Abdominal Pain - Acute


  • Statewide logo

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

  • See also

    Adolescent Gynaecology
    Intussusception
    DKA
    Acute scrotal pain or swelling
    Constipation
    Gastroenteritis

    Henoch Schonlein Purpura
    Headache (Migraine)

    Pneumonia (Community acquired)

    Unsettled or crying infant (Colic)
    Urinary Tract Infection (UTI)
    Sepsis
    Poisoning - Acute Guidelines for Initial Management (Toxin exposure or overdose)

    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 need no 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 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 Causes of Abdominal Pain by Age 
    Time critical illnesses are in Red

    Neonates

    Infants and Children

    Adolescents

    Hirschprungs enterocolitis

    Incarcerated hernia

    Intussusception

    Irritable/unsettled infant

    Meckels diverticulum

    Necrotising enterocolitis

    Testicular torsion

    UTI

    Volvulus

       

    Appendicitis

    Abdominal trauma

    Constipation

    DKA

    Gastroenteritis

    Henoch Schonlein Purpura

    Incarcerated hernia

    Intussusception

    Meckel’s diverticulum

    Mesenteric adenitis

    Migraine

    Pneumonia

    Pyloric stenosis

    Testicular torsion

    UTI

    Volvulus

    Appendicitis

    Abdominal trauma

    Cholecystitis/

    Cholelithiasis

    Constipation

    DKA

    Ectopic pregnancy

    Gastroenteritis

    Inflammatory Bowel disease

    Migraine

    Ovarian cyst-torsion or rupture

    Pancreatitis

    Pelvic Inflammatory Disease/STI

    Renal calculi

    Testicular torsion

    UTI

    Important non-abdominal causes of abdominal pain to consider:

    Assessment

    History

    Symptoms and signs with associated differential diagnose

    Acute Abdominal Pain

    Past medical history: associated with rarer causes of abdominal pain

    • Children with Hirschprung’s disease and Cystic Fibrosis can develop a complication known as enterocolitis which 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.
    • In children with liver disease, nephrotic syndrome, splenectomy, ascites and those with VP shunts primary bacterial peritonitis can occur.
    • Children on chemotherapy and immunosuppressant agents are at increased risk of pancreatitis.
    • Children who are tube fed including PEG/NG/NJ are at increased risk of pancreatitis.
    • In children with inflammatory bowel disease, especially those with concurrent C. difficile infection or immunocompromised children, toxic megacolon can occur.

    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
    • Children with peritonism:
      • will often not want to move in the bed
      • will be unable to walk or hop comfortably
      • will have abdominal tenderness with percussion
      • internal rotation of the right hip can irritate an inflamed appendix
    • Inguinoscrotal examination, including testes.
      • Look for hernia.
    • Look for basal pneumonia.
    • 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)
          • Is not clinically indicated for testicular torsion and may delay time critical surgery.
          • Useful if the history is suggestive of intussusception, even if examination is normal.

    Treatment

      • Fluid resuscitation may be required. (see Intravenous fluids)
      • Provide adequate analgesia. IV morphine may be required or intranasal fentanyl as initial analgesia in severe pain. (see Analgesia and sedation)
      • Keep children fasting and commence maintenance fluids if a surgical cause is suspected.
      • Early referral of children with possible diagnoses requiring surgical management.
      • Consider a nasogastric tube if bowel obstruction is suspected.
      • Consider IV antibiotics in surgical causes (discuss with the surgical team first).

    Consider consultation with local paediatric or surgical team when:

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

    Consider transfer when:

    Child requiring care beyond the comfort level of the hospital.
    Note: When transferring infants or children with possible surgical conditions, ensure the child has adequate analgesia, venous access and intravenous fluids prior to transfer as third space losses can be large and lead to haemodyanamic collapse.
    For emergency advice and paediatric or neonatal ICU transfers, call the Paediatric Infant Perinatal Emergency Retrieval (PIPER) Service: 1300 137 650.

    Consider discharge when:

    • Many children with Non-specific abdominal pain can be discharged home after history and examination (see 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  

    Kids Health Info: Abdominal pain

    Additional Notes

    Appendicitis in young children (pre-school)

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

     Non-specific abdominal Pain

    • Some children suffer recurrent nonspecific abdominal pain, with no organic cause identifiable. This is usually termed Non-specific abdominal pain and affects 10-15% of children (usually primary school aged).
    • Children present with intense severe pain. They often cannot bend over or get comfortable. In between episodes they feel completely fine.
    • Diagnosis can only be made if pain remits completely and there is no associated vomiting, change in bowel habit or oral intake or any fever.
    • Constipation is sometimes a contributing factor, but tends to be overdiagnosed as a cause of abdominal pain.
    • Psychogenic factors (eg: family, school or other stressful issues) need to be considered in some cases.
    • Non-pharmacological measures (reassurance, relaxation, rubbing and heat packs) can be tried and often help.
    • Follow-up is important. Consider outpatient referral for General Paediatric / Adolescent clinic assessment.

    Last updated February 2018