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.

Belly Pain- Is it an Appendix?

A common reason for parents to bring their kids to the ED is belly pain.  Doctor’s offices and “quick care” urgent care clinics also send us a lot of kids with belly pain.  Everyone has the same  basic concern- is it appendicitis?  Does the child need an operation?

In this column and on my TV spot on KATC, I often encourage families to stay home or wait to see their doctor for things that are obviously not emergencies.  Runny noses, fevers, diarrhea, rashes, even ear pain- Stay home!  Give ibuprofen!  Belly pain, though, should not be waited on very long.  Belly pain lasting more than a few hours needs to be discussed with a doctor, first on the phone, and then in the office or E.D.

What is appendicitis?  The appendix is a tiny pouch that usually hangs off your intestines in your right lower side.  Appendicitis is when poop gets trapped in the appendix, gets infected, and the appendix slowly swells like a boil.  With swelling and infection comes pain, fever, and nausea.  A “ruptured” appendix is when the appendix bursts and the pus and infection spread throughout the abdomen.  We always hope to diagnose appendicitis and get it out before rupture, but that is sometimes just not possible.

Though most belly pains turn out to be stomach virus or constipation, the diagnosis of appendicitis can be tricky.   Early on appendicitis can act like stomach virus and fool the doctor.  Sometimes the child is admitted to the hospital, the doctors and surgeons debate and ponder, and finally days later the surgeon decides to take the patient to surgery for the pain.  Only then, with the patient opened up, does the surgeon look in and go “ah-ha” and make the diagnosis.

With belly pain, first call your doctor.  Some doctors are comfortable making the diagnosis in the office and then sending the patient right to a surgeon.  Some refer the family to the ED for diagnosis.  Make sure you take your child to a hospital that cares for children and has surgeons available.  In Lafayette, that is Lafayette General Medical Center and usually Women’s and Children’s Hospital too.

What does a child with appendicitis look like?  First, the pain starts as a steady, slowly worsening pain.  Often the pain starts in the middle of the belly, under the belly  button, and later is more in the right lower side.  Kids with appendicitis lose their appetite and sometimes vomit later in the illness.  They also often have later fevers.  This is usually unlike stomach virus, where kids vomit first, have early fevers, and have crampy belly pain that comes and goes away.

At the hospital, the ED doctor and surgeon often make the diagnosis and decide on surgery by just taking a history (hearing the ”story” of the illness) and examining the child.  Few tests are needed besides a few blood tests.  CT scanning is usually unnecessary.  One estimate is that only 10% of appendicitis cases need a CT to make the diagnosis.  CT adds a lot of radiation exposure, and sometimes can miss an appendicitis or mislead the doctors with extraneous information.

The surgery itself is usually uncomplicated and safe, as long as the appendix hasn’t ruptured.  The child often goes home in a day or two after surgery.  If the appendix has ruptured, that means recovery takes a week or two of antibiotics and care in the hospital.

So if your child has belly pain, but is walking, smiling, eating and the pain goes away soon, it probably is not appendicitis.  If he or she starts with pain that is steady and worsening over some hours, come on in!