Stomach Ache- Is It Time For A Visit From The Surgeon?

I can still see my oldest daughter, 10 years-old then, with her forehead on the dinner table.  She could not eat, her stomach hurt too bad.  At that time she was having some school trouble, so my wife and I passed it off as anxiety or a virus, and excused her to go lie on the couch.  Later that night when I got home from violin lessons, my wife and daughter were curled up together on my daughter’s bed.  Now the pain was on her right lower side, and was getting worse.  I had a feel of her abdomen, and we went to my Emergency Department.  There were blood and urine tests and an IV, a visit from the surgeon, and the next morning my daughter had her appendix taken out.

Abdominal pain is a common reason for visits to the Emergency Department.  Often parents are worried that the pain means something bad, like appendicitis, that needs surgery.  When the pain is accompanied by vomiting and diarrhea, parents worry that the child might get dehydrated.  The diarrhea and vomiting is messy too, and they want it to stop.  Parents also come because the pain just plain hurts, and they don’t want to see their child suffer.

So when is stomach ache not an emergency?  First, when it starts with diarrhea and vomiting, that is usually a “stomach virus,” an infection the child caught from someone else.  The vomiting usually only lasts half a day, the diarrhea for 3 to 4 days, and it is unusual for a child to get so dehydrated that they need to come to the Emergency Department.  The cramps are typically mild and easily treated with pepto-bismol, ibuprofen, or tylenol.  When a child vomits, food and milk need to be withheld for 6 hours, and he or she given only clear liquids like gatorade, starting with small amounts to go easy on the stomach. 

Abdominal pain that has been going on for weeks and months is also not an emergency.  Pain going that long needs to be seen by the kid’s regular doctor, who can organize a methodic search for the cause, or refer the child to a specialist if the pain continues.  By definition, pain that lasts weeks is not an emergency-the child would have already needed hospitalization or surgery in the first few days of pain if it were.  Going to Emergency Departments for chronic pain means seeing a different doctor every time and having expensive, haphazard, thus and sometimes ineffective strategies for diagnosis and treatment.  Chronic pain is often caused by constipation, or anxiety, or a combination of these and other factors.

What is an emergency?  The most common emergency with abdominal pain in children is appendicitis.  Appendicitis typically starts with pain, not vomiting and fever.  The pain is steady and slowly worsens.  It rarely comes and goes.  Later in the course, after the pain has moved to the right lower side, comes the fever and vomiting.  Diarrhea is unusual in appendicitis.  Appendicitis needs surgery, so if the child has steadily worsening pain, call your doctor or bring him in to the Emergency Department.

Severe pain, where the kid is rolling about on the floor crying with pain, needs to come in.  This is often because of cramping from constipation, but pain that bad needs to be looked at.  Occasionally severe pain can be caused by something worse, like kidney stones in a teenager or a blockage in a toddler. 

Other worrisome signs with abdominal pain are vomiting for more than 8 hours.  Dehydration becomes a concern after that, and the parent should call the doctor to talk about it.  A child who becomes progressively more tired and lethargic is concerning.  This could mean dehydration or a worse infection than a stomach virus.  Finally, any child with abdominal pain and shortness of breath needs to come right in.  Again, this could mean a worsening infection or dehydration.

So next time your child starts with some vomiting, has diarrhea with some cramps, relax.  It is probably a stomach virus, will run its course, and just needs some clear liquids and over-the-counter medicine like peptobismol or tylenol.  If your kid has pain that steadily worsens or is severe, call your doctor.  Your child too may need a visit from a surgeon.

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