Abdominal pain
| See also: | Adolescent Gynaecology - Lower Abdominal Pain Intussusception Guideline UTI Guideline Gastroenteritis Guideline Pneumonia Guideline Constipation Guideline |
Assessment
The assessment of the child with acute abdominal pain depends on a good history and careful examination. The following algorithm may be used as a guide to the systematic consideration of various categories of causes of acute abdominal pain.
Typical features of some important causes of acute abdominal pain in children are described in the following table.
| Diagnosis | Typical features | |
| History | Examination | |
| Acute appendicitis | Abdominal pain becomes increasingly severe, and often localises to RIF | tenderness, guarding, and rebound usually greatest in right iliac fossa, though may be more diffuse. |
| Intussusception | Intermittent colicky abdominal pain, vomiting and the passage of blood and/or mucus per rectum. There is frequently a preceding respiratory or diarrhoeal illness. | Pallor, lethargy. A sausage-shaped mass is palpable in about 2/3 of cases, crossing the midline in the epigastrium or behind the umbilicus |
| Midgut volvulus | Bowel obstruction - abdominal pain, distension; usually bile-stained vomiting | Distension, tenderness |
| Constipation | can present with quite severe abdominal pain in children; often recurrent | Firm stool palpable in lower abdomen (sometimes entire colon) |
| UTI | infants: fever, vomiting, lethagy. older children: dysuria, haematuria | fever; suprapubic tenderness; loin tenderness if associated pyelonephritis; FWT may be +ve (leukocyte esterase, nitrites) |
| Pneumonia | fever; may have cough, vomiting | fever; tachypnoea, recession; focal signs at one base |
| Gastroenteritis | vomiting, diarrhoea, fever | tenderness, increased bowel sounds; signs of dehydration |
Management
- Establish intravenous access, and measure electrolytes if the patient appears dehydrated, and cultures of blood and stool if potentially septic.
- Fluid resuscitation may be required (initial bolus 20ml/kg normal saline)
- Keep the patient fasted until surgical assessment
- Provide adequate analgesia
- Place a nasogastric tube if bowel obstruction
Notes
- Acute appendicitis must be considered in any child with severe abdominal pain. In the very young child, in whom the risk of perforation is higher, the presenting symptoms are less specific. The diagnosis is clinical - no laboratory or radiological tests are required.
- The peak age for intussusception is 6-12 months. Plain AXR may show signs of bowel obstruction, with decreased gas in the right colon. The diagnosis is confirmed by air insufflation or barium enema, with reduction usually possible by the same means (unless signs of peritonitis - risk of perforation).
- Midgut volvulus is commonest in the newborn period, but can occur in later childhood. Predisposing factors include malrotation and abnormal mesentery.
- Vomiting is rarely due to constipation.
- Some children suffer recurrent non-specific abdominal pain, with no organic cause identifiable. Constipation is often an important contributing factor. Psychogenic factors (eg. family, school issues) need to be considered. These children should be referred for general paediatric assessment.
- Some less common diagnoses need to be considered in patients with certain underlying chronic illnesses. Hirschsprungâs disease can be complicated by enterocolitis, with sudden painful abdominal distension and bloody diarrhoea. These patients can become rapidly unwell with dehydration, electrolyte disturbances, and systemic toxicity, and are at risk of colonic perforation. Primary bacterial peritonitis can occur in children with nephrotic syndrome, splenectomy and those with VP shunts.
