Clinical Practice Guidelines

Abdominal pain

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    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

    • 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


    Infants and Preschool

    School age child


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


    Henoch Schonlein Purpura
    Mesenteric adenitis
    Ovarian Pathology
    Testicular torsion
    Viral Illness

    Ectopic pregnancy
    Inflammatory Bowel disease
    Ovarian cyst-torsion or rupture
    Pelvic Inflammatory Disease
    Renal calculi
    Testicular torsion
    Viral illness



    • 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


    • 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.


    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.


    • 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