumonia
Pediatr Pulmonol. 2003 Apr;35(4):269-73.
- Kanegaye JT, Harley JR. Pneumonia in unexpected locations: an occult
cause of pediatric abdominal pain. J Emerg Med. 1995 Nov-Dec;13(6):773-9.
Online Review Article References:
http://www.aafp.org/afp/20030601/2321.pdf |
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