Abdominal pain - acute symptoms

Key points

• Repeated examination of the abdomen helps to see whether signs persist or evolve and how the child responds to treatment.
• Appropriate analgesia should be given; it does not mask potentially serious causes of pain.
• Most children need no investigations; targeted tests are guided by the most likely cause.
• Appendicitis in young children may not present with classic symptoms and can present as sepsis or perforation.
• Children with possible surgical or gynaecological causes should be referred early.

Overview

This Royal Children's Hospital Melbourne clinical practice guideline covers the assessment and management of acute abdominal pain in children. Abdominal pain is a common non-specific symptom, often due to self-limited conditions such as gastroenteritis, constipation and viral illness; the key task is to separate conditions that need specific or urgent, particularly surgical, management.

Causes by age

In neonates, urgent causes include intussusception, necrotising enterocolitis, volvulus, incarcerated hernia, testicular torsion, sepsis and Hirschsprung-associated enterocolitis. In infants and children they include abdominal trauma, appendicitis, foreign body ingestion such as button batteries, intussusception, pyloric stenosis, testicular or ovarian torsion, toxin ingestion, diabetic ketoacidosis, sepsis and malignancy; in adolescents also ectopic pregnancy and ovarian cyst torsion or rupture. Common non-urgent causes include constipation, gastroenteritis, urinary tract infection and mesenteric adenitis, as well as extra-abdominal causes such as pneumonia, tonsillitis or migraine. In neonates, parents may attribute symptoms to abdominal pain, so a broad differential is needed. Non-specific abdominal pain is common, but red flags for other causes should be assessed before making this diagnosis.

History and examination

History covers pain characteristics, systemic symptoms, diet, stools, vomiting (bilious or bloody), urinary symptoms, menstrual, sexual and psychosocial history in adolescents, and underlying medical conditions. Examination includes the child's movements, gait and level of comfort, vital signs and hydration, inspection and palpation of the abdomen for focal or generalised tenderness, percussion and rebound tenderness, guarding, masses and palpable faeces, and examination of the genitalia. Serial examination of the abdomen is required. Rectal or vaginal examination is rarely indicated; it should be discussed with a senior clinician and, if needed, performed only once.

Investigations and treatment

Investigations are directed by the likely differential diagnosis: urinalysis (with culture or a pregnancy test if indicated), liver function tests, lipase, venous blood gas, blood glucose, full blood examination and CRP. An abdominal X-ray is for suspected obstruction and does not help in diagnosing constipation. Ultrasound should be discussed with a senior clinician; it is useful in suspected ovarian torsion or intussusception but is not indicated in the initial assessment of testicular torsion, where it may delay time-critical surgery. Treatment follows the likely cause: fluid resuscitation if required, adequate analgesia (IV morphine or intranasal fentanyl may be needed for severe pain), fasting depending on the differential with enteral or IV fluids if diagnosis is delayed, a nasogastric tube if bowel obstruction is suspected, and early surgical or gynaecological referral.

Consultation and discharge

Consultation with the local paediatric team is advised for a suspected surgical cause, severe pain, signs of peritonism, bilious vomiting, scrotal pain or swelling, or a child needing admission. Discharge can be considered when there are no concerning features, the presentation fits non-specific abdominal pain, follow-up is arranged and parents know when to seek medical attention.

Frequently asked questions

Does pain relief hide serious causes of abdominal pain?

No. The guideline states that appropriate analgesia should be used and will not mask potentially serious causes.

Do all children with acute abdominal pain need blood tests or imaging?

No. Most children need no investigations; tests are chosen according to the most likely diagnosis.

Why is appendicitis harder to recognise in children under 5 years?

It is often diagnosed late and may lack classical symptoms, presenting instead with fever, vomiting, perforation, sepsis or diarrhoea mimicking gastroenteritis.

Source

The Royal Children's Hospital Melbourne. Clinical Practice Guidelines: Abdominal pain - acute. Last updated April 2024. Endorsed by the Paediatric Improvement Collaborative (PIC). This summary was prepared by Medpresso from the original guideline and is not a substitute for the full text or for medical advice.