Abdominal pain - acute

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  • See also

    Abdominal pain - chronic
    Adolescent gynaecology - lower abdominal pain
    Acute scrotal pain or swelling 
    Constipation
    Vomiting

    Key Points

    1. Repeated examination is useful to identify the persistence or evolution of signs, and evaluate response to treatment
    2. Appropriate analgesia should be used and will not mask potentially serious causes of pain
    3. Investigations are guided by the most likely cause. Most children do not need investigations
    4. Appendicitis in young children may not present with classic symptoms and can present as sepsis or perforation

    Background

    • Abdominal pain is a common non-specific symptom that is often associated with self-limited conditions such as gastroenteritis, constipation and viral illness
    • The key consideration in acute abdominal pain is the differentiation between conditions which require specific or urgent management, particularly surgical management
    • Non-specific abdominal pain is common. Assess for red flags for other causes prior to making this diagnosis. See Abdominal pain - chronic
    • Symptoms in neonates may be attributed by parents as abdominal pain. A thorough examination and a broad differential should be considered in this group. Also see Unsettled baby

    Causes of abdominal pain by age

     

    Conditions requiring urgent medical or surgical management

    Other common causes

    Neonates

    Intussusception
    Necrotising enterocolitis
    Volvulus
    Incarcerated hernia 
    Testicular torsion
    Sepsis
    Hirschsprung associated enterocolitis (HAEC)

    Dietary protein allergy

    Infants and children

    Abdominal trauma
    Appendicitis (see Appendicitis in young children <5 years old under additional notes)
    Foreign body ingestion (eg button battery)
    Intussusception  
    Pyloric stenosis
    Volvulus
    Testicular torsion
    Ovarian torsion
    Incarcerated hernia
    Toxin ingestion
    DKA
    Sepsis
    Malignancy (eg neuroblastoma, Wilms tumour)

    Constipation
    Gastroenteritis
    Urinary tract infection
    Mesenteric adenitis  
    Epididymitis
    Henoch-Schönlein purpura
    Hip pathology
    Migraine
    Myocarditis/pericarditis
    Respiratory tract infections (tonsillitis/pharyngitis, pneumonia)
    Hepatitis
    Meckel's diverticulitis 

    Adolescents

    Abdominal trauma 
    Appendicitis 
    Ectopic pregnancy
    Ovarian cyst - torsion/rupture 
    Testicular torsion
    DKA
    Sepsis
    Primary bacterial peritonitis


    Constipation 
    Gastroenteritis 
    Urinary tract infection
    Cholecystitis/  
    Cholelithiasis  
    Pancreatitis
    Hepatitis
    Inflammatory bowel disease 
    Pelvic inflammatory disease
    Renal calculi
    Epididymitis
    Hip pathology
    Migraine
    Myocarditis/pericarditis

    Assessment

    History

    • Pain characteristics and associated symptoms (see Additional notes for causes associated with these pain characteristics)
    • Systemic symptoms: fever, lethargy, irritability, anorexia, weight loss
    • Dietary history
    • Stool eg diarrhoea, constipation, blood, mucus 
    • Vomiting eg bilious, blood
    • Urinary symptoms eg dysuria, polyuria, polydipsia
    • Menstrual and sexual history in adolescents
    • Psychosocial history, HEADSSS in adolescents
    • Neonates and infants may present with persistent crying, irritability, poor feeding and lethargy, draw up legs, refusal to weight bear
    • Underlying medical conditions (see Additional notes for medical conditions with complications which may cause abdominal pain)

    Examination

    • Observe the child's movements, gait, position and level of comfort
    • Vital signs, hydration
    • Abdomen
      • Inspect for distension, herniae, bruising
      • Palpate for
        • focal vs generalized tenderness
        • percussion tenderness and, if negative, rebound tenderness*
        • guarding or rigidity*
        • abdominal masses
        • palpable faeces
      • Serial examination of the abdomen is required
    • Examine genitalia eg for testicular torsion
      • Rectal or vaginal examination is rarely indicated in a child, this should be discussed with a senior clinician and if needed, should only be performed once
    • Assess for extra-abdominal causes (see Causes of abdominal pain by age table above)

    *Peritonism:

    • Children will often not want to move in the bed and will be unable to walk or hop comfortably, and will have abdominal tenderness with percussion, internal rotation of the right hip can irritate an inflamed appendix

    Management

    Investigations

    Most children need no investigations
    Targeted investigation is directed by the likely differential diagnoses. These may include:

    • Urine analysis (+/- culture +/- pregnancy test if indicated)
    • LFTs eg for hepatitis
    • Lipase eg for pancreatitis
    • Venous blood gas for lactate/acidosis
    • Blood glucose for DKA
    • LFTs, lipase and UEC for abdominal injury
    • FBE and CRP (+/- ESR) eg for inflammatory/infectious cause such as inflammatory bowel disease
    • Imaging
      • AXR if obstruction suspected. It is not helpful in diagnosing constipation
      • CXR if pneumonia is suspected
      • Ultrasound may be requested after discussion with a senior clinician (very low yield if used indiscriminately)
        • It is not clinically indicated in the initial assessment for testicular torsion and may delay time critical surgery. May be requested after discussion with surgeons
        • Useful in suspected ovarian torsion
        • Useful if the history is suggestive of intussusception, even if examination is normal
        • May identify renal calculi

    Treatment

    Treatment will be guided by the likely cause

    • Fluid resuscitation may be required (see Intravenous fluids)
    • Provide adequate analgesia. IV morphine or intranasal fentanyl may be required as initial analgesia in severe pain (see Acute pain management)
    • Consider fasting, depending on differential diagnosis. Consider enteral or intravenous fluids if assessment or diagnosis is delayed, eg 4 hours if very young (see local fasting guidelines)
    • Early referral of children with possible diagnoses requiring surgical or gynaecological management
    • Consider a nasogastric tube if bowel obstruction is suspected

    Consider consultation with local paediatric team when

    • Surgical cause suspected
    • Severe pain
    • Signs of peritonism
    • Bilious vomiting
    • Scrotal pain/redness and swelling
    • Child requiring admission

    Consider transfer when

    Child requires care beyond the comfort level of the local hospital.
    Note: Prior to transferring infants or children with possible surgical conditions, ensure the child has adequate analgesia, venous access and intravenous fluids

    For emergency advice and paediatric or neonatal ICU transfers, see Retrieval Services

    Consider discharge when

    • There are no concerning clinical features
    • Presentation consistent with non-specific abdominal pain (see Abdominal pain - chronic)
    • A clear follow-up plan has been arranged, eg with local GP
    • Parents have been given advice regarding when to seek medical attention

    Parent information

    Abdominal pain

    Additional notes

    Appendicitis in young children <5 years old

    • Often diagnosed late in the course of illness
    • May not present with classical symptoms
    • Presentation often includes
      • fever, vomiting, abdominal pain
      • perforation or sepsis
      • diarrhea mimicking gastroenteritis
    • Requires careful attention to fluid and antibiotic management.

    Causes of abdominal pain based on pain characteristics and associated symptoms

    Quality

    Causes

    Sudden onset

    Testicular or ovarian torsion/rupture 
    Intussusception  
    Volvulus
    Perforated viscus
    Incarcerated hernia

    Episodic/colicky

    Constipation 
    Gastroenteritis 
    Intussusception  
    Mesenteric adenitis
    Ovarian torsion

    Dull, increasing severity and localisation

    Appendicitis

    Location

    Causes

    Epigastric or right upper quadrant

    Pancreatitis
    Cholecystitis
    Cholelithiasis
    Gastritis/peptic ulcer disease
    Pleural effusion
    Pneumonia

    Central/periumbilical

    Constipation 
    Gastroenteritis 
    Mesenteric adenitis
    Bowel obstruction
    Intussusception  

    Right lower quadrant

    Appendicitis
    Ectopic pregnancy
    Ovarian cyst - torsion/rupture 
    Intussusception 
    Incarcerated hernia

    Left lower quadrant

    Constipation
    Ectopic pregnancy
    Ovarian cyst - torsion/rupture 
    Inflammatory bowel disease
    Hirschsprung associated enterocolitis (HAEC)
    Incarcerated hernia

    Associated symptoms

    Causes

    Bloody diarrhoea

    Gastroenteritis 
    Meckel diverticulum
    Inflammatory bowel disease

    Bilious vomiting

    Volvulus
    Obstruction

    Polyuria, polydipsia, weight loss

    DKA

    Dysuria, frequency and fever

    Urinary tract infection

    Vomiting and diarrhoea

    Gastroenteritis 

    Vomiting without diarrhoea

    Urinary tract infection
    Obstruction
    Volvulus
    Ovarian torsion

    Cough, fever, SOB

    Pleural effusion
    Pneumonia


    Underlying condition

    Potential complications causing abdominal pain

    Hirschsprung disease

    Enterocolitis

    • presents with sudden painful abdominal distension and bloody diarrhoea.
    • children can rapidly deteriorate with dehydration, electrolyte disturbances and systemic toxicity and are at risk of colonic perforation

    Cystic fibrosis

    Liver disease and/or ascites

    Primary bacterial peritonitis

    Nephrotic syndrome

    Splenectomy

    VP shunt

    Peritoneal dialysis

    Chemotherapy

    Pancreatitis

    On immunosuppressants

    PEG/NG/NJ fed

    Inflammatory bowel disease (especially if concurrent Clostridium difficile)

    Toxic megacolon

    Immunocompromised

    Sickle cell disease

    Vaso-occlusive crisis

    • acute painful episodes of abdominal pain

    Cholecystitis

    Obesity

    Cholelithiasis

    Spina bifida/coeliac disease

    Constipation

    Previous surgery

    Bowel obstruction

    Last updated April 2024

  • Reference List

    1. D’Agostino, J. Common abdominal emergencies in children, Emergency Medicine Clinics of North America. 2002. 20 (1), 139 – 153
    2. Jaffe DM, Reynolds SL. Diagnosing abdominal pain in a pediatric emergency department. Pediatric Emergency Care. 1992. 8 (3), 126 – 128
    3. Leung AK, Sigalet DL. Acute abdominal pain in children. Am Fam         Physician 2003; 67:2321
    4. Radzik D, Zaramella C. Early analgesia for children with acute abdominal pain: Is it applicable without affecting diagnostic accuracy. Acute Pain. 2007. 9 (1), 48-49
    5. Ravichandran D, Burge DM. Pneumonia presenting with acute abdominal pain in children. Br J Surg 1996; 83:1707
    6. Reynolds SL, Jaffe DM. Diagnosing abdominal pain in a pediatric emergency department. Pediatr Emerg Care 1992; 8:126
    7. Scholer SJ, Pituch K, Orr DP, Dittus RS. Clinical outcomes of children with acute abdominal pain. Pediatrics 1996; 98:680
    8. Tsao K, Anderson KT. Evaluation of abdominal pain in children.  https://bestpractice.bmj.com/topics/en-us/787  (viewed 14 October 2023)