J. R. CoIl. Surg. Edinb., 43, December, 390—392

The diagnostic value of symptoms and signs in childhood abdominal pain

N.M. A. WILLIAMS, J. M. JOHNSTONE AND N. W. EVERSON
Department of Surgery, Leicester Royal Infirmary, Leicester, UK

The assessment and diagnosis of abdominal pain in childhood continues to be a clinical challenge. We audited the presenting symptoms and signs in a consecutive series of 447 children presenting to a paediatric surgical unit in an attempt to quantify the value of particular symptoms and signs in differentiating acute appendicitis (AA) from non-specific abdominal pain (NSAF). The onset of pain in the centre of the abdomen and radiation of pain was not sufficient to differentiate between NSAP and AA. Progression of pain, nausea, vomiting, anorexia and diarrhoea were significantly more common in children with AA (P < 0.01). Similarly, facial flushing, tachycardia (pulse >100 beats/min), guarding and rebound tenderness were significantly more common in children with AA (P < 0.001). Knowledge of this quantitative data could help clinicians adjust the weighting given to the presence of a particular symptom or sign in children with acute abdominal pain.

Keywords: abdominal pain, appendicitis, diagnosis, non-specific abdominal pain, symptoms.

Over a 1-year period, one child in 250 under 12 years of age will be admitted to hospital and one in 500 will undergo emergency surgery.1 Abdominal pain is a common problem in childhood, although it is clearly apparent that not all children with abdominal pain will have a surgical problem requiring an emergency operation.2 It is this fact which makes the diagnosis and management of abdominal pain in childhood an ongoing clinical challenge. To examine this in greater detail, we audited data relating to symptoms and physical findings on examination for all paediatric admissions with abdominal pain over a 12-month period.

METHOD

This is the only hospital in Leicester with a provision for paediatric surgical care, serving an under 15-year-old childhood population of 173 000 (OPCS data for 1995). The case notes of all children with abdominal pain admitted over a 12-month period (1994) were retrieved and data was transcribed onto a prepared proforma. This data was subsequently inputted into a commercially available software package for numerical and statistical analysis. Data analysis to compare variables between patient groups was by x2 test.

Patient groups

In the study period, 447 children with abdominal pain were admitted to this paediatric surgical unit. There were 238 (53.2%) boys and 46 children (11.5%) were under 5 years of age. To facilitate data analysis and for ease of comparison between groups of children with differing diagnoses, this cohort has been placed into five groups:

In this study we compared and contrasted the presenting symptoms and signs between group 1 and group 2 in an attempt to more accurately define those clinical features which are more suggestive of acute appendicitis. Data from those children in group 2 who had a normal appendix removed (group 2a) was compared with those found to have histologically proven AA (group 2b).

RESULTS

The crude annual admission rate of all children in the region was one in 390 and the appendicectomy rate was one in 1350. There were 120 boys (53.8%) and 103 girls (46.2%) in group 1 and 67 boys (52%) and 61 girls (48%) in group 2. The under 5 year-olds accounted for 6.4% of group 1 and 6.2% of group 2.

Non-specific abdominal pain versus appendicectomy (Table 1)

Symptoms

There was no difference in site of Onset of pain (central or right-sided) between group 1 and group 2 (74 vs. 75%), neither was there any difference between the groups for children presenting with central abdominal pain on admission (54 vs. 48%). By contrast, right iliac fossa pain was the site of presentation in 2 7.3% of children with NSAP but in 45% of children with AA (P < 0.05). The pain was aggravated by movement in 16% of children with NSAP and in 41% of children with AA (P < 0.001). Bowel habit was normal in 79% of children with NSAP and 68% of children with AA (F> 0.1} whereas diarrhoea was present in 13 and 23%, respectively (P < 0.02). The presence or absence of urinary symptoms was not significant between the groups.

Signs

Children with AA were more likely to be anxious or flushed, whilst children with NSAP were more likely to have a normal appearance. Tachycardia was significantly more prevalent in children with AA. Tenderness was confined to the right iliac fossa in 37% of children with NSAP but in 70% of children with AA (P < 0.01). Guarding and rebound tenderness were less prevalent in children with NSAP. Bowel sounds were present and normal in 95% of children with NSAP and in 90% of children with AA (P= NS) and, therefore, was not suitable for differentiation between the two diagnoses.

Table 1 Frequency of symptoms present in children with NSAP and AA

Symptom NSAP
(n=233)		 AA
(n=128)		 x2 P=
Pain        
Colicky 60 14 8.46 <0.01
Steady 46 73 22.5 <0.001
Central or right side 177 106 0.06 NS
Radiation of pain 11 13 3.02 NS
Pain progressing worse 34 51 15.7 <0.001
Nausea present 123 104 5.01 <0.05
Vomiting 93 98 11.2 <0.001
Anorexia present 67 85 15.4 <0.001
Diarrhoea present 30 29 3.44 NS
Dysuria present 23 20 1.65 NS
Anxious or distressed 26 62 33.1 <0.001
Flushed 46 61 14.3 <0.001
Pulse>100min-1 50 63 13.1 <0.001
Rebound tenderness 16 52 37.2 <0.001
Guarding 17 65 52.8 <0.001

 

Normal versus inflamed appendix (Table 2)

Symptoms

There were no significant differences between children with a normal appendix (group 2a) and those with an inflamed appendix (group 2b) for site of pain at onset (right iliac fossa, 74 vs. 68%), no radiation of pain (61 vs. 83%) or aggravation by movement or coughing (35% vs. 44%). Similarly, duration of pain was 1 day or less in 56% and 58%, respectively (P= NS). Diarrhoea was significantly more common in children with an inflamed appendix, and urinary symptoms were equally common in both groups. Curiously, 40% of children with a normal appendix had had previous similar pain prior to the event admission (compared with 16% of those in group 2b, P< 0.02).

Signs

More children with an inflamed appendix had a temperature >37.10 C compared with children with a normal appendix. Tachycardia was not able to differentiate the two groups (P> 0.1). Palpable tenderness in the right iliac fossa was equally prevalent in both groups (74 vs. 75%) as was percussion tenderness (26 vs. 45%, P < 0.01). Guarding, however, was significantly more common in group 2b (30 vs. 54%, P < 0.05).

Of the investigations performed (midstream urine, full blood count), urine was normal in 70% of both groups. By contrast, a white cell count >12 x 106 was present in 26% of group 2a but in 51% of group 2b (P < 0.05).

Table 2 Frequency of symptoms and signs in children with a normal and those with an inflamed appendix

Symptom/sign Group 2a Group 2b x2 P=
Pain        
Intermittent 9 35 3.81 <0.05
Steady 78 52 1.31 <0.5
Nausea (yes) 65 85 4.18 <0.05
Vomiting (yes) 57 82 9.37 <0.01
Anorexia present 57 70 1.55 <0.5
Diarrhoea 9 69 27.8 <0.01
Anxious or distressed 25 51 2.22 <0.1
Temperature        
<370C 52 33 2.96 <0.05
>37.10C 44 63 2.95 <0.05
Pulse>100 beats/min 22 37 1.94 >0.1
Rebound tenderness 26 45 2.76 >0.1
Guarding 30 54 4.15 <0.05
White cell count>12 26 51 4.67 <0.05

DISCUSSION

Management of the child (or adult) with acute abdominal pain continues to remain a source of dilemma, debate and controversy; the major dilemma being whether the patient has a problem requiring surgery.3-6 When Fitz first described the condition of AA in 1886 his clinical report was based on a careful history and the gentle but astute elicitation of physical signs.7 However, not all patients with right iliac fossa pain have AA and NSAP, therefore, is the alternative diagnosis.2 Distinguishing between NSAP and other conditions requiring surgical intervention has been the focus of much attention.3 Interestingly, recent publications and reviews have focused on investigations and other diagnostic tests in improving diagnostic accuracy.7-16 However, Jones succinctly addresses this trend:

... although new investigations can provide welcome assistance, the assessment of the acute abdomen must continue to be predominantly a bedside exercise. No computer can provide reliable feedback without being provided with the details of an accurate history and a skilful, gentle elicitation of the physical signs.3

In the present study, we have focused on the clinical history and the examination findings and their discriminative value.

Whether abdominal pain was colicky or steady, helped differentiate between AA and NSAP. However, pain being described as steady was not quite as discriminating between children with histologically proven AA and those who had undergone removal of a normal appendix. Progression of pain, nausea, vomiting and anorexia were all symptoms that could usefully help to distinguish children with AA from those with NSAP. Surprisingly, the prevalence of anorexia, tachycardia and rebound tenderness were not significantly different between those children with a normal appendix removed and those who had histologically proven appendicitis (Table 2).

In the present study, we have evaluated the relative prevalence of symptoms and signs present in children with acute abdominal pain, and have compared those having appendicectomy with those presumed to have NSAP. The clinician may then adjust the weighting given to the presence or absence of a symptom or sign. Management of acute abdominal pain remains a clinical discipline and although the portfolio of investigations appears to be expanding,17 these have to be evaluated in the light of the full clinical picture.18,19 It is this simple fact that makes management of acute abdominal pain an ongoing challenge.

REFERENCES
  1. Winsey HF, Jones PF. Acute abdominal pain in childhood: analysis of a year’s admissions. Br Med J 1967; i: 653—5.
  2. Jones PF. Acute abdominal pain in childhood, with special reference to cases not due to acute appendicitis. Br MedJ 1969; i: 284—6.
  3. Jones PF. Practicalities in the management of the acute abdomen. BrJ Surg 1990; 77: 365—7.
  4. Sutton C. Computer-aided diagnosis: a review. BrJ Surg 1989; 76: 82—5.
  5. Hoffman J, Rasmussen 00. Aids in the diagnosis of acute appendicitis. BrJSurg 1989; 76: 774-9.
  6. Paterson-Brown S, Vipond MN, Gatzen C, Thompson IN, Dudley HAF. Clinical decision making and laparoscopy versus computer prediction in the management of the acute abdomen. BrJSurg 1989; 76:1011—13.
  7. Fitx RH. Perforating inflammation of the vermiform appendix with special reference to early diagnosis and treatment. AmJMed Sci 1886; 92: 321—5.
  8. Doraiswamy LV. Leucocyte count in the diagnosis and prognosis of acute appendicitis in children. BrJ Surg 1979; 66: 782—4.
  9. Thompson MM, Underwood MI, Dookeran KA, Lloyd DM, Bell PRF. Role of sequential leucocyte counts and C-reactive protein measurements in acute appendicitis. BrJSurg 1992; 79: 822—4.
  10. Goodwin AT, Swift RI, Bartlett MJ, Fernando BS, Chadwick SJD. Can serum inrerleukin-6 levels predict the outcome of patients with right iliac fossa pain? Ann Roy Coll Surg EngI 1997; 79: 130—3.
  11. Eisenberg RL, Heinekin P, Hedgeock MW, Federle M, Goldberg HI. Evaluation ofplain abdominal radiographs in the diagnosis of abdominal pain. Ann Intern Med 1982; 97: 257—61.
  12. Rubin SZ, Martin DJ. Ultrasonography in the management of possible appendicitis in childhood. JPaed Surg 1990; 25: 737—40.
  13. Wong ML, Casey SO, LeonidasJC, Elkowitz SS, BeckerJ. Sonographic diagnosis of acute appendicitis in children. JPaed Surg 1994; 68:179—60.
  14. Puyaert JBCM, Rutgers PH, Lalisang RI etal. A prospective study of ultrasonography in the diagnosis of appendicitis. N EngJ Med 1987;317: 666-9.
  15. Jona JZ, Belin RP, Selke AC. Barium enema as a diagnostic aid in children with abdominal pain. Surg Gynecol Obstet 1977; 144: 351—5.
  16. Gelfand DW. What is the role of barium enema in the patient with suspected appendicitis? AJR 1995; 164: 762—3.
  17. Sugarbaker PH, Bloom BS, Sanders JH, Wilson RE. Pre-operative laparoscopy in diagnosis of abdominal pain. Lancet 1975; i: 442—5.
  18. Paterson-Brown S, Vipond MN. Modern aids to clinical decision-making in the acute abdomen. BrJSurg 1990; 77:13—8.
  19. Williams N. Peritoneal aspiration cytology as a diagnostic aid in acute appendicitis. BrJSurg 1994; 81:1083-4.

Paper accepted on 29 January 1998

Correspondence: Mr J. M. Johnstone, Department of Surgery, Leicester Royal Infirmary, Leicester LE1 5WW, UK

© 1998 The Royal College of Surgeons of Edinburgh, J. R. CoIl. Surg. Edinb., 43, December, 390—392