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Probability diagnosis

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Infant ‘colic’ (2–16 weeks)

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Gastroenteritis (all ages)

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Mesenteric adenitis

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Serious disorders not to be missed

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Infection:

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  • acute appendicitis (mainly 5–15 years)

  • pneumonia (esp. right lower lobe)

  • pyelonephritis

  • peritonitis

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Cancer:

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  • colon cancer (rare)

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Other:

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  • intussusception (peaks at 6–9 months)

  • bowel obstruction

  • coeliac disease

  • strangulated inguinal hernia

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Pitfalls (often missed)

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Child abuse

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Constipation

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Torsion of testes

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Lactose intolerance

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Peptic ulcer

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Infection: mumps, tonsillitis, pneumonia (esp. right lower lobe), EBM, UTI, hepatitis

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Adnexal disorders in females (e.g. ovarian)

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Rarities:

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  • Meckel diverticulitis

  • Henoch–Schönlein purpura

  • inflammatory bowel disease

  • sickle crisis

  • lead poisoning

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Masquerades checklist

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Diabetes mellitus

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Drugs

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UTI

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Psychogenic consideration

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Important cause

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Key history

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Differentiate the severe problems demanding surgery from the non-surgical ones. About 1 in 15 will have a surgical cause for pain. The causes are often age specific so a family history is important.

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Key examination

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  • Note general appearance, vital signs and oral cavity

  • Abdominal examination: inspection, auscultation, palpation and percussion (in that order)

  • Rectal examination is mandatory: look for constipation including impacted faeces

  • Examine lungs, especially if lower lobe pneumonia suspected

  • Consider gentle abdominal palpation with a soft toy

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Key investigations

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  • Rule out urinary infection with urinalysis. Blood, protein and leucocytes may all be present with acute appendicitis. Nitrites are more specific for UTIs

  • FBE/ESR/CRP

  • Scanning according to findings

  • Imaging (e.g. oxygen/barium enema) as appropriate

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Diagnostic tips

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  • Consider mesenteric adenitis in a flushed febrile child with an URTI or tonsillitis.

  • Vomiting occurs in at least 80% of children with appendicitis and diarrhoea in about 20%.

  • A pale infant with severe colic and vomiting indicates acute intussusception.

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