Summary
Urgent Considerations
Gastrointestinal (GI) emergencies
- Untreated acute appendicitis may progress to ischemia, necrosis, and eventually perforation. The clinician may encounter a range of presentations. Patients often complain of abdominal pain localized to the right lower quadrant; in more severe cases the pain may be diffuse (e.g., if perforation results in generalized peritonitis).
- Perforation should be considered when a patient presents with a long duration of symptoms and/or suspected appendicitis with marked systemic signs of illness (e.g., high fever [>101°F, 38.3°C]), tachycardia, and anorexia).
- Ultrasound (US) is the preferred diagnostic study (avoids radiation exposure).[66] In children, specificity of ultrasound is similar to that of computed tomography (CT) (0.91 vs. 0.92); CT has greater sensitivity than US (0.96 vs. 0.89).[67] The overall sensitivity and specificity of either US or CT scans in differentiating perforated from nonperforated appendicitis is not very good.[66] [68]
- Treatment (antibiotics and possibly surgery) of acute or perforated appendicitis should be instituted promptly, but the condition is more urgent than emergent. Once antibiotics are administered, appendectomy for out-of-hours cases selected for operative management can be safely deferred until the following day.[13] [14]
- Appendectomy can be done with an open approach or laparoscopically. Laparoscopic appendectomy is associated with lower postoperative pain, lower incidence of surgical site infection, and higher quality of life in children.[13] Referral to a children's hospital or a pediatric surgeon should be considered for children younger than 5 years of age.[69]
- Urgency of intervention is dependent on the clinical severity of the obstruction.
- Strangulated obstructions are usually complete obstructions in which the blood supply to the bowel is cut off as a result of edema, twisting of the bowel, or adhesions. These usually demonstrate diffuse or local peritonitis, fever, and leukocytosis. Untreated, they progress to intestinal necrosis and/or perforation. Urgent surgical treatment is mandatory.
- Nonstrangulated obstructions involve a loop of bowel that is partially or completely obstructed but has an adequate blood supply and is not necrotic. This type of obstruction is usually not associated with peritonitis, fever, or leukocytosis, but may be associated with abdominal distension, nausea, and vomiting. Although surgical intervention may be necessary, it is usually not urgent. However, prolonged delay may progress to strangulation.
- May lead to venous obstruction and bowel-wall edema and can progress, if untreated, to bowel necrosis, perforation, and, rarely, death.[70] [71] Treatment should be initiated at the time of diagnosis. The goal is correction of hypovolemia and electrolyte abnormalities, and antibiotic administration, followed by urgent reduction.
- Reduction can be accomplished with a radiographic enema study (air is preferred over contrast reagent) or by surgery.[72]
- Malrotation with midgut volvulus is a surgical emergency, and bilious vomiting in any child should prompt concern for this condition until confirmed otherwise.
- With a corresponding history and physical exam (bilious vomiting and feeding difficulty, especially in infants during the first month of life), no further diagnostic intervention is necessary, and prompt surgical exploration is recommended.
- Ambiguous cases may proceed to an upper GI contrast study (the gold standard test). However, this should not preclude surgical intervention if clinical suspicion is high.
- Prompt attention should be paid to an incarcerated inguinal or umbilical hernia due to the danger of bowel strangulation (compromise of blood flow to the bowel with consequent bowel ischemia and gangrene). Incarceration, with or without strangulation, occurs if intra-abdominal contents become trapped in the protruding hernia sac.
- Clinically, the hernia is irreducible and tender. Associated symptoms may include nausea, vomiting, and generalized abdominal pain. In severe cases, fever, abdominal distension, and skin changes may be present.
- Peritonitis is a contraindication to attempted nonoperative reduction.
- If strangulation is evident, surgery is required urgently to resect the gangrenous segment of bowel.
- The most common medical/surgical emergency affecting neonates, particularly premature infants, especially those weighing less than 1500 g.[28]
- Signs and symptoms include feeding intolerance, apnea, lethargy, bloody stools, abdominal distension, tenderness, abdominal wall erythema, and bradycardia.
- Early intervention is mandatory to prevent morbidity and mortality due to multiple organ impairment. Treatment may be medical or surgical, and is determined by severity of the clinical presentation.
Genitourinary emergencies
- If undiagnosed or incorrectly managed, a ruptured ectopic pregnancy may lead to maternal death due to rupture of the implantation site and intraperitoneal hemorrhage.
- The classic presentation includes lower abdominal pain, amenorrhea, and vaginal bleeding. Patients with a positive urine pregnancy test and the absence of an intrauterine pregnancy on transvaginal ultrasound are considered to have an ectopic pregnancy until confirmed otherwise.
- A quick and focused ultrasonographic exam to assess for the presence of free fluid or blood may be helpful when this diagnosis is suspected, but this should not delay other care.
- Hemodynamic instability associated with a ruptured ectopic pregnancy results from severe hypovolemia secondary to blood loss. As such, the management of these patients involves stabilization with emergency fluid resuscitation and immediate transfer to the operating room. Rapid volume repletion with isotonic solution and blood products is of paramount importance to avoid ischemic injury and multi-organ damage.
- Urgent laparoscopy with salpingectomy or salpingostomy is performed for a ruptured ectopic pregnancy.
- Twisting or torsion of the ovary compromises the arterial inflow and venous outflow, producing ischemia, which, if not relieved, can affect the viability of the ovary.
- It presents with acute-onset lower abdominal pain and, frequently, nausea and vomiting. Symptoms may be intermittent and fluctuate in severity.
- It is not known how long an ovary can withstand ischemia without permanent damage (it may be up to 72 hours or even longer), but definitive operative intervention should be undertaken as soon as possible.[77] [78] A delay in the timing of surgery is associated with a reduction in the possibility of ovarian salvage.[79]
- Should be ruled out in any male child presenting with abdominal pain. The twisting of the testis and spermatic cord causes obstruction of arterial inflow and venous drainage from the testis.
- It typically presents with sudden-onset testicular pain; however, younger boys may only complain of abdominal tenderness, nausea, and/or vomiting.
- Physical findings suggestive of testicular torsion include loss of the cremasteric reflex, diffuse testicular tenderness, elevated testes, and a horizontal rather than vertical position of the testes.
- Prompt recognition and early surgical intervention are necessary to prevent testicular loss. Manual detorsion may be attempted while preparations for surgery are being made.
Sepsis
- Patients with intra-abdominal sepsis may present with abdominal pain.[84]
- Sepsis is a spectrum of disease where there is a systemic and dysregulated host response to an infection.[85]
- Presentation ranges from subtle, nonspecific symptoms (e.g., feeling unwell with a normal temperature) to severe symptoms with evidence of multi-organ dysfunction and septic shock. Patients may have signs of tachycardia, tachypnea, hypotension, fever or hypothermia, poor capillary refill, mottled or ashen skin, cyanosis, newly altered mental state, or reduced urine output.[86]
- Sepsis and septic shock are medical emergencies.
- In children, risk factors for sepsis include: age under 1 year, impaired immunity (due to illness or drugs), recent surgery or other invasive procedures, any breach of skin integrity (e.g., cuts, burns), and indwelling lines or catheters.[86]
- Early recognition of sepsis is essential because early treatment - when sepsis is suspected but is yet to be confirmed - is associated with significant short- and long-term benefits in outcome.[86] However, detection can be challenging because the clinical presentation of sepsis can be subtle and nonspecific. A low threshold for suspecting sepsis is therefore important.
- The key to early recognition is the systematic identification of any patient who has signs or symptoms suggestive of infection and is at risk of deterioration due to organ dysfunction. Several risk stratification approaches have been proposed. All rely on a structured clinical assessment and recording of the patient's vital signs.[86] [87] [88] [89] It is important to check local guidance for information on which approach your institution recommends.
- The timeline of ensuing investigations and treatment should be guided by this early assessment.[89]
- Treatment guidelines have been produced by the Surviving Sepsis Campaign and remain the most widely accepted standards.[90] Within the first hour:[90]
- Follow institutional protocols for management of sepsis/septic shock in children; these improve the speed and reliability of care
- Obtain blood cultures before administering antibiotics (provided this does not substantially delay antibiotic administration)
- Administer broad-spectrum antibiotics
- Administer ≤40-60 mL/kg crystalloid, in boluses of 10-20 mL/kg, titrated to clinical signs of cardiac output and stopped if there is evidence of volume overload
- Use trends in blood lactate levels to guide resuscitation. If the child's hypotension is refractory to fluid resuscitation, consider use of vasopressors.
Etiology
Gastrointestinal
- A common condition, with a reported pooled prevalence of 9.5%.[1]
- Symptoms usually result from low-fiber, poor-nutrient intake, and too little water, which leads to high levels of colonic reabsorption of water and hardening of the stool. Additional risk factors include genetic predisposition, infection, stress, obesity, low birth weight, cerebral palsy, spina bifida, and learning difficulties.
- Constipation starts as an acute problem but can progress to fecal impaction and chronic constipation.
- It tends to develop during three stages of childhood: weaning (infants), toilet training (toddlers), starting school (older children).
- Characterized by paroxysms of uncontrollable crying in an otherwise healthy and well-fed infant ages <5 months. The duration of crying is >3 hours per day, and >3 days per week, for at least 3 weeks.[4]
- The crying typically starts in the first weeks of life and ends by 4-5 months of age.
- Food allergy may play a role in the pathogenesis.
- Colic occurs equally in both male and female infants.[5] Infants with colic tend to have siblings who also have this condition.
- Develops when the appendiceal lumen becomes obstructed by stool, barium, food, or parasites.
- Can occur in all age groups, but is rare in infants. A cohort study in Sweden found that 2.5% of children had had appendicitis by age 18 years.[6]
- If left untreated, acute appendicitis may progress to ischemia, necrosis, and eventually perforation. The overall rate of perforation is about 30%.[7]
- Stump appendicitis may occur after an appendectomy when the residual stump is >0.5 cm. It can occur after both open and laparoscopic surgery.[16]
- May be due to acute or chronic viral infection (especially rotavirus), or bacterial or parasitic infection.
- Causes vague, cramping abdominal pain in association with fever, vomiting, and diarrhea.
- Eosinophilic gastroenteritis, defined as a condition affecting the GI tract with eosinophil-rich inflammation without a known cause for the eosinophilia, can result in significant abdominal pain.[17]
- Hemolytic uremic syndrome, characterized by microangiopathic hemolytic anemia, thrombocytopenia, and nephropathy, can occur as a complication of gastroenteritis caused by verotoxin-producing Escherichia coli. Abdominal pain is a common presenting symptom.[18]
- Occurs when a proximal segment of the intestine telescopes into the lumen of an immediately distal segment. In most cases, the intussusception is in the ileocecal area.
- Usually occurs in infants between 3 and 12 months of age. Peak incidence is 5-7 months of age.[19]
- Intussusception should be suspected in an infant in this age group presenting with colicky abdominal pain, flexing of the legs, fever, lethargy, and vomiting.
- In infants <2 years of age, episodes of intussusception are most likely caused by mesenteric lymphadenopathy secondary to an associated illness (e.g., viral gastroenteritis). In older children, mesenteric lymphadenopathy is still the most likely cause, but other etiologies should be considered (e.g., intestinal lymphomas, Meckel diverticulum). Therefore, children ≥6 years or with jejunojejunal or ileoileal intussusception should be evaluated for a pathologic lead point.
- Ileoileal intussusception may also be indicative of Henoch-Schonlein purpura (HSP). HSP is a vasculitis that affects small veins and primarily occurs in children <11 years of age.
- Occasionally, an ultrasound exam will show small-bowel to small-bowel intussusception. If there are no obstructive symptoms, and the wall of the bowel is normal, with length <3.5 cm, and normal vascularity with no colonic involvement, then these findings are usually transient and require no further intervention.[20]
- A finger-like projection located in the distal ileum arising from the antimesenteric border; usually 40-60 cm from the ileocecal valve, measuring 1-10 cm long and 2 cm wide.Image
- The majority of symptomatic patients present before the age of 2 years.
- Meckel diverticulum is a common cause of pediatric gastrointestinal bleeding and should be considered if there is painless rectal bleeding.
- The prevalence is estimated to be up to 3%.[21]
- Refers to inflammation of the mesenteric lymph nodes. This process may be acute or chronic.
- It is often mistaken for other diagnoses, such as appendicitis; up to 23% of patients undergoing negative appendectomy have been found to have nonspecific mesenteric adenitis.[24]
- One retrospective study reported that, compared with children who have appendicitis, patients who have mesenteric adenitis are more likely to have high fever (above 102.2°F [39°C]) and dysuria, and are less likely to have migratory pain, vomiting, or typical abdominal signs of appendicitis on examination.[25]
- Most commonly diagnosed in the first year of life but can present later in childhood; higher male preponderance in the most common anatomic variant (rectosigmoid disease).
- Congenital condition characterized by partial or complete colonic obstruction associated with the absence of intramural ganglion cells. Because of the aganglionosis, the lumen is tonically contracted, causing a functional obstruction. The aganglionic portion of the colon is always located distally, but the length of the segment varies.Image
- May be associated with Down syndrome and multiple endocrine neoplasia type IIA.
- Small or large bowel obstruction may be the result of various etiologies and can occur at any age. Abdominal pain may not occur until the obstruction has progressed to include extensive abdominal distension or intestinal ischemia. Intestinal obstruction may mimic intestinal ileus, which usually does not require surgical intervention.
- Intestinal obstruction in a child without a history of prior surgery is traditionally considered an indication for surgery.
- The etiology of intestinal obstruction can be congenital or acquired. Congenital causes include atresias or stenosis, which present in the newborn period. Acquired causes include small bowel adhesions, strangulated or incarcerated hernias, and tumors.
- Congenital causes:
- Duodenal atresia or stenosis may cause complete or partial obstruction of the duodenum as a result of failed recanalization during development. This results in either stenosis with incomplete obstruction of the duodenal lumen (allowing some but not all gas and liquid to pass) or an atresia where the duodenum ends blindly causing a true complete obstruction.
- Jejunoileal atresia or stenosis is a complete or partial obstruction of any part of the jejunum or ileum. Although uncertain, it is believed to result from a vascular accident during development. Jejunal stenosis may still have bowel lumen continuity with a narrowed lumen and thickened muscular layer. There are four types of atretic bowel: type I, an obstructing web or septum with intact bowel wall and mesentery; type II, an atretic cord of remnant bowel with an intact mesentery; type IIIa, a missing atretic segment with a mesenteric defect; type IIIb, atresia with the distal bowel coiled ("apple peel") around a distal mesenteric vessel; and type IV, multiple segmental atresias ("sausage-links").
- Hernias may be internal or external and congenital (most commonly in children) or acquired.
- Colonic atresia is a rare complete obstruction of any part of the colon, although it usually occurs near the splenic flexure. Like jejunoileal atresia, it is thought to occur as a result of a vascular event.Image
- Meconium ileus is an important cause of intestinal obstruction in the neonatal period; cystic fibrosis should be suspected as an associated disease. There may be associated pancreatic abnormalities.
- Duplication cysts occur most commonly in the small intestine; they may serve as a lead point for volvulus and intussusception and can also result in obstruction. In the presence of duodenal duplication cysts, peptic ulcer disease, hemorrhage, or perforation may result secondary to ectopic gastric mucosa.
- Acquired causes:
- May occur at any age.
- Tumors may be intraluminal or extra-intestinal.
- Hernias may be internal or external and congenital or acquired (e.g., prior operation, incisional, traumatic).Image
- A history of previous intra-abdominal surgery or inflammation (such as necrotizing enterocolitis) should prompt concern for adhesive small bowel obstruction.
- Bowel obstruction without previous surgical or inflammatory history in the pediatric population should raise concern for etiologies such as a mass or cyst that requires intervention.
- Omental cysts, although rare, can present with intestinal obstruction; may be confused with ovarian cysts on ultrasound.
- In patients with cystic fibrosis, partial bowel obstruction may sometimes be referred to as distal intestinal obstruction syndrome (DIOS, formerly known as meconium ileus-equivalent syndrome). DIOS is not related to meconium. It refers to a distal small bowel obstruction caused by impacted bowel contents that typically occurs in adolescents and adults with cystic fibrosis.
- This can occur in any age group but is most common in children <1 year old; at least 60% of children present before 1 month of age.[26] Midgut volvulus is the most common type.
- Green (bilious) vomiting is a cardinal symptom of duodenal obstruction secondary to midgut volvulus.[26]
- Intestinal malrotation is a term used to encompass the entire spectrum of anatomic arrangements that result from incomplete rotation of the gut during embryonic development. Volvulus of the entire small bowel and part of the colon is only possible when malrotation exists.
- In malrotation, the most significant pathologic concerns are a lack of gut fixation to the retroperitoneum and narrow midgut mesenteric base that predisposes patients to midgut volvulus, which occurs when the duodenum or colon twist around this mesenteric base.
- Colonic volvulus (sigmoid or cecal) is rare.[27] It usually occurs in children with a history of chronic constipation, in dysmotility disorders, or in patients who have cognitive deficits with limited mobility.
- A disease primarily of premature infants, particularly those weighing less than 1500 g.[28] The pathogenesis is multifactorial and not well understood, although ischemia, reperfusion injury, and infectious pathogens may play a role.
- Typical symptoms are feeding intolerance, abdominal distension, and bloody diarrhea at approximately 1-2 weeks of age.[29] Other signs and symptoms include apnea, lethargy, abdominal tenderness, abdominal wall erythema, and bradycardia.
- Gastric and duodenal ulcers are uncommon among the pediatric population.[30] When they occur, they are classified as primary or secondary peptic ulcers.
- Primary ulcers occur without predisposing factors and are most commonly located in the duodenum or pyloric channel. They manifest most often in older children and adolescents with a positive family history. Rarely, primary peptic ulcers can occur in the first month of life, presenting with bleeding and possible perforation. Most are located in the stomach. Primary ulcers may be associated with Helicobacter pylori.
- Secondary ulcers are usually associated with stress, burns, trauma, infection, neonatal hypoxia, chronic illness, and ulcerogenic medications or lifestyle habits (e.g., nonsteroidal anti-inflammatory drugs [NSAIDs], salicylates, corticosteroids, smoking, or intake of caffeine, nicotine, or alcohol).[30] It is important to treat the predisposing condition. Exacerbations and remissions can last for weeks to months.
- Ulcerative colitis affects the rectum and extends proximally; it is characterized by diffuse inflammation of the colonic mucosa and a relapsing, remitting course. Ulcerative colitis is uncommon in children, but prevalence is increasing.[33]
- Crohn disease may involve any or all parts of the entire GI tract from mouth to perianal area. Unlike ulcerative colitis, Crohn disease is characterized by skip lesions. The transmural inflammation often leads to fibrosis, causing intestinal obstruction. The inflammation can also result in sinus tracts that burrow through and penetrate the serosa, giving rise to perforations and fistulas. Onset of Crohn disease typically occurs in the second to fourth decade of life.[34] [35] [36]
- Ulcerative colitis often presents with bloody diarrhea, whereas this is an unusual presentation in Crohn disease. Both conditions cause cramping abdominal pain, anorexia, and weight loss when they present late in the course of the disease. Depending on the intestinal location of Crohn disease, it may mimic other disease processes such as acute appendicitis.
- IBD in the pediatric population can start with very subtle signs that are difficult to interpret. IBD should be considered for any vague, ongoing chronic abdominal pain combined with a slowing of the patient's normal growth curve.
- Systemic autoimmune disease triggered by dietary gluten peptides found in wheat, rye, barley, and related grains.
- Immune activation in the small intestine leads to villous atrophy, hypertrophy of the intestinal crypts, and increased numbers of lymphocytes in the epithelium and lamina propria. Locally these changes lead to GI symptoms and malabsorption.
- Celiac disease is a common disorder in the US and in Europe. A relatively uniform prevalence has been found in many countries, with pooled global seroprevalence and biopsy-confirmed prevalence of 1.4% and 0.7%, respectively.[37]
- Patients may present with recurrent abdominal pain, cramping, or distension.[38] Other common symptoms include bloating and diarrhea. Dermatitis herpetiformis, an intensely pruritic papulovesicular rash that affects the extensor limb surfaces, almost universally occurs in association with celiac disease.[39]
- Cholelithiasis describes the entity of stones in the gallbladder (usually asymptomatic or an incidental finding). Biliary colic refers to the classic description of intermittent, recurrent right upper quadrant (RUQ) pain that resolves without intervention. This is usually caused by intermittent obstruction of the cystic duct due to cholelithiasis and contraction of a distended gallbladder.Images
- Cholecystitis refers to inflammation of the gallbladder precipitated by obstruction of bile through the cystic duct. Symptoms do not usually resolve spontaneously, and there are specific findings on diagnostic imaging. Cholecystitis may be acalculous (without stones) or calculous (with stones). Choledocholithiasis is the term describing a gallstone(s) in the common bile duct.
- Characterized by symptoms of biliary colic (intermittent, recurrent RUQ pain that resolves without intervention) in the absence of documented stones in the gallbladder; the diagnosis should be considered in those with symptoms suggestive of biliary colic but with negative laboratory tests and ultrasound in their workup for symptomatic cholelithiasis.
- Caused by abnormal or altered contraction of the gallbladder resulting in biliary colic. Patients frequently have gone through a comprehensive workup prior to being diagnosed with this entity; increasing recognition and testing for the disease has led to more frequent diagnosis in children.[40]
- The viral hepatitides include A, B, C, D, and E.
- Hepatitis A virus remains a significant cause of acute viral hepatitis and jaundice, particularly in developing countries, in travelers to those countries, and in sporadic food-borne outbreaks in developed countries.
- Hepatitis B virus (HBV) frequently causes acute hepatitis and is the most common cause of chronic hepatitis in Africa and the Far East.
- Hepatitis C virus (HCV) represents the leading cause of chronic viral hepatitis in developed countries.
- Hepatitis D virus is a defective virus that needs the presence of hepatitis B to cause clinically recognizable disease.
- Hepatitis E virus represents a major cause of mortality in developing countries, especially among pregnant females.
- Refers to inflammation of the pancreas; it does not necessarily imply that infection is present.
- Pancreatitis in children is often due to drugs, infection, anatomic abnormalities, or trauma.[41] Corticosteroids, adrenocorticotropic hormones, estrogens including contraceptives, azathioprine, asparaginase, tetracycline, chlorothiazides, and valproic acid may induce pancreatitis. Congenital causes include choledochal cyst causing abnormal pancreas and bile drainage and pancreas divisum. Infectious causes include mumps and infectious mononucleosis.
- Excessive alcohol and gallstones are the most common causes of pancreatitis in adults; these causes are relatively less common in children, although they may still occur. Pediatric pancreatitis is rare, but the growing population of children with gallstones will likely increase future incidence.Image
- Cysts are classified as either primary or secondary (acquired). Primary cysts are usually congenital and have a true epithelial lining. Eighty percent of splenic cysts are pseudocysts related to infection, infarction, or trauma.[42] Most cysts are incidental diagnoses, although some patients may present with dull, left-sided abdominal pain. In pediatric patients, the most common splenic masses are congenital and/or acquired cysts.[43]Images
- Splenic infarction occurs when there is occlusion of the splenic blood supply. It may affect the whole organ or only a portion of the spleen, depending on the blood vessels involved. The incidence of splenic infarction is difficult to assess.
- A multicenter prospective study found that abdominal trauma accounted for 3% of admissions to pediatric trauma units.[44]
- Generally classified as penetrating or blunt.
- Occult blunt abdominal trauma should always be considered in the setting of vague or inconsistent history. The liver, spleen, and kidneys are the most commonly injured intra-abdominal organs in blunt trauma. Most cases of blunt injury to the liver and spleen are managed nonoperatively.
- It is important to exclude duodenal and/or pancreatic injuries with bicycle handlebar injuries and/or direct blows to the abdomen. Hollow viscus injuries (e.g., stomach and intestines) are more common with penetrating trauma.
- It is essential to consider child abuse/nonaccidental trauma in this patient population.
Genitourinary
- Infection may arise along any part of the urinary tract including the urethra, bladder, ureter, and kidney. Diagnosis and treatment is paramount to prevent potential long-term adverse effects, including renal or urinary tract scarring and hypertension.
- Estimates of the true incidence of UTI depend on rates of diagnosis and investigation. UTI is more common in girls. UTIs affect approximately 4% and 10% of children by ages 1 year and 6 years, respectively.[45]
- Bacterial infections are the most common cause, particularly Escherichia coli infection.
- Dysmenorrhea, or painful menstruation, is one of the most common gynecologic conditions affecting females of reproductive age.[46]
- Primary dysmenorrhea is characterized by menstrual pain in the absence of pelvic pathology.
- Refers to stones that may be located anywhere in the genitourinary tract; the majority of stones are noted in the kidneys, followed by the bladder and ureter.
- Most patients have a predisposing factor, such as a family history of nephrolithiasis, high-risk diet (e.g., high oxalate intake), or chronic disease (e.g., renal tubular acidosis).
- Stones less than 5 mm in diameter will generally pass spontaneously.
- A urologic emergency caused by the twisting of the testicle on the spermatic cord, leading to constriction of the vascular supply and time-sensitive ischemia and/or necrosis of testicular tissue.Images
- Has a bimodal distribution, with extravaginal testicular torsion affecting neonates in the perinatal period, and intravaginal testicular torsion affecting males of any age but most commonly adolescent boys.[47]
- Systemic symptoms such as nausea and vomiting are not usually present. The thin skin of the scrotum sometimes allows visualization of the torsed appendage ("blue dot or black dot sign").
- The differential diagnosis includes pain from torsion of a testicular appendage; this may develop more gradually (over days to weeks) and frequently is pinpoint (superior pole of testes).
- Epididymitis can also mimic testicular torsion, but it is more gradual in onset with less severe symptoms.
- Although it can affect females of any age it most commonly occurs in the early reproductive years.[51]
- In children, torsion of the ovary is often associated with the presence of an ovarian tumor, most commonly a teratoma.
- Twisting or torsion of the ovary compromises the arterial inflow and venous outflow, producing ischemia, which, if not relieved promptly, can affect the viability of the ovary.
- Represents a spectrum of upper genital tract infections that includes any combination of endometritis, salpingitis, pyosalpinx, tubo-ovarian abscess, and pelvic peritonitis; usually caused by Neisseria gonorrhoeae or Chlamydia trachomatis and less commonly by normal vaginal flora including streptococci, anaerobes, and enteric gram-negative rods.
- PID is rare in the absence of sexual activity; PID in a young child should prompt workup for possible sexual abuse.
- Miscarriage and ectopic pregnancy should be a concern in any female of reproductive age presenting with lower abdominal pain, amenorrhea, and vaginal bleeding.
- Ectopic pregnancy occurs when a fertilized ovum implants and matures outside the uterine endometrial cavity, with the most common sites being the fallopian tube (97%), the ovary (3.2%), and the abdomen (1.3%).[57] Use of oral contraceptives before age 16 years is associated with increased risk of ectopic pregnancy.[58] The classic presentation includes lower abdominal pain, amenorrhea, and vaginal bleeding. Hemorrhage from a ruptured ectopic pregnancy can be fatal.
Pulmonary
Functional abdominal pain
- Typically affects children between 5 and 14 years of age.
- Prevalence estimates vary from 10% to 30% in samples of school students, to 87% in some gastroenterology clinics.[63]
- Family history of functional disorder common (irritable bowel syndrome, mental illness, migraine, anxiety).
- Clarifying the type of functional disorder is important to determine which treatments are most likely to improve symptoms.
- Defined as one or more of the following bothersome symptoms on at least 4 days per month: postprandial fullness, early satiation, epigastric pain, or burning not associated with defecation. After appropriate evaluation the symptoms cannot be fully explained by another medical condition.[60]
- Abdominal pain at least 4 days per month associated with one or more of:
- Related to defecation
- Change in stool frequency
- Change in stool form.
- In children with constipation, the pain does not resolve with resolution of constipation.
- After appropriate evaluation the symptoms cannot be fully explained by another medical condition.
- Paroxysmal episodes of intense, acute periumbilical, midline, or diffuse abdominal pain lasting at least 1 hour. The abdominal pain must be the most severe and distressing symptom.
- Episodes separated by weeks or months.
- Pain is incapacitating and interferes with normal activities.
- Stereotypical pattern and symptoms in the individual.
- Pain associated with 2 or more of:
- Anorexia
- Nausea
- Vomiting
- Headache
- Photophobia
- Pallor.
- After appropriate evaluation the symptoms cannot be fully explained by another medical condition.
- Episodic or continuous abdominal pain that does not occur solely during physiologic events (e.g., eating, menstruation)
- Insufficient criteria for irritable bowel syndrome, functional dyspepsia, or abdominal migraine diagnosis
- After appropriate evaluation the symptoms cannot be fully explained by another medical condition.
- Family history of inflammatory bowel disease, celiac disease, or peptic ulcer disease
- Persistent right upper or right lower quadrant pain
- Dysphagia
- Odynophagia
- Persistent vomiting
- Gastrointestinal bleeding
- Nocturnal diarrhea
- Arthritis
- Perirectal disease
- Involuntary weight loss
- Deceleration of linear growth
- Delayed puberty
- Unexplained fever.
Differential Diagnosis
Diagnostic Approach
History
- Neonates, infants, and toddlers: may present with abdominal pain caused by congenital causes or diseases linked to prematurity, such as necrotizing enterocolitis, Meckel diverticulum, Hirschsprung disease, volvulus, intestinal obstruction caused by congenital atresia, or stenosis. Intussusception is also common in this age group.
- School-age children: idiopathic constipation and infectious causes of pain are most common in this age group. Functional abdominal pain and abdominal migraine may also present in school-age children.
- Adolescents: conditions related to menstruation, sexually transmitted infections, and pregnancy should be considered. Testicular torsion, ovarian torsion, irritable bowel syndrome, and inflammatory bowel disease are more common in this age group.
- A useful mnemonic for abdominal pain is "CLAIR PRADER:" Characteristics, Location, Aggravating factors, Intensity, Relieving factors, Periodicity, Rhythmicity, Associations, Duration, Exacerbating factors, and Radiation.
- Onset, frequency, timing, and duration of the pain episode.
- Whether the pain is localized or diffuse: right lower quadrant (RLQ) pain suggests appendicitis; epigastric pain suggests peptic ulcer disease; diffuse pain may indicate perforation or peritonitis. Poorly localized pain that improves with movement is likely to be visceral pain from hollow organs. Well localized pain that worsens with movement is likely to arise from parietal peritoneum, parietal muscle, or skin.[92]
- Whether the pain radiates or migrates between areas of the abdomen: abdominal pain radiating to the back is suggestive of cholecystitis or pancreatitis; pain that begins centrally and migrates to the RLQ is typical of appendicitis.
- Any factors that make the pain better or worse, such as movement, defecation, food, or medication: in cholelithiasis/cholecystitis pain often occurs after eating (particularly fatty foods); epigastric pain due to peptic ulcer disease is usually related to eating meals; painful defecation may indicate constipation.
- The character of the pain: pain associated with peptic ulcer disease is dull rather than burning in nature; sharp or stabbing pain is typical of appendicitis.
- An acute exacerbation with a history of chronic pain can confound the diagnosis. It is important to determine if the nature of the acute pain is different (in character, location, or other factors) from the background, chronic pain. It is easy to miss or overlook an unrelated acute pathology in a patient with a chronic pain history of any sort (e.g., acute appendicitis in children with longstanding functional bowel complaints). The clinician must be wary of this trap, and there is no substitute for experience.
- Fever, nausea, vomiting, anorexia (gastroenteritis, mesenteric adenitis)
- Diarrhea (gastroenteritis)
- Fatigue or jaundice (viral hepatitis)
- Lethargy, headache, photophobia (abdominal migraine)
- Cough, shortness of breath (pneumonia or empyema)
- Pain elsewhere (e.g., sudden-onset testicular pain suggests testicular torsion)
- Blood in stool (ulcerative colitis, necrotizing enterocolitis, dysentery, hemolytic uremic syndrome) or mucus in stool (suggests bacterial or parasitic infection)
- Blood or bile in vomitus (small bowel obstruction)
- Genitourinary symptoms: dysuria, frequency of micturition, and hematuria suggest a urinary tract infection (UTI); vaginal discharge is suggestive of pelvic inflammatory disease; current menstruation may be indicative of dysmenorrhea.
- If there is a history of trauma, ascertain whether it is blunt or penetrating, and accidental or nonaccidental.
- Travel to a developing country increases risk of viral hepatitis infection and infectious gastroenteritis.
- The presence of bilious vomiting without passage of stool/flatus suggests complete small bowel obstruction. Bilious vomiting with passage of stool or flatus suggests partial small bowel obstruction.
- Infrequent bowel action or fecal incontinence is suggestive of constipation. Infants may extend their legs and squeeze anal and buttock muscles to prevent stooling; toddlers often rise up on their toes, shift back and forth, and stiffen their legs and buttocks.
- In addition to daily stooling pattern, evaluation of constipation includes pertinent medical history, onset of constipation symptoms, severity, and any previous treatments. Dietary history, paying attention to fiber and fluid intake, is helpful.
- New or unusual food intake may support the diagnosis of gastroenteritis.
- Patients with sickle cell disease or cystic fibrosis are at higher risk of developing gallstones
- Patients with spina bifida, learning difficulties, or cerebral palsy are prone to constipation
- Splenic infarction may be a consequence of sickle cell disease
- Recent or current upper respiratory tract infection is suggestive of mesenteric adenitis or pulmonary cause
- Failure to pass meconium in the first 36 hours of life is strongly suggestive of Hirschsprung disease
- Hirschsprung disease can be associated with Down syndrome
- Necrotizing enterocolitis should be considered in a premature neonate weighing less than 1500 g.
- Some medications, such as iron supplements, can cause constipation. Corticosteroids, adrenocorticotropic hormones, estrogens including contraceptives, azathioprine, asparaginase, tetracycline, chlorothiazides, and valproic acid may induce pancreatitis. Nonsteroidal anti-inflammatory drugs (NSAIDs), salicylates, and corticosteroids are associated with peptic ulcer development.
- Positive family history is a risk factor for inflammatory bowel disease, nephrolithiasis, and functional abdominal pain.
- This should include a discussion of family dynamics and may help determine if pain is functional or due to organic cause.
- Psychological factors (e.g., depression, abuse, attention deficit disorder, oppositional disorder), weaning, toilet training, start of schooling, or other causes of stress may play a role in constipation.
- History of nicotine, caffeine, or alcohol consumption may suggest peptic ulcer; excess alcohol consumption is a risk factor for pancreatitis.
- Adolescents may avoid answering sensitive questions regarding sexual history and drug use truthfully in the presence of parents or guardians; therefore, it may be appropriate to conduct some parts of the history with the adolescent alone.
Physical exam
- Consideration of vital signs should be based on age-appropriate normal values.
- It is important to determine whether signs of volume depletion are present (tachycardia, hypotension, dry mucous membranes, poor capillary refill, sunken fontanel in infants). Children with gastroenteritis may quickly become volume depleted.
- Cholecystitis, pancreatitis, and splenic infarction typically cause fever.
- Patients with appendicitis do not usually have significant changes in vital signs. Body temperature may be increased by 1.8°F (1°C).
- Children with constipation are usually well with normal vital signs.
- Patients presenting with central abdominal pain, with or without guarding and rigidity, that settles in the RLQ should arouse suspicion of appendicitis. Classic abdominal signs of appendicitis are RLQ abdominal tenderness (McBurney sign) and localized rebound tenderness, if the appendix is anterior. Compressing the left lower quadrant (LLQ) may elicit pain in the RLQ (Rovsing sign). Patients with appendicitis may lie still and try not to move, particularly in severe cases with significant peritoneal irritation.
- Acute mesenteric adenitis often resembles acute appendicitis; however, pain in the abdomen is usually diffuse with tenderness not localized to the RLQ. Guarding may be present but rigidity is usually absent. One retrospective study found that, compared with children who have appendicitis, patients who have mesenteric adenitis are more likely to have high fever (above 102.2°F [39°C]) and dysuria, and are less likely to have migratory pain, vomiting, or typical abdominal signs of appendicitis on examination.[25]
- Patients with gastroenteritis usually exhibit diffuse abdominal pain without evidence of peritonitis (no guarding or rebound tenderness). Abdominal distension and hyperactive bowel sounds are common findings.
- The presence of abdominal distension and tenderness associated with decreased or absent bowel sounds is strongly suggestive of large bowel obstruction. In severe cases of constipation, abdominal distension may be present with a palpable fecal mass per abdomen or rectum.
- Flank pain or costovertebral angle tenderness may indicate pyelonephritis or nephrolithiasis.
- Epigastric pain may indicate peptic ulcer disease or pancreatitis. Patients with pancreatitis may lie with their knees and hips flexed and avoid moving. It is important to note that, in younger patients with pancreatitis (<3 years of age), abdominal tenderness may not be the main finding; these patients may demonstrate increased irritability and abdominal distension. With hemorrhagic pancreatitis, discoloration may be noted around the umbilical area (Cullen sign) or in the flanks (Grey-Turner sign) due to blood tracking along defined fascial planes.
- Tenderness in the right upper quadrant (RUQ) is a classic sign of gallbladder disease, as is Murphy sign (cessation of inspiration during concurrent deep RUQ palpation). Patients with biliary dyskinesia usually present in a similar fashion to those with cholelithiasis and cholecystitis and may have RUQ tenderness on palpation.
- Patients with splenic infarction typically present with left-sided abdominal pain and fevers. Pain may also be reported in the left side of the chest or the left shoulder. Those with a splenic cyst are either asymptomatic or present with dull left-sided abdominal pain in the absence of fever.[97]
- In trauma patients, signs of accidental (e.g., seat belt mark suggesting a motor vehicle accident) and nonaccidental injury (particularly if history is suspicious) should be sought (e.g., cigarette burns, subdural hemorrhages in an infant/young toddler). The presence of seat belt marks increases the likelihood that intra-abdominal injuries are present, particularly in the presence of lumbar fracture or persistent tachycardia.[98]
- If clinical findings are minimal and the child appears well, a diagnosis of functional abdominal pain should be considered. Diagnostic criteria for functional abdominal pain are symptom based, not physical exam or laboratory based.[61]
- Signs of peritonitis, such as absent bowel sounds, bilious vomiting, bloody diarrhea or occult blood in stool, fever (≥100.4°F [≥38°C]), rebound tenderness, rigidity, and guarding indicate a possible need for surgery.
- A neonatal exam must evaluate for the presence of an anus along with the proper location within the sphincter complex.
- Testicular torsion is likely in any male child with abdominal tenderness plus loss of the cremasteric reflex, diffuse testicular tenderness, elevated testes, and a horizontal rather than vertical position of the testes on exam.
- Blood at the urethral meatus, or hematuria, after trauma may suggest urinary tract or kidney injury.
- The presence of an anal fissure and/or hemorrhoids (rare in children; may be mistaken for skin tags from Crohn disease), imperforate anus, or anal stenosis (particularly in a neonate or infant) on inspection of the perianal skin may provide further diagnostic clues.
- Generalized lymphadenopathy is common and signs of an upper respiratory tract infection may be present in children with mesenteric adenitis (e.g., hyperemic pharynx or oropharynx suggesting pharyngitis).
- Jaundice is rare with cholelithiasis or acute cholecystitis and, if present, suggests an obstruction of the common bile duct. Jaundice associated with abdominal tenderness, hepatomegaly (splenomegaly may also be present), and lymphadenopathy, particularly in a child of school age, should arouse suspicion of viral hepatitis (commonly hepatitis A).
- Children with spina bifida, learning difficulties, and cerebral palsy are prone to constipation, and features of these conditions may be obvious on exam (e.g., sacral dimples or pits and/or tags/tufts indicative of abnormality of spinal cord).
- Henoch-Schonlein purpura (HSP) may be the initiating factor in an older child with abdominal pain (usually <11 years of age), and therefore signs of HSP should be sought (rash of palpable purpura, blood in the stools).
- Extraintestinal manifestations of inflammatory bowel disease may be evident (e.g., iritis, arthritis, sacroiliitis, erythema nodosum, pyoderma gangrenosum).
- The presence of cyanosis, tachypnea, decreased breath sounds on auscultation, dullness on percussion (indicates consolidation), and abdominal tenderness and distension without guarding or rebound should arouse suspicion of a pulmonary cause such as pneumonia or empyema.
- In a neonate, the triad of abdominal distension, delayed passage of meconium (not occurring in the first 36 hours of life), and vomiting is highly suggestive of Hirschsprung disease.
- Necrotizing enterocolitis should be considered in a premature neonate weighing less than 1500 g. Early signs may include inability to tolerate feeds, abdominal distension and tenderness, blood in the stool, and abdominal wall erythema. In severe cases, systemic signs of sepsis may be present.
- A neonate presenting with bilious vomiting, with (partial obstruction) or without (complete obstruction) the passage of meconium, is highly suggestive of small bowel obstruction. Causes such as meconium ileus, intestinal atresia, and midgut volvulus should be excluded with further investigations.
- Meckel diverticulum should be considered in a child <2 years old with abdominal tenderness (Meckel diverticulitis); hematochezia, typically dark red, maroon, or red-brick-colored jelly-like stools (indicates intestinal bleeding as they contain heterotopic gastric tissue); or signs of obstruction such as nausea, vomiting, and constipation (intussusception, volvulus, or herniation can result).
- Ectopic pregnancy and miscarriage should be suspected in any female of reproductive age presenting with lower abdominal pain, amenorrhea, and vaginal bleeding. Pelvic exam may reveal a mass, eliciting cervical motion tenderness if hemoperitoneum is present; tubal rupture can cause hemodynamic instability.
- Clinical features of a ruptured ovarian cyst usually occur prior to the expected time of ovulation and may mimic ectopic pregnancy. Pain arises from local peritonitis secondary to hemorrhage.[48] [49] [50] Signs of peritonitis may be present in the lower abdomen and pelvis; adnexal size is unremarkable due to collapsed cyst.
- The presence of a tender pelvic mass associated with nausea and vomiting may suggest ovarian torsion. In addition, in patients old enough to undergo pelvic exam, cervical motion tenderness may be elicited; typically no vaginal discharge is present, but there may be some mild to moderate vaginal bleeding.
- Physical findings of pelvic inflammatory disease (PID) vary widely and may include lower abdominal tenderness, adnexal tenderness, and cervical motion tenderness.[54] Fever and cervical or vaginal discharge may also be present. PID is rare in the absence of sexual activity; PID in a young child should prompt workup for possible sexual abuse.
- Patients with PID may also present with RUQ pain resulting from inflammation of the liver capsule or diaphragm, referred to as Fitz-Hugh-Curtis syndrome. This is secondary to an ascending infection. Referred pain to the right shoulder may result from irritation of the diaphragm.[99]
- Primary dysmenorrhea should be considered if lower abdominal tenderness is associated with current menstruation.
Laboratory tests
- CBC, recommended in all patients (useful in evaluating infection and inflammation).
- Complete chemistry panel, recommended in all patients (electrolyte disturbances associated with GI causes are common).
- Blood type and screen and rhesus status when ectopic pregnancy is suspected.
- Liver function tests (LFTs) are helpful baseline investigations when considering a hepatobiliary or pancreatic cause. In abdominal trauma, results from one retrospective study suggest that LFTs may be used as a screening tool to determine need for computed tomography (CT) scan; in a hemodynamically normal patient with normal AST/ALT, it may be possible to avoid CT scan.[100]
- Serum lipase, or amylase if lipase is unavailable, is indicated if pancreatitis is suspected.[101]
- Inflammatory markers. Although nonspecific, erythrocyte sedimentation rate and C-reactive protein may suggest underlying infection or inflammation. Furthermore, these inflammatory markers correlate closely with disease activity in cases of inflammatory bowel disease.
- A positive fecal occult blood test can support a suspicion of intussusception. However, a negative test cannot reliably rule out the diagnosis.[102]
- Fecal calprotectin is increasingly used to distinguish between inflammatory bowel disease and noninflammatory bowel disease, with a sensitivity of 90% and a specificity of 80%.[103]
- A coagulation profile, including prothrombin time and international normalized ratio (INR), is usually necessary in cases of suspected viral hepatitis to measure liver synthetic function.
- Stool microscopy and culture may be helpful in determining an infectious etiology of gastroenteritis. Risk factors and features of the clinical presentation help guide the choice of tests for specific pathogens. Guidelines recommend that when there is fever or bloody diarrhea, investigations for enteropathogens for which antimicrobial agents may confer clinical benefit (including Salmonella enterica subspecies, Shigella, and Campylobacter) should be done.[104]
- Blood cultures are indicated when sepsis is a concern. Blood cultures are recommended: in children with infectious diarrhea who are <3 months of age or who are immunocompromised; when enteric fever is suspected (including travel to enteric fever-endemic area, or contact with travelers from enteric fever-endemic areas who have a febrile illness of unknown etiology); when there are systemic manifestations of infection; and with high-risk conditions such as hemolytic anemia.[104]
- Urine culture is necessary if urinalysis is suggestive of a UTI.
- Sputum culture is indicated in patients with suspected pneumonia. Aspiration of frank pus on thoracentesis is diagnostic of empyema.
- In cases of patients with suspected peptic ulcer disease, Helicobacter pylori breath test or stool antigen test may be helpful.
- Polymorphonuclear leukocytes (PMNs) seen on wet mount of vaginal secretions confirms vaginal infection in cases of PID. All women who receive a diagnosis of PID should be tested for gonorrhea, chlamydia, HIV, and syphilis.[54]​ Hepatitis studies may be considered.
- In patients with suspected exposure to or symptoms of hepatitis A, B, C, D, and E, the following laboratory tests are warranted: hepatitis A antibody IgM, hepatitis B surface, core, and e antigen or viral load, hepatitis C serology or viral load, hepatitis D and E serologies.
Imaging and other investigations
Library
Necrotic appendix
CT scan demonstrating fecalith (white arrow) outside the lumen of the appendix consistent with perforated appendix
Intussusception: blood vessels become trapped between layers of intestine, leading to reduced blood supply, edema, strangulation of bowel, and gangrene. Sepsis, shock, and death may eventually occur
Intraoperative photo of Meckel diverticulum
Abdominal x-ray of a neonate with abnormal stooling pattern and constipation. The dilated transverse and descending colon is suggestive of Hirschsprung disease
Abdominal x-ray demonstrating double bubble gas pattern consistent with duodenal atresia
Infant with right groin bulge consistent with incarcerated inguinal hernia. The lack of overlying skin edema and erythema does not rule out strangulation of the small intestine
Gallbladder ultrasound demonstrating cholelithiasis with characteristic shadowing
Abdominal x-ray with opacities in the RUQ consistent with gallstones
CT scan of teenage girl presenting with mid-epigastric abdominal pain as a result of gallstone pancreatitis. The large fluid collection in the pancreatic bed (white arrow) and lack of pancreatic enhancement suggest liquefactive necrosis of the pancreas
CT scan demonstrating fluid-filled cyst within the spleen
Intraoperative photo of large splenic cyst
Young boy with right testicular pain. The testicle is swollen, tender, and erythematous as a result of torsion of the appendix testes. The clinical signs and symptoms mimic those of testicular torsion
Infant boy with swollen, tender, and erythematous left testicle. The testicle is retracted consistent with testicular torsion
Torsion of an appendix testis resulting in acute infarction
Intraoperative photo of ovarian mass that presented as ovarian torsion
CT scan of a young girl presenting with ovarian torsion. The large pelvic cystic lesion contains calcifications (white arrow) consistent with a teratoma or dermoid cyst
Contrast enema demonstrating ileocolic intussusception (black arrow)
Abdominal x-ray of a young boy with acute, severe abdominal pain, demonstrating stool throughout the colon and rectum
CT scan demonstrating intra-abdominal abscess consistent with perforated appendix
Upper GI contrast study demonstrating malrotation with volvulus. The duodenum fails to develop the normal anatomic C-loop. There is failure of contrast to pass, resulting in a characteristic bird beak consistent with acute midgut volvulus
Citations
Di Lorenzo C, Colletti RB, Lehmann HP, et al; AAP Subcommittee, NASPGHAN Committee on Chronic Abdominal Pain. 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. J Pediatr Gastroenterol Nutr. 2005 Mar;40(3):249-61.[Abstract][Full Text]
Di Lorenzo C, Colletti RB, Lehmann HP, et al; American Academy of Pediatrics Subcommittee on Chronic Abdominal Pain; NASPGHAN Committee on Abdominal Pain. Chronic abdominal pain in children: a clinical report of the American Academy of Pediatrics and the North American Society for Pediatric Gastroenterology, Hepatology and Nutrition. J Pediatr Gastroenterol Nutr. 2005 Mar;40(3):245-8.[Abstract][Full Text]
Dahabreh IJ, Adam GP, Halladay CW, et al; Agency for Healthcare Research and Quality. Comparative Effectiveness Review: number 157. Diagnosis of right lower quadrant pain and suspected acute appendicitis. Dec 2015 [internet publication].[Abstract][Full Text]
Tabbers MM, DiLorenzo C, Berger MY, et al; European Society for Pediatric Gastroenterology, Hepatology, and Nutrition; North American Society for Pediatric Gastroenterology. Evaluation and treatment of functional constipation in infants and children: evidence-based recommendations from ESPGHAN and NASPGHAN. J Pediatr Gastroenterol Nutr. 2014 Feb;58(2):258-74.[Abstract][Full Text]
Diercks DB, Adkins EJ, Harrison N, et al. American College of Emergency Physicians. Clinical policy: critical issues in the evaluation and management of emergency department patients with suspected appendicitis. Approved by ACEP Board of Directors February 1, 2023. Ann Emerg Med. 2023 Jun;81(6):e115-52.[Abstract][Full Text]
1. Koppen IJ, Vriesman MH, Saps M, et al. Prevalence of functional defecation disorders in children: a systematic review and meta-analysis. J Pediatr. 2018 Jul;198:121-30.e6.[Abstract]
2. Zeevenhooven J, Koppen IJ, Benninga MA. The new Rome IV criteria for functional gastrointestinal disorders in infants and toddlers. Pediatr Gastroenterol Hepatol Nutr. 2017 Mar;20(1):1-13.[Abstract][Full Text]
3. Benninga MA, Faure C, Hyman PE, et al. Childhood functional gastrointestinal disorders: neonate/toddler. Gastroenterology. 2016 Feb 15;150(6):P1443-55.[Abstract]
4. Wessel MA, Cobb JC, Jackson EB, et al. Paroxysmal fussing in infancy, sometimes called colic. Pediatrics. 1954 Nov;14(5):421-35.[Abstract]
5. Lucassen PL, Assendelft WJ, van Eijk JT, et al. Systematic review of the occurrence of infantile colic in the community. Arch Dis Child. 2001 May;84(5):398-403.[Abstract][Full Text]
6. Omling E, Salö M, Saluja S, et al. Nationwide study of appendicitis in children. Br J Surg. 2019 Nov;106(12):1623-31.[Abstract][Full Text]
7. Howell EC, Dubina ED, Lee SL. Perforation risk in pediatric appendicitis: assessment and management. Pediatric Health Med Ther. 2018 Oct 26;9:135-45.[Abstract][Full Text]
8. Alvarado A. A practical score for the early diagnosis of acute appendicitis. Ann Emerg Med. 1986 May;15(5):557-64.[Abstract]
9. Samuel M. Pediatric appendicitis score. J Pediatr Surg. 2002 Jun;37(6):877-81.[Abstract]
10. Cotton DM, Vinson DR, Vazquez-Benitez G, et al; Clinical Research on Emergency Services and Treatments (CREST) Network. Validation of the Pediatric Appendicitis Risk Calculator (pARC) in a community emergency department setting. Ann Emerg Med. 2019 Oct;74(4):471-80.[Abstract][Full Text]
11. Kharbanda AB, Vazquez-Benitez G, Ballard DW, et al. Development and validation of a novel Pediatric Appendicitis Risk Calculator (pARC). Pediatrics. 2018 Apr;141(4):e20172699.[Abstract][Full Text]
12. Mandeville K, Pottker T, Bulloch B, et al. Using appendicitis scores in the pediatric ED. Am J Emerg Med. 2011 Nov;29(9):972-7.[Abstract]
13. Di Saverio S, Podda M, De Simone B, et al. Diagnosis and treatment of acute appendicitis: 2020 update of the WSES Jerusalem guidelines. World J Emerg Surg. 2020 Apr 15;15(1):27.[Abstract][Full Text]
14. Li J. Revisiting delayed appendectomy in patients with acute appendicitis. World J Clin Cases. 2021 Jul 16;9(20):5372-90.[Abstract][Full Text]
15. Papandria D, Goldstein SD, Rhee D, et al. Risk of perforation increases with delay in recognition and surgery for acute appendicitis. J Surg Res. 2013 Oct;184(2):723-9.[Abstract][Full Text]
16. Manatakis DK, Aheimastos V, Antonopoulou MI, et al. Unfinished business: a systematic review of stump appendicitis. World J Surg. 2019 Nov;43(11):2756-61.[Abstract]
17. Sunkara T, Rawla P, Yarlagadda KS, et al. Eosinophilic gastroenteritis: diagnosis and clinical perspectives. Clin Exp Gastroenterol. 2019 Jun 5;12:239-53.[Abstract][Full Text]
18. Salvadori M, Bertoni E. Update on hemolytic uremic syndrome: diagnostic and therapeutic recommendations. World J Nephrol. 2013 Aug 6;2(3):56-76.[Abstract][Full Text]
19. Jiang J, Jiang B, Parashar U, et al. Childhood intussusception: a literature review. PLoS One. 2013;8(7):e68482.[Abstract][Full Text]
20. Mateen MA, Saleem S, Rao PC, et al. Transient small bowel intussusceptions: ultrasound findings and clinical significance. Abdom Imaging. 2006 Jul-Aug;31(4):410-6.[Abstract]
21. Hansen CC, Søreide K. Systematic review of epidemiology, presentation, and management of Meckel's diverticulum in the 21st century. Medicine (Baltimore). 2018 Aug;97(35):e12154.[Abstract][Full Text]
22. Elsayes KM, Menias CO, Harvin HJ, et al. Imaging manifestations of Meckel's diverticulum. AJR Am J Roentgenol. 2007 Jul;189(1):81-8.[Abstract][Full Text]
23. Lin XK, Huang XZ, Bao XZ, et al. Clinical characteristics of Meckel diverticulum in children: a retrospective review of a 15-year single-center experience. Medicine (Baltimore). 2017 Aug;96(32):e7760.[Abstract][Full Text]
24. Karabulut R, Sonmez K, Turkyilmaz Z, et al. Negative appendectomy experience in children. Ir J Med Sci. 2011 Mar;180(1):55-8.[Abstract]
25. Gross I, Siedner-Weintraub Y, Stibbe S, et al. Characteristics of mesenteric lymphadenitis in comparison with those of acute appendicitis in children. Eur J Pediatr. 2017 Feb;176(2):199-205.[Abstract]
26. Shalaby MS, Kuti K, Walker G. Intestinal malrotation and volvulus in infants and children. BMJ. 2013 Nov 26;347:f6949.[Abstract]
27. Destro F, Maestri L, Meroni M, et al. Colonic volvulus in children: surgical management of a challenging condition. Children (Basel). 2021 Oct 30;8(11):982.[Abstract][Full Text]
28. Battersby C, Santhalingam T, Costeloe K, et al. Incidence of neonatal necrotising enterocolitis in high-income countries: a systematic review. Arch Dis Child Fetal Neonatal Ed. 2018 Mar;103(2):F182-9.[Abstract]
29. Neu J, Walker WA. Necrotizing enterocolitis. N Engl J Med. 2011 Jan 20;364(3):255-64.[Abstract][Full Text]
30. Sullivan PB. Symposium: gastroenterology. Peptic ulcer disease in children. Paediatr Child Health. 2010 Oct;20(10):462-4.[Full Text]
31. Rinawi F, Assa A, Eliakim R, et al. The natural history of pediatric-onset IBD-unclassified and prediction of Crohn's disease reclassification: a 27-year study. Scand J Gastroenterol. 2017 May;52(5):558-63.[Abstract]
32. Carvalho RS, Abadom V, Dilworth HP, et al. Indeterminate colitis: a significant subgroup of pediatric IBD. Inflamm Bowel Dis. 2006 Apr;12(4):258-62.[Abstract][Full Text]
33. Ye Y, Manne S, Treem WR, et al. Prevalence of inflammatory bowel disease in pediatric and adult populations: recent estimates from large national databases in the United States, 2007-2016. Inflamm Bowel Dis. 2020 Mar 4;26(4):619-25.[Abstract][Full Text]
34. Feuerstein JD, Cheifetz AS. Crohn disease: epidemiology, diagnosis, and management. Mayo Clin Proc. 2017 Jul;92(7):1088-103.[Abstract][Full Text]
35. Torres J, Mehandru S, Colombel JF, et al. Crohn's disease. Lancet. 2017 Apr 29;389(10080):1741-55.[Abstract]
36. Molodecky NA, Soon IS, Rabi DM, et al. Increasing incidence and prevalence of the inflammatory bowel diseases with time, based on systematic review. Gastroenterology. 2012 Jan;142(1):46-54.e42.[Abstract][Full Text]
37. Singh P, Arora A, Strand TA, et al. Global prevalence of celiac disease: systematic review and meta-analysis. Clin Gastroenterol Hepatol. 2018 Jun;16(6):823-36.e2.[Abstract][Full Text]
38. National Institute for Health and Care Excellence. Coeliac disease: recognition, assessment and management. Sep 2015 [internet publication].[Full Text]
39. Al-Toma A, Volta U, Auricchio R, et al. European Society for the Study of Coeliac Disease (ESsCD) guideline for coeliac disease and other gluten-related disorders. United European Gastroenterol J. 2019 Jun;7(5):583-613.[Abstract][Full Text]
40. Santucci NR, Hyman PE, Harmon CM, et al. Biliary dyskinesia in children: a systematic review. J Pediatr Gastroenterol Nutr. 2017 Feb;64(2):186-93.[Abstract][Full Text]
41. Suzuki M, Sai JK, Shimizu T. Acute pancreatitis in children and adolescents. World J Gastrointest Pathophysiol. 2014 Nov 15;5(4):416-26.[Abstract][Full Text]
42. Burgener FA, Meyers SP, Tan RK, et al. Differential diagnosis in magnetic resonance imaging. New York: Thieme; 2002:530.
43. Aslam S, Sohaib A, Reznek RH. Reticuloendothelial disorders: the spleen. In: Adam A, Dixon A, eds. Grainger and Allison's Diagnostic radiology. 5th ed. Philadelphia: Churchill Livingstone; 2008:1759-70.
44. Bradshaw CJ, Bandi AS, Muktar Z, et al. International study of the epidemiology of paediatric trauma: PAPSA Research Study. World J Surg. 2018 Jun;42(6):1885-94.[Abstract][Full Text]
45. Ladomenou F, Bitsori M, Galanakis E. Incidence and morbidity of urinary tract infection in a prospective cohort of children. Acta Paediatr. 2015 Jul;104(7):e324-9.[Abstract]
46. De Sanctis V, Soliman A, Bernasconi S, et al. Primary dysmenorrhea in adolescents: prevalence, impact and recent knowledge. Pediatr Endocrinol Rev. 2015 Dec;13(2):512-20.[Abstract]
47. Zhao LC, Lautz TB, Meeks JJ, et al. Pediatric testicular torsion epidemiology using a national database: incidence, risk of orchiectomy and possible measures toward improving the quality of care. J Urol. 2011 Nov;186(5):2009-13.[Abstract][Full Text]
48. Katz VL. 18. Benign gynecologic lesions: vulva, vagina, cervix, uterus, oviduct, ovary. In: Katz VL, Lentz GM, Lobo RA, et al., eds. Comprehensive gynecology. 5th ed. Philadelphia: Mosby; 2007:419-72.
49. Boyle KJ, Torrealday S. Benign gynecologic conditions. Surg Clin North Am. 2008 Apr;88(2):245-64.[Abstract]
50. Schultz KA, Ness KK, Nagarajan R, et al. Adnexal masses in infancy and childhood. Clin Obstet Gynecol. 2006 Sep;49(3):464-79.[Abstract]
51. Emeksiz HC, Derinöz O, Akkoyun EB, et al. Age-specific frequencies and characteristics of ovarian cysts in children and adolescents. J Clin Res Pediatr Endocrinol. 2017 Mar 1;9(1):58-62.[Abstract][Full Text]
52. Dasgupta R, Renaud E, Goldin AB, et al. Ovarian torsion in pediatric and adolescent patients: A systematic review. J Pediatr Surg. 2018 Jul;53(7):1387-91.[Abstract]
53. Trent M. Pelvic inflammatory disease. Pediatr Rev. 2013 Apr;34(4):163-72.[Abstract][Full Text]
54. Workowski KA, Bachmann LH, Chan PA, et al. Sexually transmitted infections treatment guidelines, 2021. MMWR Recomm Rep. 2021 Jul 23;70(4):1-187.[Abstract][Full Text]
55. WHO Department of Reproductive Health and Research. Vaginal bleeding in early pregnancy. Managing complications in pregnancy and childbirth: a guide for midwives and doctors. 2007:S-7.[Full Text]
56. American College of Obstetrics and Gynaecology. Early pregnancy loss. Practice bulletin 200. Nov 2018 [internet publication].[Full Text]
57. Bouyer J, Coste J, Fernandez H, et al. Sites of ectopic pregnancy: a 10 year population-based study of 1800 cases. Hum Reprod. 2002 Dec;17(12):3224-30.[Abstract][Full Text]
58. Gaskins AJ, Missmer SA, Rich-Edwards JW, et al. Demographic, lifestyle, and reproductive risk factors for ectopic pregnancy. Fertil Steril. 2018 Dec;110(7):1328-37.[Abstract][Full Text]
59. Sectish TC, Prober CG. Pneumonia. In: Behrman RE, Kliegman RM, Jenson HB, eds. Nelson textbook of pediatrics. 18th ed. Philadelphia: WB Saunders; 2007:1795-800.
60. Hyams JS, Di Lorenzo C, Saps M, et al. Childhood functional gastrointestinal disorders: child/adolescent. Gastroenterology. 2016 May;150(6):P1456-68.e2.[Abstract]
61. Drossman DA, Chang L, Chey WD, et al. Rome IV: functional gastrointestinal disorders - disorders of gut-brain interaction. 4th ed. Raleigh, NC: Rome Foundation; 2017.
62. Baaleman DF, Di Lorenzo C, Benninga MA, et al. The effects of the Rome IV criteria on pediatric gastrointestinal practice. Curr Gastroenterol Rep. 2020 Mar 19;22(5):21.[Abstract][Full Text]
63. Boronat AC, Ferreira-Maia AP, Matijasevich A, et al. Epidemiology of functional gastrointestinal disorders in children and adolescents: a systematic review. World J Gastroenterol. 2017 Jun 7;23(21):3915-27.[Abstract][Full Text]
64. Di Lorenzo C, Colletti RB, Lehmann HP, et al; AAP Subcommittee, NASPGHAN Committee on Chronic Abdominal Pain. 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. J Pediatr Gastroenterol Nutr. 2005 Mar;40(3):249-61.[Abstract][Full Text]
65. Di Lorenzo C, Colletti RB, Lehmann HP, et al; American Academy of Pediatrics Subcommittee on Chronic Abdominal Pain; NASPGHAN Committee on Abdominal Pain. Chronic abdominal pain in children: a clinical report of the American Academy of Pediatrics and the North American Society for Pediatric Gastroenterology, Hepatology and Nutrition. J Pediatr Gastroenterol Nutr. 2005 Mar;40(3):245-8.[Abstract][Full Text]
66. American College of Radiology. ACR appropriateness criteria: suspected appendicitis - child. 2018 [internet publication].[Full Text]
67. Dahabreh IJ, Adam GP, Halladay CW, et al; Agency for Healthcare Research and Quality. Comparative Effectiveness Review: number 157. Diagnosis of right lower quadrant pain and suspected acute appendicitis. Dec 2015 [internet publication].[Abstract][Full Text]
68. Fraser JD, Aguayo P, Sharp SW, et al. Accuracy of computed tomography in predicting appendiceal perforation. J Pediatr Surg. 2010 Jan;45(1):231-5.[Abstract]
69. The Royal College of Surgeons of England; British Association of Paediatric Surgeons. Commissioning guide: paediatric emergency appendicectomy. Jul 2014 [internet publication].[Full Text]
70. Hackam DJ, Upperman J, Grikscheit T, et al. Pediatric surgery: gastrointestinal tract. In: Schwartz's principles of surgery. 11th ed. New York: McGraw-Hill; 2019.
71. McCollough M, Sharieff GQ. Abdominal pain in children. Pediatr Clin North Am. 2006 Feb;53(1):107-37, vi.[Abstract]
72. Gluckman S, Karpelowsky J, Webster AC, et al. Management for intussusception in children. Cochrane Database Syst Rev. 2017 Jun 1;(6):CD006476.[Abstract][Full Text]
73. Cantor RM. Pediatric trauma. In: Marx JA, Hockberger RS, Walls RM, eds. Rosen's emergency medicine: concepts and clinical practice. 6th ed. Philadelphia: Mosby; 2006:267-81.
74. Dayan PS, Klein BL. Chapter 71: acute care of the victim of multiple trauma. In: Behrman RE, Kliegman RM, Jenson HB, eds. Nelson textbook of pediatrics. 18th ed. Philadelphia: WB Saunders; 2007.
75. Rey-Bellet Gasser C, Gehri M, Joseph JM, et al. Is it ovarian torsion? A systematic literature review and evaluation of prediction signs. Pediatr Emerg Care. 2016 Apr;32(4):256-61.[Abstract]
76. Grunau GL, Harris A, Buckley J, et al. Diagnosis of ovarian torsion: is it time to forget about Doppler? J Obstet Gynaecol Can. 2018 Jul;40(7):871-5.[Abstract]
77. Oelsner G, Shashar D. Adnexal torsion. Clin Obstet Gynecol. 2006 Sep;49(3):459-63.[Abstract]
78. Breech LL, Hillard PJ. Adnexal torsion in pediatric and adolescent girls. Curr Opin Obstet Gynecol. 2005 Oct;17(5):483-9.[Abstract]
79. Kives S, Gascon S, Dubuc É, et al. No. 341 - diagnosis and management of adnexal torsion in children, adolescents, and adults. J Obstet Gynaecol Can. 2017 Feb;39(2):82-90.[Abstract]
80. American College of Obstetricians and Gynecologists. Adnexal torsion in adolescents: ACOG Committee Opinion No. 783. Obstet Gynecol. 2019 Aug;134(2):e56-63.[Abstract][Full Text]
81. Geimanaite L, Trainavicius K. Ovarian torsion in children: management and outcomes. J Pediatr Surg. 2013 Sep;48(9):1946-53.[Abstract]
82. European Association of Urology. Paediatric urology. 2022 [internet publication].[Full Text]
83. Altinkilic B, Pilatz A, Weidner W. Detection of normal intratesticular perfusion using color coded duplex sonography obviates need for scrotal exploration in patients with suspected testicular torsion. J Urol. 2013 May;189(5):1853-8.[Abstract]
84. Sartelli M, Chichom-Mefire A, Labricciosa FM, et al. The management of intra-abdominal infections from a global perspective: 2017 WSES guidelines for management of intra-abdominal infections. World J Emerg Surg. 2017 Jul 10;12:29.[Abstract][Full Text]
85. Singer M, Deutschman CS, Seymour CW, et al. The third international consensus definitions for sepsis and septic shock (Sepsis-3). JAMA. 2016 Feb 23;315(8):801-10.[Abstract][Full Text]
86. National Institute for Health and Care Excellence. Sepsis: recognition, diagnosis and early management. Sep 2017 [internet publication].[Full Text]
87. Royal College of Physicians. National Early Warning Score (NEWS) 2. Dec 2017 [internet publication].[Full Text]
88. American College of Emergency Physicians (ACEP) Expert Panel on Sepsis. DART: an evidence-driven tool to guide the early recognition and treatment of sepsis and septic shock. 2016 [internet publication].[Full Text]
89. Academy of Medical Royal Colleges. Statement on the initial antimicrobial treatment of sepsis. May 2022 [internet publication].[Full Text]
90. Weiss SL, Peters MJ, Alhazzani W, et al. Surviving sepsis campaign international guidelines for the management of septic shock and sepsis-associated organ dysfunction in children. Intensive Care Med. 2020 Feb;46(suppl 1):10-67.[Abstract][Full Text]
91. Greear GM, Romano MF, Katz MH, et al. Testicular torsion: epidemiological risk factors for orchiectomy in pediatric and adult patients. Int J Impot Res. 2021 Mar;33(2):184-90.[Abstract]
92. Kim JS. Acute abdominal pain in children. Pediatr Gastroenterol Hepatol Nutr. 2013 Dec;16(4):219-24.[Abstract][Full Text]
93. Tabbers MM, DiLorenzo C, Berger MY, et al; European Society for Pediatric Gastroenterology, Hepatology, and Nutrition; North American Society for Pediatric Gastroenterology. Evaluation and treatment of functional constipation in infants and children: evidence-based recommendations from ESPGHAN and NASPGHAN. J Pediatr Gastroenterol Nutr. 2014 Feb;58(2):258-74.[Abstract][Full Text]
94. National Institute for Health and Care Excellence. Constipation in children and young people: diagnosis and management. Jul 2017 [internet publication].[Full Text]
95. Mattoo TK, Shaikh N, Nelson CP. Contemporary management of urinary tract infection in children. Pediatrics. 2021 Feb;147(2).[Abstract][Full Text]
96. Morello W, La Scola C, Alberici I, et al. Acute pyelonephritis in children. Pediatr Nephrol. 2016 Aug;31(8):1253-65.[Abstract][Full Text]
97. Birmole BJ, Kulkarni BK, Vaidya MM, et al. Splenic cyst. J. Postgrad Med. 1993 Jan-Mar;39(1):40-1.[Abstract][Full Text]
98. American College of Surgeons. Advanced trauma life support student course manual, 10th edition. Chicago, IL; 2018.[Full Text]
99. Ekabe CJ, Kehbila J, Njim T, et al. Chlamydia trachomatis-induced Fitz-Hugh-Curtis syndrome: a case report. BMC Res Notes. 2017 Jan 3;10(1):10.[Abstract][Full Text]
100. Zeeshan M, Hamidi M, O'Keeffe T, et al. Pediatric liver injury: physical examination, fast and serum transaminases can serve as a guide. J Surg Res. 2019 Oct;242:151-6.[Abstract]
101. Tenner S, Baillie J, DeWitt J, et al. American College of Gastroenterology guideline: management of acute pancreatitis. Am J Gastroenterol. 2013 Sep;108(9):1400-15.[Abstract][Full Text]
102. Chin A, De Wit K. Inability of a negative faecal occult blood test to rule out intussusception in children. Emerg Med J. 2017 Jul;34(7):489-90.[Abstract]
103. Walsham NE, Sherwood RA. Fecal calprotectin in inflammatory bowel disease. Clin Exp Gastroenterol. 2016;9:21-9.[Abstract][Full Text]
104. Shane AL, Mody RK, Crump JA, et al. 2017 Infectious Diseases Society of America clinical practice guidelines for the diagnosis and management of infectious diarrhea. Clin Infect Dis. 2017 Nov 29;65(12):e45-80.[Abstract][Full Text]
105. Mitsuyama K, Niwa M, Takedatsu H, et al. Antibody markers in the diagnosis of inflammatory bowel disease. World J Gastroenterol. 2016 Jan 21;22(3):1304-10.[Abstract][Full Text]
106. Reese GE, Constantinides VA, Simillis C, et al. Diagnostic precision of anti-Saccharomyces cerevisiae antibodies and perinuclear antineutrophil cytoplasmic antibodies in inflammatory bowel disease. Am J Gastroenterol. 2006 Oct;101(10):2410-22.[Abstract]
107. Lee JY, Kim JH, Choi SJ, et al. Point-of-care ultrasound may be useful for detecting pediatric intussusception at an early stage. BMC Pediatr. 2020 Apr 13;20(1):155.[Abstract][Full Text]
108. Holmes JF, Brant WE, Bond WF, et al. Emergency department ultrasonography in the evaluation of hypotensive and normotensive children with blunt abdominal trauma. J Pediatr Surg. 2001 Jul;36(7):968-73.[Abstract]
109. Calder BW, Vogel AM, Zhang J, et al. Focused assessment with sonography for trauma in children after blunt abdominal trauma: a multi-institutional analysis. J Trauma Acute Care Surg. 2017 Aug;83(2):218-24.[Abstract]
110. Holmes JF, Kelley KM, Wootton-Gorges SL, et al. Effect of abdominal ultrasound on clinical care, outcomes, and resource use among children with blunt torso trauma: a randomized clinical trial. JAMA. 2017 Jun 13;317(22):2290-6.[Abstract]
111. Lee KH, Lee S, Park JH, et al. Risk of hematologic malignant neoplasms from abdominopelvic computed tomographic radiation in patients who underwent appendectomy. JAMA Surg. 2021 Apr 1;156(4):343-51.[Abstract][Full Text]
112. Diercks DB, Adkins EJ, Harrison N, et al. American College of Emergency Physicians. Clinical policy: critical issues in the evaluation and management of emergency department patients with suspected appendicitis. Approved by ACEP Board of Directors February 1, 2023. Ann Emerg Med. 2023 Jun;81(6):e115-52.[Abstract][Full Text]
113. Kulaylat AN, Moore MM, Engbrecht BW, et al. An implemented MRI program to eliminate radiation from the evaluation of pediatric appendicitis. J Pediatr Surg. 2015 Aug;50(8):1359-63.[Abstract]
114. Mushtaq R, Desoky SM, Morello F, et al. First-line diagnostic evaluation with MRI of children suspected of having acute appendicitis. Radiology. 2019 Apr;291(1):170-7.[Abstract][Full Text]
115. Lee SM, Kim WS, Choi YH. Pediatric magnetic resonance enterography: focused on Crohn's disease. Pediatr Gastroenterol Hepatol Nutr. 2015 Sep;18(3):149-59.[Abstract][Full Text]
116. Brody AS, Frush DP, Huda W, et al; American Academy of Pediatrics Section on Radiology. Radiation risk to children from computed tomography. Pediatrics. 2007 Sep;120(3):677-82.[Abstract][Full Text]
117. Carney DE, Kokoska ER, Grosfeld JL, et al. Predictors of successful outcome after cholecystectomy for biliary dyskinesia. J Pediatr Surg. 2004 Jun;39(6):813-6.[Abstract]
118. Coluccio M, Claffey AJ, Rothstein DH. Biliary dyskinesia: fact or fiction? Semin Pediatr Surg. 2020 Aug;29(4):150947.[Abstract]
119. Nasri B, Glass T, Singh K, et al. Biliary hyperkinesia: an indication for cholecystectomy? Surg Endosc. 2021 Jul;35(7):3244-8.[Abstract]
120. Subcommittee on urinary tract infection. Reaffirmation of AAP clinical practice guideline: the diagnosis and management of the initial urinary tract infection in febrile infants and young children 2-24 months of age. Pediatrics. 2016 Dec;138(6):e20163026.[Abstract][Full Text]
121. National Institute for Health and Care Excellence. Urinary tract infection in under 16s: diagnosis and management. July 2022 [internet publication].
122. Subcommittee on Urinary Tract Infection. Reaffirmation of AAP clinical practice guideline: the diagnosis and management of the initial urinary tract infection in febrile infants and young children 2-24 months of age. Pediatrics. 2016 Dec;138(6):e20163026.[Abstract][Full Text]
123. Ammenti A, Alberici I, Brugnara M, et al; Italian Society of Pediatric Nephrology. Updated Italian recommendations for the diagnosis, treatment and follow-up of the first febrile urinary tract infection in young children. Acta Paediatr. 2020 Feb;109(2):236-47.[Abstract][Full Text]
124. Webster J, Osborne S, Rickard CM, et al. Clinically-indicated replacement versus routine replacement of peripheral venous catheters. Cochrane Database Syst Rev. 2019 Jan 23;(1):CD007798.[Abstract][Full Text]
125. Simundic AM, Bölenius K, Cadamuro J, et al. Joint EFLM-COLABIOCLI recommendation for venous blood sampling. Clin Chem Lab Med. 2018;56(12):2015-38.[Abstract]
126. Zouari M, Louati H, Abid I, et al. C-reactive protein value is a strong predictor of acute appendicitis in young children. Am J Emerg Med. 2018 Jul;36(7):1319-20.[Abstract]
127. Sunkara T, Rawla P, Yarlagadda KS, et al. Eosinophilic gastroenteritis: diagnosis and clinical perspectives. Clin Exp Gastroenterol. 2019 Jun 5;12:239-53.[Abstract][Full Text]
128. College of American Pathologists. Urinalysis checklist. Apr 2014 [internet publication].[Full Text]
129. Downs SM. Technical report: urinary tract infections in febrile infants and young children. The Urinary Tract Subcommittee of the American Academy of Pediatrics Committee on Quality Improvement. Pediatrics. 1999 Apr;103(4):e54.[Abstract]
130. Whiting P, Westwood M, Watt I, et al. Rapid tests and urine sampling techniques for the diagnosis of urinary tract infection (UTI) in children under five years: a systematic review. BMC Pediatr. 2005 Apr 5;5(1):4.[Abstract][Full Text]
131. Shiels WE 2nd, Maves CK, Hedlund GL, et al. Air enema for diagnosis and reduction of intussusception: clinical experience and pressure correlates. Radiology. 1991 Oct;181(1):169-72.[Abstract]
132. Evers MB. Meckel's diverticulum. In: Townsend CM Jr, Beauchamp RD, Evers BM, et al, eds. Sabiston textbook of surgery. 18th ed. Philadelphia: Saunders Elsevier; 2007:1321-3.
133. Cohen RB, Olafson SN, Krupp J, et al. Timing of Gastrografin administration in the management of adhesive small bowel obstruction (ASBO): does it matter? Surgery. 2021 Aug;170(2):596-602.[Abstract]
134. Maung AA, Johnson DC, Piper GL, et al. Evaluation and management of small-bowel obstruction: an Eastern Association for the Surgery of Trauma practice management guideline. J Trauma Acute Care Surg. 2012 Nov;73(5 suppl 4):S362-9.[Abstract][Full Text]
135. Chan B, Gordon S, Yang M, et al. Abdominal ultrasound assists the diagnosis and management of necrotizing enterocolitis. Adv Neonatal Care. 2021 Oct 1;21(5):365-70.[Abstract]
136. Husby S, Koletzko S, Korponay-Szabó I, et al. European Society Paediatric Gastroenterology, Hepatology and Nutrition guidelines for diagnosing coeliac disease 2020. J Pediatr Gastroenterol Nutr. 2020 Jan;70(1):141-56.[Abstract][Full Text]
137. Rompianesi G, Hann A, Komolafe O, et al. Serum amylase and lipase and urinary trypsinogen and amylase for diagnosis of acute pancreatitis. Cochrane Database Syst Rev. 2017 Apr 21;(4):CD012010.[Abstract][Full Text]
138. Goldstein B, Giroir B, Randolph A, et al; International Consensus Conference on Pediatric Sepsis. International pediatric sepsis consensus conference: definitions for sepsis and organ dysfunction in pediatrics. Pediatr Crit Care Med. 2005 Jan;6(1):2-8.[Abstract]
139. Mahajan P, Grzybowski M, Chen X, et al. Procalcitonin as a marker of serious bacterial infections in febrile children younger than 3 years old. Acad Emerg Med. 2014 Feb;21(2):171-9.[Abstract][Full Text]
140. Milcent K, Faesch S, Gras-Le Guen C, et al. Use of procalcitonin assays to predict serious bacterial infection in young febrile infants. JAMA Pediatr. 2016 Jan;170(1):62-9.[Abstract][Full Text]
141. Pantell RH, Roberts KB, Adams WG, et al; Subcommittee on Febrile Infants. Evaluation and management of well-appearing febrile infants 8 to 60 days old. Pediatrics. 2021 Aug;148(2):e2021052228.[Abstract][Full Text]
142. American College of Radiology. ACR appropriateness criteria: acute onset of scrotal pain - without trauma, without antecedent mass. 2018 [internet publication].[Full Text]