Clinical Practice Guidelines

Abdominal pain

  • This guideline has been adapted for statewide use with the support of the Victorian Paediatric Clinical Network

    See also

    Background to condition

    • Abdominal pain in children can be caused by a wide range of surgical and non-surgical conditions.
    • Repeated examination may be useful to look for the persistence or evolution of abdominal signs.
    • Some children will have a cause found, however a significant number of children will be diagnosed with “nonspecific abdominal pain”.
    • Neonates often present due to parental concern over “perceived abdominal pain” and broad differentials for presentation should be considered.

    Common causes of Abdominal Pain
    Notes:

    • There is overlap between groups and classical symptoms may not be present; eg appendicitis in the preschool age group.
    • Functional abdominal pain is very common but is a diagnosis of exclusion.
    • Highlighted in red=time critical illness

    Neonates

    Infants and Preschool

    School age child

    Adolescents

    Hirschprung’s enterocolitis
    Incarcerated hernia
    Intussuception
    Irritable/unsettled infant
    Meckel’s diverticulum
    UTI
    Volvulus

    Appendicitis
    Gastroenteritis
    Intussusception
    Pneumonia
    UTI
    Volvulus
    Constipation

    Appendicitis
    DKA
    Gastroenteritis
    Henoch Schonlein Purpura
    Mesenteric adenitis
    Migraine
    Ovarian Pathology
    Pneumonia
    Constipation
    Testicular torsion
    UTI
    Viral Illness

    Appendicitis
    DKA
    Ectopic pregnancy
    Cholecystitis/
    Cholelithiasis
    Gastroenteritis
    Inflammatory Bowel disease
    Ovarian cyst-torsion or rupture
    Pancreatitis
    Pelvic Inflammatory Disease
    Renal calculi
    Testicular torsion
    UTI
    Viral illness


    Assessment

    History: 

    • Onset of pain
      •  sudden onset of pain,  consider
        • testicular or ovarian torsion
        • intussusception
        • perforated viscus. 
    • Character of pain
      • Episodic severe pain
        • intussusception
        • mesenteric adenitis,
        • gastroenteritis
        • constipation
      • Testicular torsion in patients with pain referred to the scrotum.
    • Associated Symptoms
      • Bilious vomiting implies volvulus or bowel obstruction and warrants surgical review. 
      • Pallor and lethargy during episodes of abdominal pain occurs in intussusception.
      • Rash and purpura on extensor surface of lower limbs/buttocks: consider Henoch Schonlein Purpura
      • Cough and fever with RUQ or LUQ pain- pneumonia
      • Dysuria, and frequency - UTI.
      • Polyuria, polydipsia, loss of weight - diabetic ketoacidosis
      • Menstrual and sexual history in post-pubertal girls as ectopic pregnancy can be fatal.   
    • Past medical history: associated with rarer causes of abdominal pain
      • Hirschprung’s disease and Cystic Fibrosis - complicated by enterocolitis with sudden painful abdominal distension and bloody diarrhoea. These patients can rapidly deteriorate with dehydration, electrolyte disturbances and systemic toxicity and are at risk of colonic perforation.
      • Primary bacterial peritonitis can occur in children with liver disease, nephrotic syndrome, splenectomy, ascites and those with VP shunts.
      • Pancreatitis can be caused by drugs including chemotherapy and immunosuppressant agents.
      • Inflammatory bowel disease- toxic megacolon

    Examination:

    • Assess hydration status
    • Children with peritonism
      • will often not want to move in the bed
      • be unable to walk or hop comfortably
      • Abdominal tenderness with percussion.
      • Internal rotation of the right hip can irritate an inflamed appendix.
    • Examine abdomen
      • focal vs generalised tenderness,
      • rebound tenderness,
      • guarding or rigidity
      • abdominal masses,
      • distension
      • palpable faeces. 
    • Respiratory examination.
    • Inguinoscrotal examination – including testes. Look for hernia
    • Rectal or vaginal examination is rarely indicated in a child and should only be performed by one person.

    Investigations:

    These will depend on differential diagnosis but may include the following. Many children need no investigations.

    • urine MCS
    • blood sugar for DKA
    • electrolytes +/- LFTs
    • Lipase (pancreatitis)
    • urine pregnancy test/ quantitative beta hCG
    • Coeliac serology and total IgA - consider for chronic abdo pain
    • Imaging
      • AXR if obstruction suspected. Not helpful in diagnosing constipation.
      • CXR if pneumonia suspected
      • Ultrasound
        • May be requested after discussion with senior staff
        • Is not clinically indicated for testicular torsion.

    Acute management

    • ABC
    • Early referral of patients with possible diagnoses requiring surgical management.
    • Fluid resuscitation may be required (initial bolus 20ml/kg normal saline)
    • Establish and maintain intravenous access in sick children.
    • Measure electrolytes and blood sugar if the patient appears dehydrated
    • Keep patients fasting if surgical cause suspected
    • Provide adequate analgesia – iv morphine may be required or  intranasal fentanyl as initial analgesia in severe pain (see Analgesia and sedation)
    • Consider a nasogastric tube if bowel obstruction suspected
    • Consider IV antibiotics in surgical causes (discuss with surgeon first)
    • Other investigations and management will be guided by clinical findings
    • Note: When transferring infants or children with possible surgical conditions, ensure analgesia, venous access and intravenous fluids as third space losses can be large and lead to haemodyanamic collapse.

    Discharge advice

    • Many children with nonspecific abdominal pain can be discharged home after history, examination and urine dipstick or microscopy with expectant management. 
    • A clear follow up plan should be arranged – often with a local GP. Parents should be informed of when to seek medical attention.

    Consider consultation with local paediatric or surgical  team

    • Severe pain
    • Diagnosis unclear
    • Patient requiring admission

    When to consider transfer to tertiary centre

    • Child requiring care beyond the comfort level of the hospital.

    For emergency advice and paediatric or neonatal ICU transfers, call the Paediatric Infant Perinatal Emergency Retrieval (PIPER) Service: 1300 137 650.

    Additional Notes:

    Appendicitis in young children

    • Rarely presents with classical symptoms
    • Often presents as perforation or sepsis
    • Usually a late diagnosis and requires careful attention to fluid and antibiotic management.

    Intussusception

    • Usually severe bouts of episodic pain
    • Followed by episodes of pallor and lethargy.
    • PR bleeding or “redcurrent jelly stool” is a late sign.

    Non-specific abdominal Pain:

    • Some children suffer recurrent nonspecific abdominal pain, with no organic cause identifiable. This is usually termed functional abdominal pain and affects 10-15% of children. 
    • Constipation is sometimes a contributing factor, but tends to be overdiagnosed as a cause of abdominal pain.
    • Psychogenic factors (eg: family, school issues) need to be considered in some cases.
    • Non-pharmacological measures (reassurance, relaxation, heat packs) can be tried.
    • Follow-up is important. Consider outpatient referral for General Paediatric / Adolescent clinic assessment.

    Last updated March 2013