1 Introduction

Abdominal discomfort is a prevalent pediatric presentation in the emergency room [1], with acute appendicitis being the most common surgical etiology [2]. Abdominal discomfort in children may result from several illnesses, ranging from benign medical issues such mesenteric adenitis, gastroenteritis, or constipation to severe complications like as perforated appendicitis, intussusception, or malrotation with volvulus [3].

Abdominal pain is a leading cause of kid visits to doctors and emergency departments. The causes of stomach pain range from mild self-limited illnesses to significant medical disorders requiring urgent medical intervention, hence pediatric abdominal pain is split into two groups. Female teenagers are more likely to have constipation, functional digestive difficulties, gastroenteritis, colitis, urinary tract infections, lung infections, and pelvic inflammatory disease, which do not require surgery [4]. The second group includes acute abdominal emergencies that require surgical intervention due to life-threatening dangers. Depending on the injury site, acute abdominal emergencies can be traumatic or non-traumatic [5].

Appendicitis, a condition in which the appendix becomes inflamed and infected, is another common cause of abdominal pain in children with a peak incidence during adolescence, and requires urgent medical attention [6, 7].

Diagnosing appendicitis and ruling out other conditions is frequently challenging, particularly in infants who may be unable to articulate their symptoms. Imaging modalities are increasingly employed yet possess restrictions, such as exposure to ionizing radiation (computed tomography) and reliance on operator proficiency (ultrasonography) [8, 9]. Furthermore, postponements in conducting imaging may hinder the timely initiation of final treatment in pediatric patients necessitating surgical intervention [10]. Consequently, the assessment of abdominal pain in pediatric patients in the emergency department should focus on distinguishing between those with clinically significant conditions requiring surgical intervention and those with nonspecific presentations who may require additional diagnostic evaluation, including laboratory or imaging studies, observation and reassessment in the emergency department, or surgical referral.

Diabetic ketoacidosis, lower lobe pneumonia, and acute porphyria should be considered in patients with moderate-severe pain with little localizing findings in abdomen [8].

Gynecological causes of the pediatrics abdominal pain in 6-16 yrs. age children include ovarian torsion and menstruation-related pain. Ovarian torsion occurs when the ovary twists on its axis, cutting off its blood supply, and can cause severe abdominal pain. Menstruation-related pain, also known as dysmenorrhea, is common in adolescent girls and can cause lower abdominal pain and cramping during menstruation [9].

It is important for healthcare providers to evaluate children presenting with abdominal pain thoroughly to determine the underlying cause and appropriate treatment. A careful history and physical examination, along with appropriate laboratory and radiologic tests, can help to narrow down the possible causes of abdominal pain. Treatment may include medications, lifestyle changes, or surgery according to the specific etiology [10].

This study was clarified to determine the causes, associated symptoms, and clinical outcomes of abdominal pain in pediatric age group 6-16 years old admitted to the Emergency Department of Al Diwaniyah maternity and children teaching Hospital, in Diwaniyaha Governorate, Republic of Iraq.

2 Patients and methods

2.1 Study design and setting

This cross-sectional study was conducted at the Maternity and Children Teaching Hospital, Al Diwanyah, Iraq, from from the 5-1-2022 to 24-4-2022. The hospital is a tertiary care center that caters to the medical needs of the local pediatric population.

2.2 Study population

The study population comprised pediatric age group 6-16 years old admitted to Emergency Department of the hospital with complaints of abdominal pain during the study period.

2.3 Sample size

A total of 66 pediatric patients were enrolled in the study, following a non-probability consecutive sampling technique. Patients were included if they were of pediatric population and presented with abdominal pain. Patients with a chronic underlying disease causing abdominal pain, such as renal failure, inflammatory bowel disease , sickle cell disease or who had received chemotherapy in previous three months were excluded from the study. Exclusion criteria were applied before the data was taken.

2.4 Data collection

Information was gathered through a structured questionnaire administered to the patient’s parents or caregivers, and through clinical examination and medical records review. The questionnaire included demographic data such as age, gender, and weight was measured by weight scale, as well as a detailed history of the abdominal pain, including onset, duration, site, severity, character, radiation, and any associated symptoms. Information about any relieving and aggravating factors of the pain was also collected. A detailed family history of similar diseases and recent travel history was obtained.

2.5 Clinical examination and diagnosis

All patients underwent a thorough clinical examination by a senior pediatrician, which included general physical examination and focused abdominal examination. Based on the history, clinical examination, and necessary Initial laboratory tests include complete blood count (CBC), total serum bilirubin (TSB), serological test for Hepatitis A, stool analysis, urinalysis, abdominal and chest radiography and ultrasonography are done to the patients accordingly to associated symptom. Laboratory and imaging investigations, a provisional diagnosis was made.

2.6 Statistical analysis

The collected data were entered into a computerized database and analyzed using Statistical Package for Social Sciences (SPSS) version 25. Descriptive statistics were used to summarize the data. Categorical variables were presented as frequencies and percentages. Continuous variables were presented as mean and standard deviation. A chi-square test was used to examine the association between categorical variables. A p-value of less than 0.05 was considered statistically significant.

2.7 Ethical considerations

The study was conducted in accordance with the ethical principles of the Declaration of Helsinki. Ethical approval was obtained from the authorities of the Maternity and Children Teaching Hospital. Consent was obtained from the parents or caregivers of all participants. All data were kept confidential and used for research purposes only.

3 Results

The demographic characteristics of patients enrolled in this study are shown in Table 1. The mean age of all enrolled patients was 9.80 ±2.89 years and it ranged between 6 to 16 years. There was no significant difference in mean age between males and females (p = 0.431). The mean weight of all enrolled patients was 28.23 ±10.44 kg and it ranged between 14 to 60 kg. There was significant difference in mean weight between males and females (p = 0.046) and the mean weight was higher in females in comparison with males.

Characteristic of abdominal pain are shown in Table 2. Regarding site most commonly pain was central in location followed by being generalized and then other sites included epigastric site, lower abdomen, right upper quadrant, right lower quadrant, left upper quadrant and lumber site. Onset was most commonly gradual and less frequently sudden, 71.2 % versus 28.8 %, respectively and there was no significant difference between males and females regarding onset of pain (p = 0.327). With respect to duration of pain, it was categorized into minutes (31.8 %), hours (37.9 %) and days (30.3 %) and there was no significant difference in duration of pain between males and females (p = 0.247). Severity of pain was classified into mild, moderate and severe, which were seen in 19.7 %, 42.4 % and 37.9 %, respectively and severe pain was significantly higher in females in comparison with makes and mild pain was more common in males in comparison with females (p = 0.048). Regarding character of pain, colic was the most frequent one and with respect to radiation, no radiation was the rule. Other associated symptoms are shown in Table 3 including constipation, diarrhea, fever, joint pain, nausea, vomiting, dysuria, frequency, urgency, polyuria and change in urine color; nevertheless, none of these symptoms was significantly higher with respect to gender (p \(>\) 0.05). Investigations are shown in Table 4 including x-ray, CBC, GUE, GSE, Widal test, renal function test and liver function test. No significant difference in investigations was seen in enrolled males and females (p \(>\) 0.05). Diagnosis was outlined in Table 5.

4 Discussion

This study aimed to investigate the pediatric age group 6-16 years old and provide insights into the problem by analyzing demographic characteristics, pain characteristics, associated symptoms, relieving and aggravating factors, and diagnoses. The findings of this study can be compared and contrasted with previous studies to gain a comprehensive understanding of the issue.

The present study found that appendicitis accounted for 6.1% of the cases, which is lower than the findings of Reust and Williams [11] , who reported appendicitis as the most common cause of acute abdominal pain requiring surgery. However, it is important to note that the current study had a large proportion of undiagnosed cases (53.0%), which may include more instances of appendicitis or other surgical causes of abdominal pain.

Functional abdominal pain disorders (FAPDs) were not specifically identified in this study. Still, the high percentage of undiagnosed cases may indicate the presence of FAPDs, such as irritable bowel syndrome (IBS), functional dyspepsia, abdominal migraine, and functional abdominal pain not otherwise specified (FAP-NOS), as described by Thapar et al. [12]. These disorders involve complex interactions within the microbiota–gut–brain axis and require further investigation to elucidate their underlying mechanisms and potential interventions.

The current study identified gastroenteritis as a cause of abdominal pain in 6.1% of cases, which is considerably lower than the 31% reported by Kim [13]. However, it is worth mentioning that the current study’s undiagnosed cases may include more instances of gastroenteritis or other non-surgical causes of abdominal pain.

The findings of the current study are in line with the study conducted by Bacchetta et al. [14], which reported that urinary tract infections (UTIs) and related symptoms are more prevalent in females across different age groups, including pediatrics. Both studies attribute this higher prevalence to anatomical differences between the sexes, with females having a shorter urethra that potentially allows bacteria easier access to the urinary tract.

As for the other symptoms – gas, constipation, diarrhea, heartburn, fever, joint pain, nausea, and vomiting – the current study found that the prevalence of these symptoms did not significantly differ between genders. While Harrington and Hooton’s study does not specifically address the gender distribution of these symptoms, it is widely accepted in the medical literature that the prevalence of these symptoms can vary depending on a multitude of factors such as age, geography, diet, and other environmental or genetic factors. Therefore, the finding in the current study that these symptoms do not significantly differ between genders may align with other studies depending on these specific circumstances and populations examined.

Chronic abdominal pain, defined as recurrent or persistent abdominal pain lasting more than two months, was not specifically investigated in this study. However, Kim et al. [15], reported constipation as a major cause of chronic abdominal pain in children, which was also identified in 15.2% of the present study’s cases. Furthermore, the undiagnosed cases in the current study may involve chronic abdominal pain caused by FAPDs, inflammatory bowel disease, peptic ulcer disease, or lactose intolerance.

Abdominal/pelvic ultrasound is the best modality for initial evaluation of many causes of pediatric abdominal pain and considers the first investigation in almost all cases of acute abdomen [16, 17].

5 Conclusion

This study provides valuable insights into the prevalence, risk factors, and specific causes of pediatrics abdominal pain in 6-16 yrs. age children. Our findings, along with those of previous studies, highlight the complex nature of pediatric abdominal pain and its significant impact on children’s well-being, including their quality of life and school attendance. Moreover, our study emphasizes the importance of early identification and appropriate management of abdominal pain in children to minimize its negative effects on their lives. Further research should focus on investigating the undiagnosed cases and exploring potential causes, improved diagnostic techniques, and interventions to better manage abdominal pain in children.