Abdominal Pain in Children: History Taking and Differential Diagnoses

Overview

Communication skills

Where possible, include children/young people in the history-taking process. An older child or adolescent may not want to discuss sensitive information in front of parents, or an infant or very young child with limited or no speech requires the history to be taken from the parents. In older children, finding the balance between autonomy and getting a full history can be tricky. In general, where possible, histories from both children and parents should be collected and interpreted.

Remember, the child is your patient, not the parent.

Problems encountered in paediatric history taking

Asking closed questions may be problematic in children. Children may often say yes to closed questions as they may think it is the ‘correct answer’, especially if they are anxious. It is better to use open questions where possible.

• For example, it is better to ask “Where does it hurt?” and let the child point to where it hurts rather than asking “Do you have stomach pain?” and the child says yes.

As well as this, only taking the history from the parent/carer and not involving the child (where possible) may be problematic. The carer may state a feature that they think is going on based on what they think the child’s behaviour means. This impairs the ability to collect a good history and the parent/carer may have biases and influence their reporting of symptoms.

History of Presenting Complaint

Overview

With each symptom, always (if relevant) ask about:

• When did it start?
• Did it come on suddenly or gradually?
• Is it continuous or intermittent?
• Has this ever happened before?

Abdominal pain

Assess abdominal pain with SOCRATES:

• Site – where is the pain?
  • E.g. right lower quadrant pain may suggest appendicitis, diffuse pain may suggest peritonitis, epigastric pain may suggest gastro-oesophageal reflux disease
• Onset – when did the pain start?
  • What was the child doing when it started?
  • Is it continuous or intermittent?
• Character – what does the pain feel like?
  • E.g. sharp, stabbing pain can suggest appendicitis
• Radiation – does the pain spread anywhere?
  • E.g. central pain radiating to the right lower quadrant can suggest appendicitis
• Associated symptoms – see review of systems below
• Timeline – how long has the pain been ongoing?
  • Is it getting better, worse, or staying the same?
• Exacerbating/relieving factors – does anything make the pain better or worse?
• Severity – how would they rate the pain?
  • The Wong-Baker FACES pain rating scale may be useful as shown below:

Also remember to ask about abdominal trauma.

Paediatric systems review

Briefly screen for the following, and adjust where appropriate:

• Screening for general features:
  • Fever, chills, rigours, sweating
  • Crying – is it consolable or inconsolable?
  • Growth, weight loss 
  • Behaviour, appetite, alertness, activity, sleeping
• Screening for cardiorespiratory features:
  • Cough, shortness of breath
  • Noisy breathing (stridor, wheezing), rapid breathing
  • Cyanosis
• Screening for gastrointestinal features:
  • Vomiting – check if there is any blood, coffee-ground bits, or bile making it green
  • Diarrhoea, constipation, stool character (e.g. mucus, blood, melaena etc.)
    • Bloody diarrhoea is generally rare in children and may be due to infection or inflammatory bowel disease
  • Abdominal pain, abdominal distension
• Screening for genitourinary features:
  • Urine output and hydration – number of wet nappies, number of times using the toilet
  • Dysuria, frequency, urgency, enuresis, loin pain
  • Haematuria
  • Scrotal swelling
  • In adolescents, ask about menstruation and urethral discharge
• Screening for neurological features:
  • Headaches, neck stiffness, photophobia
  • Level of consciousness
  • Seizures, fits, falls, or ‘funny turns’
  • Changes in gait, abnormal movements
  • Vision changes, hearing changes
  • Hypotonia (floppiness), hypertonia (stiffness, spasticity)
• Screening for ear, nose, and throat features:
  • Ear: pain, discharge, hearing changes
  • Nose: epistaxis, discharge, congestion
  • Throat, mouth, and neck: sore throat, neck swelling, limited neck movement, mouth ulcers
• Screening for haematological features:
  • Bleeding, bruising, gum bleeding, fatigue, pallor 
• Screening for skin features:
  • Rash, itching, crusting, oozing, changes in skin pigmentation
• Screening for musculoskeletal features:
  • Limp, limitation in movement
  • Joint pain, joint swelling, joint stiffness

Birth

• How was the pregnancy?
  • Any abnormal scan results or extra scans? Why?
  • Any problems? – including maternal illness, diabetes, alcohol, drinking, drug use
• What happened during birth?
  • Number of weeks gestation?
  • Weight at birth?
  • Birth location? – such as in hospital, at home?
  • Mode of delivery? – vaginal delivery, caesarean section?
  • Any complications to both the mother or child during or after birth?
  • Did they need to stay in hospital for longer/was there any admission to neonatal intensive care?

Feeding and toileting

• Ask about diet and appetite:
  • What is their diet and appetite usually like and what is it like now?
  • Breastfed or formula milk?
  • When and how did weaning start?
• Ask about toileting:
  • Are they toilet trained?
  • How often do they go to the toilet/how many wet nappies?

Growth

• How is their weight?
  • Are they gaining weight, staying the same, or struggling to gain weight?
  • Do they have their personal child health record (PCHR, the ‘red book’)
• Have they started puberty?
  • Usually 8-13 for girls, 9-14 for boys 

Development

• Is the child meeting developmental milestones?
• Are there any concerns with development?
• How is school/nursery progress and attendance?
• Perform a developmental assessment if necessary

Immunisations

• Are they up to date with their immunisations?

General questions

• Do they have any other medical conditions?
• Have they ever had any previous surgery?
• Do they take any regular medications?
• Do they take any over-the-counter medications, herbal remedies, or supplements?

Sexual history

In some young people, a sexual history may be necessary. Remember to bear in mind that young people may not be comfortable answering these questions in front of parents/carers.

Family History

• Is there any family history of anything similar?
• In some autosomal recessive inherited diseases, consanguinity may be possible, ask about this sensitively if necessary

Allergy History

• Are they allergic to anything?
  • What happens during the allergic reaction?

Social History

• Ask about their home situation:
  • Who’s at home?
    • Ask about parents/carers, siblings, other people at home
  • What support does the child and parent/carer have?
  • What is their housing situation? – e.g. cramped housing
  • What are the parent’s occupations?
  • How is the parents’/carers’ mental health?
• Ask about the child’s activities including school and nursery:
  • Does the child go to school/nursery?
  • Has the child had to stay home from school/nursery?
• Ask about smoking, drinking, and illicit drug use sensitively:
  • Does anyone smoke inside or outside of the house?
  • Does anyone drink alcohol inside the house?
    • If relevant, does the young person drink alcohol?
  • Does anyone at home use illicit drugs?
    • If relevant, does the young person use illicit drugs?
• Ask questions regarding safeguarding:
  • Are they known to social services?
  • Are there any safeguarding concerns?
  • You may need to separately ask the child about safeguarding concerns including:
    • Are they at risk of harm?
    • Are they being made to do things they don’t want to do?
• Ask about possible infectious contacts:
  • Is anyone else at home ill?
  • Has anyone in school/nursery been ill?
  • Has there been any recent foreign travel?

Physical Examinations

Overview

In children, abdominal pain can present from multiple areas of the body alongside the abdomen, such as the genitalia (e.g. testicular torsion), the heart and lungs etc.

Therefore, children should have a full general examination including vital signs, an abdominal examination, a cardiovascular examination, a respiratory examination, and an ENT examination.

A growth chart may also be plotted.

Investigations

Overview

When suggesting investigations in an OSCE, the BOXES (Blood tests, orifice tests, x-rays, ECGs, special tests) mnemonic is useful for deciding the order of investigations. Some investigations may include:

• Blood tests:
  • Full blood count (FBC):
    • May show leukocytosis suggesting infection
  • Urea and electrolytes (U&Es):
    • May identify electrolyte abnormalities and/or renal dysfunction
  • Erythrocyte sedimentation rate (ESR) or C-reactive protein (CRP):
    • Non-specific markers of inflammation
  • Liver function tests (LFTs):
    • May show derangements in hepatobiliary/pancreatic disorders
  • Amylase/lipase:
    • May be elevated in pancreatitis
  • Blood sugar:
    • May show hypo/hyperglycaemia
  • Pregnancy test (beta human chorionic gonadotrophin:
    • Order a pregnancy test for all people who are post-menarche
  • Blood cultures:
    • If sepsis is suspected
• Orifice tests:
  • Urinalysis:
    • Should be performed in all patients, ideally at least a dipstick
  • Pregnancy test:
    • Order a pregnancy test for all people who are post-menarche
  • Stool culture:
    • If an infection is suspected
  • Faecal calprotectin:
    • If inflammatory bowel disease is suspected
  • Sputum culture:
    • If pneumonia is suspected
  • Nucleic acid amplification tests (NAAT):
    • For sexually transmitted infections
• X-rays:
  • Chest X-ray:
    • If pneumonia is suspected
  • An abdominal X-ray may be requested by a senior clinician:
    • If obstruction is suspected
• Special tests:
  • Ultrasound scans:
    • Usually arranged following discussion with seniors
    • May identify pelvic organ pathology (e.g. ovarian torsion) or testicular torsion

Differential Diagnoses: Neonates, Infants, and Toddlers

Infantile colic

• A history and examination may reveal:
  • Infant is <5 months of age when symptoms start and stop
  • Recurrent and prolonged episodes of crying, fussing, or irritability that can occur without an obvious cause and cannot be prevented or resolved by caregivers
  • There is no evidence of faltering growth, fever, or illness
  • Episodes occur in the late afternoon or evening
  • Drawing the knees up may also occur
  • Normal physical examination
• Diagnosis is clinical and urinalysis is normal

Gastro-oesophageal reflux disease (GORD)

• A history may reveal:
  • Reflux after larger feeds with troublesome features (e.g. distressed behaviour such as excessive crying when feeding, unexplained difficulties feeding, cough, hoarseness etc.)
  • Older children may be able to say they have epigastric, burning pain

Intussusception

• A history and examination may reveal:
  • Usually seen in younger children (<3 years old)
  • Infants have episodes of colicky pain with pain-free periods
  • During episodes of pain, the infant may draw their knees up and turn pale
  • There may be a sausage-shaped abdominal mass
  • There may be bloodstained stool similar to ‘red-currant jelly’ – a late sign
• Investigations:
  • Ultrasound scan:
    • Investigation of choice, may show target-shaped mass

Hirschsprung’s disease

• A history and physical examination may reveal:
  • Abdominal distention and constipation are more prominent and often precede vomiting
  • There is usually a history of delayed meconium passage (>48 hours of life)
  • More common in boys
• Investigations:
  • Abdominal X-ray:
    • To distinguish between obstruction/distention of the small bowel and colon, as this can be difficult to do in infants
  • Rectal biopsy is diagnostic:
    • Shows an absence of ganglion cells

Necrotising enterocolitis

• A history and physical examination may reveal:
  • Common in premature and/or low birth weight neonates and seen in weeks 2-3 of life
  • Feeding intolerance, bilious vomiting, abdominal distension
  • The neonate may be generally unwell with apnoea, lethargy, bloody stools, peritonitis, and shock
• Investigations:
  • Abdominal X-ray – the investigation of choice and should be performed as soon as the diagnosis is suspected
    • May show:
      • Dilated bowel loops
      • Bowel wall thickening
      • Pneumatosis intestinalis – gas in the bowel wall
    • Pneumoperitoneum if perforation has occurred

Meckel’s diverticulum (MD)

• A history and physical examination may reveal:

• Most patients are asymptomatic and a few present with inflamed diverticula that can mimic appendicitis
• Rectal bleeding – MD is the most common cause of painless massive gastrointestinal bleeding (requiring transfusion) in children aged 1-2 years
• Inflammation of the diverticula (diverticulitis):
  • May cause pain similar to appendicitis
• Intestinal obstruction – due to volvulus and intussusception
  • May present with severe/complete constipation and vomiting 
• Investigations:
  • Technetium-99m scan (‘Meckel’s scan’) – diagnostic
    • Performed if the patient is haemodynamically stable
  • Mesenteric angiography:
    • May be performed in unstable patients to localise the haemorrhage

Malrotation and volvulus and intestinal obstruction

• A history and physical examination may reveal:
  • Bilious vomiting – intestinal obstruction (due to volvulus in this case) until proven otherwise
  • Intestinal obstruction may also occur due to adhesions from previous surgery
  • Severe abdominal pain out of proportion to examination findings may be present
  • The infant may be severely unwell and in shock
  • Requires emergency surgery due to the risk of bowel ischaemia and necrosis, and subsequent peritonitis, sepsis, and death
• Investigations:
  • Ultrasound scanning:
    • To screen for intussusception
  • Upper gastrointestinal contrast studies:
    • The diagnostic test for malrotation

Bowel obstruction

• A history and physical examination may reveal:
  • Bilious vomiting – intestinal obstruction until proven otherwise
  • Nausea, abdominal distension
  • Not passing stool or flatus
• Investigations:
  • Abdominal X-ray:
    • May show dilated bowel loops

Differential Diagnoses: Children

Constipation

• A history and physical examination may reveal:
  • Poor diet, reduced fluid intake
  • A history of a neuromuscular disorder (e.g. cerebral palsy)
  • Straining when defecating, painful defecation, overflow incontinence
  • Symptoms improve with defecation
  • Examination findings are minimal, however, mild tenderness and a faecal abdominal mass may be felt
• Investigations:
  • Diagnosis is clinical

Gastroenteritis

• A history and physical examination may reveal:
  • Nausea, vomiting, diarrhoea
  • There may be associated fever, coryza, and malaise
  • Recent foreign travel
  • Other household members may be ill
  • Features occur acutely.
• Investigations:
  • U&Es:
    • Electrolyte abnormalities can be caused by diarrhoea and vomiting
    • May show renal dysfunction if dehydrated
  • Urinalysis:
    • To screen for UTI
  • Stool microscopy and culture:
    • May identify underlying pathogen

Appendicitis

• A history and physical examination may reveal:
  • Appendicitis starts with central abdominal pain that localises to the right iliac fossa
  • There may be associated fever, anorexia, nausea, and vomiting
  • Acute appendicitis is rare in infants
• Investigations:
  • Full blood count (FBC):
    • Leukocytosis may be present
  • C-reactive protein (CRP):
    • May be elevated
  • Urine dipstick test:
    • May show leukocytes
  • Ultrasound scan:
    • Diagnostic

Mesenteric adenitis

• A history and physical examination may reveal:
  • There is usually a history of a recent or current upper respiratory tract infection
  • Generalised lymphadenopathy may be present
  • Abdominal pain is diffuse

Differential Diagnoses: Adolescents

Ectopic pregnancy

• Severe sudden-onset unilateral pain in the lower left quadrant (LLQ) or right lower quadrant (RLQ) with associated vaginal bleeding
• There is usually a 6-8-week period of amenorrhoea
• An adnexal mass may be felt during a pelvic examination
• Rebound tenderness may be seen if a ruptured ectopic pregnancy is seen
• Shoulder tip pain may be seen when passing urine or opening the bowels due to peritoneal bleeding
• Pregnancy tests are essential to rule out ectopic pregnancy
• Always keep child maltreatment in mind for pregnancy or sex-related presentations 

Primary dysmenorrhoea

• A history and physical examination may reveal:
  • Recurrent crampy pain that starts a few hours before a period
  • Pain usually starts in the lower abdomen but can radiate to the back or inner thigh
  • Pain usually lasts for up to 72 hours as the period goes on
  • Other gynaecological symptoms (e.g. dyspareunia, menorrhagia, postcoital bleeding) are not present
• Investigations:
  • The diagnosis is clinical, but an ultrasound scan may be useful to screen for other pelvic pathologies

Mittelschmerz (ovulation pain)

• A history and physical examination may reveal:
  • Sharp, sudden pain that lasts for a few minutes and up to 2 days occurring midcycle
  • Usually unilateral and on the side of the ovary releasing the egg
• Investigations:
  • The diagnosis is clinical, but an ultrasound scan may be useful to screen for other pelvic pathologies

Ovarian torsion

• Sudden-onset severe unilateral pain in the LLQ or RLQ
• Nausea and vomiting are commonly present
• There may be a history of trauma or exercise
• On examination, adnexal tenderness and cervical motion tenderness may be seen, but no abnormal discharge
• Some vaginal bleeding may be seen and a very small amount of patients may have a fever
• Investigations:
  • Ultrasound scan:
    • May show a whirlpool sign or free fluid in the pelvis

Ruptured ovarian cyst

• A history and physical examination may reveal:
  • May present similarly to ovarian torsion with sudden-onset severe unilateral pain in the LLQ or RLQ
  • There may be a history of trauma or exercise before the onset of pain
  • Light vaginal bleeding may be seen
  • There may be peritonism in the lower abdomen and pelvis
• Investigations:
  • Ultrasound scan:
    • May show the cyst itself or free fluid

Testicular torsion

• A history and physical examination may reveal:
  • Acute testicular pain – may be intermittent as spontaneous detorsion can occur
  • Nausea, vomiting
  • Absent cremasteric reflex
  • Prehn’s sign negative – elevating the testis does not alleviate pain
• Investigations:
  • Testicular ultrasound

Irritable bowel syndrome

• Consists of abdominal pain, bloating, and changes in bowel habits with no rectal bleeding or unintentional weight loss
• Abdominal pain is often relieved by defecation
• Symptoms do not correlate with gluten consumption
• Investigations are unremarkable

Pelvic inflammatory disease

• May be seen in patients who have or have risk factors of sexually-transmitted infection (e.g. Chlamydia or gonorrhoea)
• May also occur following the insertion of an intrauterine device
• Menstrual irregularities, abnormal vaginal discharge, and fever may be seen
• Cervical excitation or adnexal tenderness may be present on examination

Differential Diagnoses: Other

Type 1 diabetes mellitus (T1DM) and diabetic ketoacidosis (DKA)

• The incidence of type 1 diabetes mellitus has increased recently, suspect T1DM/DKA in young children and infants if they are drinking more than usual, having more wet nappies, losing weight, are dehydrated etc.
• A history and physical examination may reveal:
  • Features are generally acute and patients may have abdominal pain
  • There may be associated nausea and vomiting, and reduced consciousness
  • There may be a history of polyuria and polydipsia
  • A triggering stressor may precede the event, such as pneumonia and urinary tract infections
  • Kussmaul’s breathing may be seen (deep and gasping hyperventilation)
  • Signs of hypovolaemia may be seen such as tachycardia, hypotension, delayed capillary refill time
  • The patient’s breath may smell like acetone
• Investigations:
  • Blood glucose:
    • Elevated
  • U&Es:
    • May show low sodium and high potassium
  • Urinalysis:
    • Positive for glucose and ketones and may be positive for nitrites if an infection is present
  • Arterial blood gases:
    • Show metabolic acidosis

Abdominal trauma due to child maltreatment

• A history and physical examination may reveal:
  • Child maltreatment may be possible, parent/carer explanations may not be consistent with the child’s presentation 
  • Bruising on non-bony parts of the body including the abdomen is unusual
  • Lacerations over areas usually covered with closes, including the abdomen, are unusual
  • Abdominal trauma without accidental trauma should raise suspicion of child maltreatment
  • Abdominal pain may be associated with distension
  • See Child maltreatment

Sepsis

• A history and physical examination may reveal:
  • Non-specific features: Fever (not always present, temperature may be normal or low), nausea, vomiting
  • Changes in behaviour and consciousness: apathy, lethargy, listlessness, reduced activity, may be difficult to rouse or drowsy
  • Features of shock: tachycardia, tachypnoea, hypotension, prolonged capillary refill time, reduced oxygen saturations in air, petechiae/purpura, altered mental status
• Investigations:
  • If sepsis is suspected, start sepsis 6 and arrange senior review:
    • Blood cultures
    • Urine output
    • Fluids intravenously
    • Antibiotics intravenously
    • Lactate measurement
    • Oxygen supplementation
  • Full blood count (FBC):
    • May show leukocytosis
    • May show thrombocytopenia if disseminated intravascular coagulopathy develops
  • Blood lactate:
    • May be elevated
  • Blood culture:
    • May identify underlying organism
  • Urinalysis:
    • May identify causative underlying organism
  • Chest X-ray:
    • May show evidence of pneumonia
  • Lumbar puncture (if not contraindicated):
    • May identify causative underlying organism

Coeliac disease

• A history and physical examination may reveal:
  • Recurrent, crampy abdominal pain, diarrhoea, may have steatorrhoea
  • There may be associated distention, dermatitis herpetiformis
  • Failure to thrive, underweight, short stature
  • There may be a personal/family history of autoimmune disease including type 1 diabetes and hypothyroidism
• Investigations:
  • Full blood count (FBC):
    • May show anaemia
  • Coeliac disease screening:
    • May be positive
  • Endoscopy and jejunal biopsy:
    • Diagnostic

Crohn’s disease

• A history and physical examination may reveal:
  • A history of chronic diarrhoea may be present
  • There may be associated fatigue, weight loss, and fever
  • An ileocaecal (right lower quadrant) mass may be present on exam
  • Oral ulcers and perianal disease (e.g. skin tags, fistulae, abscesses etc.) may be
  • present
• Investigations:
  • FBC:
    • Anaemia may be seen
  • ESR/CRP:
    • ESR/CRP may be elevated
  • Faecal calprotectin:
    • May be positive

Ulcerative colitis

• A history and examination may reveal:
  • A history of chronic diarrhoea may be present – more commonly bloody than in Crohn’s disease
  • Faecal urgency and tenesmus may be present
  • Extra-intestinal features (e.g. joint pain) may be present
• Investigations:
  • FBC:
    • Anaemia may be seen
  • ESR/CRP:
    • ESR/CRP may be elevated
  • Faecal calprotectin:
    • May be positive

Acute pancreatitis

• A history and physical examination may reveal:
  • Acute-onset severe epigastric or mid-abdominal pain that classically radiates to the back
  • There may be a history of specific causes such as biliary colic, alcohol misuse, or certain drugs
  • Pain may be severe on palpation
  • Flank bruising may be seen (Grey-Turner’s sign) or periumbilical bruising (Cullen’s sign)
• Investigations:
  • FBC:
    • May show leukocytosis
• Serum lipase/amylase:
  • Elevated at least by 3 times the upper limit of normal

Urinary tract infection

• A history and physical examination may reveal:
  • Dysuria or crying when passing urine with associated back pain
  • Tenderness in the suprapubic area
  • In neonates and infants, symptoms are very non-specific and may only present with fever, lethargy, irritability, nausea, vomiting, and poor feeding
  • Renal angle tenderness may be present if pyelonephritis occurs
• Investigations:
  • Urine dipstick:
    • May show nitrites and leukocytes
  • Urine microscopy, culture, and sensitivity:
    • May identify the causative underlying pathogen
    • Recurrent UTIs may require ultrasound scans, dimercaptosuccinic acid (DMSA) scans, and micturating cystourethrograms. See Urinary Tract Infections in Children.

Pneumonia

• A history and physical examination may reveal:
  • Cough with or without sputum
  • Coryza, malaise, anorexia, nausea, or vomiting 
  • Tachypnoea, tachycardia, dullness on percussion, decreased breath sounds, crackles, and cyanosis may be present 
  • A diagnosis of pneumonia should be considered if any of the following apply:
    • A high fever (>39°C)
    • Persistently focal crackles
• Investigations:
  • FBC:
    • May show leukocytosis suggesting infection
  • Chest X-ray:
    • May show consolidation
  • Sputum culture, microscopy, and sensitivity:
    • Identifies underlying organism

Haemolytic uraemic syndrome

• A history and physical examination may reveal:
  • More common in young children
  • A triad of thrombocytopenia, microangiopathic haemolytic anaemia, and acute kidney injury
  • Diarrhoea is present that turns bloody after 1-3 days
  • Fever and vomiting may be present
  • Anaemia are present: fatigue, pallor, shortness of breath
  • Jaundice may be present – due to haemolysis
  • Bleeding and bruising may be present – due to thrombocytopenia
• Investigations:
  • Full blood count (FBC) and reticulocytes:
    • Haemoglobin – reduced
    • Platelets – reduced
    • Reticulocyte count – increased
  • Blood film:
    • Schistocytes
  • Urea and electrolytes (U&Es):
    • Urea and creatinine increased – AKI
    • Metabolic acidosis may be seen – diarrhoea
  • Markers of haemolysis:
    • Bilirubin – elevated
    • Lactate dehydrogenase (LDH) – increased
    • Haptoglobins – low
  • Direct Coomb’s test:
    • Negative – rules out autoimmune haemolytic anaemia
  • Stool culture:
    • May detect Shiga toxin-producing E. coli
  • Polymerase chain reaction (PCR):
    • May detect Shiga toxin

IgA vasculitis (Henoch-Schönlein purpura)

• A history and physical examination may reveal:
  • There may be a history of a recent upper respiratory tract infection
  • Purpuric rash over the extensor surfaces of the arms and legs and buttocks
  • Polyarthritis
  • Abdominal pain
  • IgA nephropathy (recurrent episodes of haematuria and slight proteinuria)
• Investigations:
  • Blood pressure:
    • Elevated if renal involvement present
  • Urinalysis:
    • May show haematuria, proteinuria, or casts if renal involvement present
  • Renal biopsy:
    • A renal biopsy shows mesangial IgA deposition

Adrenal insufficiency

• A history and physical examination may reveal:
  • There may be general abdominal pain, nausea, vomiting, and weight loss
  • Postural hypotension, dizziness, and syncope may be present
  • Skin hyperpigmentation may be seen
  • Fevers may be present
• Investigations:
  • Blood glucose:
    • May show hypoglycaemia – more common in children
  • U&Es:
    • Hyponatraemia and hyperkalaemia may be seen
  • Blood gases:
    • May show normal ion gap metabolic acidosis