Abdominal pain - acute

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  • See also

    Adolescent Gynaecology
    Acute scrotal pain or swelling
    Constipation
    Intussusception

    Key Points

    1. Repeated examination is useful to look for the persistence or evolution of signs and evaluate response to treatment
    2. 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. True bilious vomiting is dark green and warrants urgent surgical input

    Background

    • The key consideration in acute abdominal pain is the differentiation between surgical and non-surgical causes
    • Non specific abdominal pain is very common but is a diagnosis of exclusion once red flags are considered.  See "Additional Notes" below for more details
    • Symptoms in neonates may be attributed by parents as abdominal pain. A thorough examination and a broad differential should be considered in this group. See  unsettled baby

    Common and time critical causes of abdominal pain by age

    Neonates

    Infants and Children

    Adolescents

    Hirschprung enterocolitis
    Incarcerated hernia 
    Intussusception
    Necrotising enterocolitis
    Volvulus
       

    Abdominal trauma 
    Appendicitis 
    Constipation 
    Gastroenteritis 
    Incarcerated hernia 
    Intussusception 
    Meckel diverticulum 
    Mesenteric adenitis  
    Ovarian torsion
    Pyloric stenosis  
    Testicular torsion 
    Volvulus

    Appendicitis  
    Abdominal trauma 
    Cholecystitis/  
    Cholelithiasis  
    Constipation 
    Ectopic pregnancy
    Gastroenteritis 
    Inflammatory bowel disease 
    Ovarian cyst – torsion/rupture 
    Pancreatitis  
    Pelvic Inflammatory Disease
    Renal calculi
    Testicular torsion

    Important non-abdominal causes of abdominal pain to consider:
    DKA
    Headache (Migraine)
    Henoch Schonlein Purpura 
    Hip pathology
    Pneumonia
    Psychological factors
    Sepsis
    Sexually transmitted infection
    Sickle Cell Disease (vaso-occlusive crisis)
    Toxin exposure or overdose
    UTI/pyelonephritis

    Assessment

    History

    Symptoms and signs with associated differential diagnoses (the following diagram is not an exhaustive list and presentations can overlap)
    Abdominal-pain-flowchart

    Relevant past medical history

    Underlying condition

    Potential complications causing abdominal pain

    Hirschprung Disease

    Enterocolitis
    (presents with sudden painful abdominal distension and bloody diarrhoea. These 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

    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)

    Examination

    • Observe the child’s movements, gait, position and level of comfort
    • Examine the abdomen for:
      • focal vs generalised tenderness
      • rebound tenderness*
      • guarding or rigidity*
      • abdominal masses
      • distension
      • palpable faeces
    • Assess for non-abdominal causes as above

    *Peritonism:

    • Child 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

    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

    Management

    Investigations

    Most children need no investigations

    Investigations to consider, depending on differential diagnosis, may include the following:

    • Urine analysis (+/- culture +/- pregnancy test if indicated)
    • Electrolytes +/- LFTs 
    • Lipase for pancreatitis
    • Venous blood gas
    • Blood sugar for DKA
    • LFTs, lipase and UEC in abdominal injury
    • Imaging
      • AXR if obstruction suspected. It is not helpful in diagnosing constipation
      • CXR if pneumonia is suspected
      • Ultrasound may be requested after discussion with senior staff (very low yield if used indiscriminately)

    Treatment

    Treatment will be guided by the likely aetiology

    • 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  Analgesia and sedation)
    • Keep children fasting. Consider enteral or intravenous fluids if assessment or diagnosis is delayed (consult 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 / surgical team when:

    • Surgical cause suspected
    • Severe pain not responding to analgesia
    • Child requiring admission

    Consider transfer when:

    Child requiring care beyond the comfort level of the 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:

    • Many children with non-specific abdominal pain can be discharged home after history and examination ( see "Additional Notes" below)
    • A clear follow up plan should be arranged, often with a local GP
    • Parents should be informed of when to seek medical attention

    Parent information

    Abdominal pain
    NSW Children’s Hospital Fact Sheets  

    Additional notes

    Appendicitis in young children

    • Often a late diagnosis
    • May not present with classical symptoms
    • Often presents as perforation or sepsis
    • Requires careful attention to fluid and antibiotic management

    Non-specific abdominal pain

    • Some children suffer recurrent non-specific abdominal pain, with no organic cause identifiable
    • Occurs in 10-15% of children (usually primary school aged)
    • Diagnosis can only be made if pain remits completely and there is no associated vomiting, fever and change in bowel habit or oral intake
    • Psychological factors (eg: family, school or other stressful issues) need to be considered in some cases
    • Investigations are usually not indicated
    • Non-pharmacological measures (reassurance, relaxation, rubbing and heat packs) can be tried and often help
    • Follow-up is important. Consider outpatient General Paediatric / Adolescent referral

    Last updated November, 2019

  • Reference List

    1. D’Agostino, J. Common abdominal emergencies in children, Emergency Medicine Clinics of North America. 2002. 20 (1), 139 – 153 [Available from: https://www.sciencedirect.com/science/article/abs/pii/S0733862703000555?via%3Dihub, viewed June 2019]
    2. Jaffe DM, Reynolds SL. Diagnosing abdominal pain in a pediatric emergency department. Pediatric Emergency Care. 1992. 8 (3), 126 – 128 [Available from: https://www.ncbi.nlm.nih.gov/pubmed?term=1614900, viewed June 2019]
    3. 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
    4. Tsao K, Anderson KT. Evaluation of abdominal pain in children. Retrieved from https://bestpractice.bmj.com/topics/en-us/787 (viewed 15 June 2019)