appendiceal colic

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</div> <bR> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Unexplained recurrent abdominal pain (RAP) is a frequent symptom in childhood. <FONT SIZE="3" COLOR="#800000" FACE="Arial" >Appendiceal</FONT> <FONT SIZE="3" COLOR="#800000" FACE="Arial" >colic</FONT> is an often-unrecognized cause of chronic stomach pain in children,</div> <div> Appendiceal<FONT SIZE="3" COLOR="#000000" FACE="Arial" > </FONT>colic<FONT SIZE="3" COLOR="#000000" FACE="Arial" >, resulting from partial or intermittent </FONT>appendiceal<FONT SIZE="3" COLOR="#000000" FACE="Arial" > luminal obstruction, is probably the most common cause of chronic </FONT>appendiceal<FONT SIZE="3" COLOR="#000000" FACE="Arial" > pain. It's likely to be responsible for the pain leading to the bulk of negative appendectomies</FONT></div> <bR> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">An organic cause is found in only 10% of cases. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">It is believed that in some children, partial luminal obstruction of the appendix by an inspissated cast of stool, may be one of the causes of this pain. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">The term appendiceal colic has been used to describe this syndrome.</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Causes of the luminal obstruction include </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">fecaloma,</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0"> fibrosis, </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">lymphoid hyperplasia,</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0"> or a foreign body. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Untreated acute appendicitis may lead to scarring, which then partially blocks the lumen, causing <FONT SIZE="3" COLOR="#800000" FACE="Arial" >appendiceal</FONT> <FONT SIZE="3" COLOR="#800000" FACE="Arial" >colic</FONT>,</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000008000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Appendiceal<FONT SIZE="3" COLOR="#000000" FACE="Arial" > </FONT>colic<FONT SIZE="3" COLOR="#000000" FACE="Arial" > may run in families.</FONT></div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">The severity, duration, and cycle of pain in <FONT SIZE="3" COLOR="#800000" FACE="Arial" >appendiceal</FONT> <FONT SIZE="3" COLOR="#800000" FACE="Arial" >colic</FONT> vary, depending on the nature of the luminal obstruction. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">In Dr. Stevenson's series of 210 patients, mean duration of pain was 11.2 months (range 1 day to 8 years). Mean age was 9.9 years (range 2-19), and 69% were female. </div> <div> <FONT SIZE="3" COLOR="#800000" FACE="Arial" ><B><IMG BORDER="0" SRC="Symb075c00b700f000008000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Appendiceal</B></FONT><B> </B><FONT SIZE="3" COLOR="#800000" FACE="Arial" ><B>colic</B></FONT><B> can be diagnosed easily in the office if the physician witnesses a painful episode. One trick is to precipitate the pain by feeding the patient just prior to the exam,</B> </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">The association with feeding is often remarkable. The patient may become pensive soon after ingesting any type of food or beverage and then quickly become visibly uncomfortable, writhing or even screaming with pain. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">The child may "rock" in a chair, curl up in a ball twisting from one side to the other, or move around holding the lower abdomen. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Unlike biliary <FONT SIZE="3" COLOR="#800000" FACE="Arial" >colic</FONT>, which is exacerbated by fatty foods, <FONT SIZE="3" COLOR="#800000" FACE="Arial" >appendiceal</FONT> <FONT SIZE="3" COLOR="#800000" FACE="Arial" >colic</FONT> can be <B>precipitated by carbohydrates and protein or anything that stimulates peristalsis, including hunger, anxiety, stress, and caffeine. Also unlike biliary </B><FONT SIZE="3" COLOR="#800000" FACE="Arial" ><B>colic</B></FONT><B>, which may worsen 1-2 hours after ingesting a fatty meal, </B><FONT SIZE="3" COLOR="#800000" FACE="Arial" ><B>appendiceal</B></FONT><B> </B><FONT SIZE="3" COLOR="#800000" FACE="Arial" ><B>colic</B></FONT><B> usually starts within 5-20 minutes, </B></div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">During a painful episode, point tenderness documented on physical exam will identify the location of the appendix.</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0"> Pressure on an appendix contracting against an obstruction will exacerbate the pain. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Children who have been suffering from long-term undiagnosed <FONT SIZE="3" COLOR="#800000" FACE="Arial" >appendiceal</FONT> <FONT SIZE="3" COLOR="#800000" FACE="Arial" >colic</FONT> may have been told that the problem was psychological. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">They may have increasing absences from school with a drop in grades.</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0"> Social life and athletic activity begin to wane, and apathy and lethargy may become pronounced.</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0"> The child may lose weight because she has learned to not eat to avoid the pain. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Since there is no visible inflammation in all cases and only a 12% prevalence of microscopic focal inflammation, imaging with ultrasound, computed tomography, or magnetic resonance -- which are most useful for documenting inflammation -- is of little use.</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0"> Moreover, a fecaloma will look like stool on ultrasound; usually they have not become calcified. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Instead, an upper gastrointestinal series with small-bowel follow-through and delayed films (12-24 hours) is more helpful. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">This series may document luminal filling defects and delayed emptying, which are important observations. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Barium enema will also work, but it is an unpleasant exam, he told this newspaper. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Routine blood work and urinalysis are virtually always normal in these patients but should be done if there is any doubt as to the diagnosis. In general, appendectomy is indicated if the history and physical are consistent with long-term or incapacitating <FONT SIZE="3" COLOR="#800000" FACE="Arial" >appendiceal</FONT> <FONT SIZE="3" COLOR="#800000" FACE="Arial" >colic</FONT>, </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Of the 210 patients diagnosed preoperatively with <FONT SIZE="3" COLOR="#800000" FACE="Arial" >appendiceal</FONT> <FONT SIZE="3" COLOR="#800000" FACE="Arial" >colic</FONT>, 205 (98%) had relief of the pain following elective appendectomy, </div> <bR> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0"> Surgeons who recommended elective appendectomy for these patients require that certain criteria be met prior to operating on the patient.</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0"> These include a history of abdominal pain for more than one month, three or more recurrent attacks of right lower quadrant (RLQ) abdominal pain and localized tenderness in the RLQ without signs of peritoneal irritation.</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0"> Radiological findings at barium examination may support the clinical findings and consist of filling defects of the appendix, non-visualization of the appendix and retained barium. </div> <bR> <div> <TABLE BORDER="2" CELLPADDING="1" CELLSPACING="1" WIDTH="992" BORDERCOLORLIGHT="#C0C0C0" BORDERCOLORDARK="#808080" FRAME="BOX" RULES="ALL" ALIGN="BOTTOM" HSPACE="0" VSPACE="0" > <tR> <tD VALIGN=CENTER BGCOLOR=#800080 HEIGHT= 30 WIDTH="982"><div> <B>Recurrent Abdominal Pain Syndrome </B></div> </tD> </tR> </TABLE></div> <div> <B>Definition</B><FONT SIZE="3" COLOR="#000000" FACE="Arial" > </FONT></div> <div> Pain occurs at least once/month for at least 3 months </div> <div> Ages 4 - 16 years (peaks at age 9 years) </div> <div> Affects activity, school attendance </div> <div> <B>Epidemiology</B><FONT SIZE="3" COLOR="#000000" FACE="Arial" > </FONT></div> <div> Prevelance in school age children: 10% </div> <div> <B>Pathophysiology</B><FONT SIZE="3" COLOR="#000000" FACE="Arial" > </FONT></div> <div> Autonomic dysfunction with altered intestinal motility </div> <div> Hyperalgesia and altered sensory pathways </div> <div> <B>Etiology</B><FONT SIZE="3" COLOR="#000000" FACE="Arial" > </FONT></div> <div> School Phobia (and related stresses) closely associated </div> <div> These children often get lower grades than peers </div> <div> <B>Associated Conditions</B><FONT SIZE="3" COLOR="#000000" FACE="Arial" > </FONT></div> <div> <U>Anorexia Nervosa</U><FONT SIZE="3" COLOR="#000000" FACE="Arial" > </FONT></div> <div> <B>Symptoms</B><FONT SIZE="3" COLOR="#000000" FACE="Arial" > </FONT></div> <div> Nonspecific recurrent abdominal pain </div> <div> Not related to meals or movement </div> <div> No associated nausea, vomiting, or <FONT SIZE="3" COLOR="#0000FF" FACE="Arial" ><U>Dysuria</U></FONT> </div> <div> <B>Signs</B><FONT SIZE="3" COLOR="#000000" FACE="Arial" > </FONT></div> <div> Well appearing child </div> <div> Exam is often normal or mild abdominal tenderness </div> <div> <B>Signs: Red flags</B><FONT SIZE="3" COLOR="#000000" FACE="Arial" > </FONT></div> <div> Pain location distant from umbilicus </div> <div> Pain that awakens child at night </div> <div> <U>Erythrocyte Sedimentation Rate</U><FONT SIZE="3" COLOR="#000000" FACE="Arial" > (ESR) elevated </FONT></div> <div> Weight loss </div> <div> <B>Labs (Limited and focused work-up)</B><FONT SIZE="3" COLOR="#000000" FACE="Arial" > </FONT></div> <div> Stool for <FONT SIZE="3" COLOR="#0000FF" FACE="Arial" ><U>Ova and Parasite</U></FONT>s for 3 samples </div> <div> <U>Giardia</U><FONT SIZE="3" COLOR="#000000" FACE="Arial" > is common cause of recurrent abdominal pain </FONT></div> <div> <U>Urinalysis</U><FONT SIZE="3" COLOR="#000000" FACE="Arial" > </FONT></div> <div> <U>Complete Blood Count</U><FONT SIZE="3" COLOR="#000000" FACE="Arial" > (CBC) </FONT></div> <div> Consider <FONT SIZE="3" COLOR="#0000FF" FACE="Arial" ><U>Erythrocyte Sedimentation Rate</U></FONT> (ESR) </div> <div> <B>Radiology</B><FONT SIZE="3" COLOR="#000000" FACE="Arial" > </FONT></div> <div> Flat and upright abdominal XRay (KUB) </div> <div> Consider <FONT SIZE="3" COLOR="#0000FF" FACE="Arial" ><U>RUQ Ultrasound</U></FONT> </div> <div> Consider pelvic ultrasound </div> <div> <B>Differential Diagnosis</B><FONT SIZE="3" COLOR="#000000" FACE="Arial" > </FONT></div> <div> <U>Peptic Ulcer Disease</U><FONT SIZE="3" COLOR="#000000" FACE="Arial" > </FONT></div> <div> Carbohydrate intolerance </div> <div> Appendiceal<FONT SIZE="3" COLOR="#000000" FACE="Arial" > </FONT>colic<FONT SIZE="3" COLOR="#000000" FACE="Arial" > </FONT></div> <div> <U>Nephrolithiasis</U><FONT SIZE="3" COLOR="#000000" FACE="Arial" > (Ureteropelvic junction obstruction) </FONT></div> <div> <U>Giardia</U><FONT SIZE="3" COLOR="#000000" FACE="Arial" > </FONT></div> <div> Blastocystis hominis </div> <div> Hereditary <FONT SIZE="3" COLOR="#0000FF" FACE="Arial" ><U>Pancreatitis</U></FONT> </div> <div> Conversion reaction </div> <div> Abdominal migraine </div> <div> Epilepsy </div> <div> Gynecologic disorder </div> <div> <B>Management</B><FONT SIZE="3" COLOR="#000000" FACE="Arial" > </FONT></div> <div> Avoid Medications </div> <div> Emphasize the patient's response to pain </div> <div> Involve the parents </div> <div> Reassure that the problem is NOT life threatening </div> <div> Be realistic and frank </div> <div> Problem may persist for extended period of time </div> <div> Treat suspected <FONT SIZE="3" COLOR="#0000FF" FACE="Arial" ><U>Constipation</U></FONT> aggressively </div> <div> <U>Mineral Oil</U><FONT SIZE="3" COLOR="#000000" FACE="Arial" > </FONT></div> <div> <U>Lactulose</U><FONT SIZE="3" COLOR="#000000" FACE="Arial" > </FONT></div> <div> Fleet Enema </div> <div> Promote full activity and a sense of health </div> <div> Encourage a well balanced diet </div> <div> Encourage adequate hydration </div> <div> Encourage adequate fiber intake </div> <div> Maintain school attendance </div> <div> <B>Course</B><FONT SIZE="3" COLOR="#000000" FACE="Arial" > </FONT></div> <div> Usually resolves by age 20 years </div> <div> <U>Irritable Bowel Syndrome</U><FONT SIZE="3" COLOR="#000000" FACE="Arial" > may develop </FONT></div> <bR> <div> <B><U>Pediatric Abdominal Pain Abdominal Pain in children</U></B> </div> <div>  </div> <bR> <div> Pediatric Abdominal Pain Causes </div> <bR> <bR> <div> <B>Types </B></div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Acute Abdominal Pain </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Characteristics </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Less than 4-6 weeks (subacute less than 12 weeks) </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Single episode, self limited and treatable </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Episodic localized pain, sharp, stabbing </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Common Causes </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Urinary tract disease </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Peptic Ulcer Disease </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Inflammatory Bowel Disease </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Gastroesophageal Reflux Disease </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Chronic Abdominal Pain </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Characteristics </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Three episodes over 3 months </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Continuous, dull, vague and diffuse abdominal pain </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Recurrent, Associated with debilitation </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Common Causes </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Constipation </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Lactose Intollerance </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Mittelschmerz </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Psychogenic (See Recurrent Abdominal Pain Syndrome) </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Secondary gain </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Sexual abuse </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">School phobia </div> <bR> <bR> <div> <B>Red Flags </B></div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Vomiting </div> <div> Localized pain away from midline </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Altered bowel habits </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Growth disturbance </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Nocturnal episodes </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Radiation of pain </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Incontinence </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Systemic symptoms </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Family history </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Peptic Ulcer Disease </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Inflammatory Bowel Disease </div> <bR> <bR> <div> History of Abdominal Pain </div> <div> Timing </div> <div> Onset of abdominal pain </div> <div> Frequency, Duration and time of day </div> <div> Location and radiation of abdominal pain </div> <div> Intensity and character </div> <div> Food associations </div> <div> Milk or cheese </div> <div> Spicy food </div> <div> Caffeinated soda, tea </div> <div> Exacerbating ammd relieving features </div> <div> Associated symptoms </div> <div> Fatigue </div> <div> Syncope </div> <div> Headache </div> <div> Vomiting (before or after pain?) </div> <div> Change in stool consistency or frquency </div> <div> Relationships to activity and school </div> <div> Which days of the weeks </div> <div> Attempted therapies </div> <bR> <bR> <div> <B>Review of systems </B></div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Genitourinary and gynecological symptoms </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Respiratory symptoms </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">CNS symptoms </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Musculoskeletal symptoms </div> <bR> <bR> <div> <B>Past Medical History </B></div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Surgical history </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Medications </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Major illnesses or hospitalizations </div> <bR> <bR> <div> <B>Family History </B></div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Ethnic Background </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Migraine headache </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Seizure Disorder </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Gastroesophageal Reflux disease (GERD) </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Peptic Ulcer Disease (PUD) </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Inflammatory Bowel Disease (IBD) </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Irritable Bowel Syndrome (IBS) </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Pancreatitis </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Hepatitis </div> <bR> <bR> <div> <B>Social History </B></div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">HEADSS </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Home </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Education </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Activities </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Drug Use </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Suicidal ideation </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Sexual activity </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Death </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Divorce </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Serious illness </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Care providers </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Siblings </div> <bR> <bR> <div> <B>Physical Exam </B></div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Perform in comfortable, non-threatening environment </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Growth </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Development </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Appearance </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Vital signs </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Comprehensive exam </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Abdominal exam </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Test rebound as "Jump on and off table" </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Avoid removing hand rapidly (loses patient trust) </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Rectal Exam necessary </div> <bR> <bR> <div> <B>Labs </B></div> <div> <B>Screening </B></div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Complete Blood Count </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Erythrocyte Sedimentation Rate </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Urinalysis </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Urine Pregnancy Test (Urine HCG) when appropriate </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Liver Function Tests </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Amylase </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Lipase </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Consider additional testing </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Helicobacter pylori titer </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Ova and Parasites (e.g. Giardia) </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Hepatitis Serologies (A,B,C) </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Lead Ingestion </div> <bR> <bR> <div> <B>Radiology </B></div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Flat and Upright abdominal XRay (KUB) </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Consider </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Barium Enema </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">RUQ Ultrasound </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Pelvic Ultrasound </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Abdominal CT </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Skeletal Survey (assess physical abuse) </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Upper GI with small bowel follow through </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Upper endoscopy (EGD) </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Colonoscopy </div> <bR> <bR> <bR> </td> </tr></table></body>