Pediatric Emergency Medicine

Pearls & Pitfalls: Pediatric Abdominal Pain Misdiagnosed

Larry Mellick, MD, MS, FAAP, FACEP
Professor of Emergency Medicine
Medical College of Georgia

Pearl: Pneumonia can present as abdominal pain in children.

Presentation: Twice within 24 hours, an 11-year-old male presented with midepigastric pain, vomiting, and a fever. At the first early morning visit, and despite the absence of diarrhea, the discharge diagnosis was gastroenteritis. At his second presentation, his temperature was 38.2° C, and his abdominal pain was reported as 7/10 on a numeric descriptor scale. Despite his history of asthma, the patient's presentation included no signs and symptoms associated with the respiratory system. Auscultation of the patient's lungs demonstrated no evidence of rales or ronchi. His bowel sounds were normal, but his midepigastric area was moderately tender to palpation. His amylase and lipase were normal, and his white count was 16,100 cells per cubic mm. Pneumonia was considered our next logical possibility to explain the abdominal pain, and an X-ray was ordered. (See Fig 1.) Subsequently, the patient's father added that his wife, a radiologist at a neighboring hospital, had mentioned the possibility of pneumonia.

Discussion: The most common typical bacterial pneumonia in all children is pneumococcal pneumonia. In one retrospective review of 254 children and young adults (age <1 month to 26 years) with pneumococcal pneumonia, the most common signs and symptoms were as follows1 

Fever: 90 percent, 
Cough: 70 percent; productive cough: 10 percent 
Tachypnea: 50 percent   
Malaise/lethargy: 45 percent 
Emesis: 43 percent 
Hypoxemia (oxygen saturation 95 percent): 50 percent 
Decreased breath sounds: 55 percent 
Crackles: 40 percent 

On the other hand, the presentation of pneumonia can be predominantly abdominal pain. The abdominal pain associated with pneumonia may be related to the basilar location of the pneumonia and be referred through a shared dermatome or mesenteric adenitis has been reported in these patients.2,3 

So, when you are evaluating abdominal pain, have a practical differential diagnoses list. Sure, hyperthyroidism, lead poisoning, Addison's disease, pancreatitis, porphyria, and abdominal migraine may be a cause of pediatric abdominal pain, but when was the last time you diagnosed one of these conditions? Here is my practical list of nonsurgical causes of abdominal pain in some semblance of rank order for what children of this age range might come to the emergency department. 

Acute gastroenteritis 
Bacterial food poisoning 
Functional or irritable bowel 
Streptococcal pharyngitis 
Urinary tract infections 
Sickle cell crisis 
Diabetic ketoacidosis 
Mesenteric adenitis

  1. Tan, TQ, Mason, EO Jr, Barson, WJ, et al. Clinical characteristics and outcome of children with pneumonia attributable to penicillin-susceptible and penicillin-nonsusceptible Streptococcus pneumoniae. Pediatrics 1998; 102:1369. 
  2. Moustaki M, Zeis PM, Katsikari M, et al. Mesenteric lymphadenopathy as a cause of abdominal pain in children with lobar or segmental pneumonia Pediatr Pulmonol. 2003 Apr;35(4):269-73. 
  3. Kanegaye JT, Harley JR. Pneumonia in unexpected locations: an occult cause of pediatric abdominal pain. J Emerg Med. 1995 Nov-Dec;13(6):773-9. 


[ Feedback → ]