Click for pdf: Approach to Pediatric abdominal pain
Abdominal pain in a child is one of the most common presentations with both trivial and life-threatening etiologies, ranging from functional pain to acute appendicitis. The majority of pediatric abdominal complaints are relatively benign (e.g. constipation), but it is important to pick up on the cardinal signs that might suggest a more serious underlying disease.
Diagnosing abdominal pain in children is also a challenging task. Conditions vary amongst age groups (ie. volvulus in neonates, intussusception in toddlers) and trying to thoroughly evaluate a child in pain can make the process all the more challenging.
BASIC ANATOMY AND PHYSIOLOGY
When taking a history and examining a child with abdominal pain, consider all the organs in the abdominal area. Pathologies of the lower lung (i.e. pneumonia) can often be interpreted as abdominal pain; similarly, genitourinary pathology (i.e. testicular torsion) can be as well. A sharp stabbing pain may suggest somatic involvement – this type of sensation is usually well localized; while dull, non-specific, throbbing pain suggests visceral involvement that is difficult to localize. Remember, the differential diagnosis of a child varies depending on their age group. (Table 1)
Table 1: Common causes of abdominal pain
|Intestinal obstruction (ie. volvulus, Hirshsprung, pyloric stenosis)||Peritonitis (i.e. necrotizing enterocolitis, GI perforation)|
|Trauma (i.e. during birth)|
Infant (<2 years)
|Hernia, volvulus, intussusception||Infantile dyschezia|
Children (2 – 18 years)
|Acute gastroenteritis||Urinary tract infection/ Pyelonephritis|
|Constipation||Toxin ingestion, food poisoning|
|Testicular torsion||Henoch-Schnolein Purpura|
|Respiratory illness, pneumonia,||Appendicitis, pancreatitis, cholecystitis|
Adolescents (12 – 18 years)
|Trauma||Toxin ingestion, food poisoning|
|Dysmenorrhea||Pregnancy (i.e. ectopic)|
|Pelvic inflammatory disease||Testicular torsion|
PRESENTATION AND EMERGENT CONSIDERATIONS
Acute pain lasts several hours to days while chronic pain can last from days to weeks to months. In a child presenting with abdominal pain, it is important to identify any emergent concerns and reach a timely diagnosis.
Red flag signs include:
- Bilious vomiting
- Bloody stool or emesis
- Night time waking with abdominal pain
- Hemodynamic instability
- Weight loss
Questions to ask
- Place/Location: identify the specific location of the pain, have child use one finger to locate her pain.
- Quality: pain can be a sharp stabbing pain (i.e. trauma) or diffuse, poorly, localized pain (i.e. chronic or visceral pain)
- Radiation: pain can radiate from its point of origin in any direction
- Severity: degree of pain on a scale of 10
- Timing/Onset: onset of the pain, duration of pain, course during the day, does it wake them at night, and the frequency of episodes
- Alleviating Factors: anything that reduces the pain – body position, movements (or lack thereof), medications.
- Aggravating Factors: anything that increases the pain – body position, movements, relation to food intake.
- Associated Symptoms: can include hematemesis, vomiting, nausea, hematochezia, melena, diarrhea, fever, and weight loss. (Relevant findings: See Table 2)
- Ask about bowel movement patterns and stool quality (size, hard/soft, odour).
- Ask about ingestion of toxin or foreign object; accidental or non-accidental trauma
- Ask about dietary history: in young children, too much milk can lead to constipation.
- Ask about past medical history and medical comorbidities.
- Cystic fibrosis predisposes to gallstones.
- Spina bifida/cerebral palsy/developmental delay predisposes to constipation.
- Sickle cell disease predisposes to splenic auto-infarction.
- Recurrent respiratory tract infections suggest mesenteric adenitis.
- Ask about sexual history – screen for STI
- Females: don’t forget about menstrual cycles (regularity, amount of bleeding, relation to abdominal pain)
- Ask about family medical history, especially inflammatory bowel diseas.
- Ask about travel history, social and psychiatric (potential stressors) history.
Table 2: Associated symptoms for abdominal pain
|Diarrhea||Gastroenteritis, Protein losing enteropathy|
|Bloody stool||UGIB/LGIB, Ulcerative colitis, necrotizing enterocolitis, dysentery, constipation|
|Hematemesis||UGID, Peptic Ulcer Disease, Gastritis|
|Bilious emesis||Small bowel obstruction|
|Jaundice||Hepatitis or Biliary Tree obstruction|
|Joint pain/swelling||IBD, HSP|
|Skin Lesions||IBD, HSP, Liver disease|
|Testicular pain||Testicular torsion|
|Dysuria/polyuria/hematuria||Urinary tract infection/Pyelonephritis|
|Shortness of breath||Pneumonia or empyema|
Common differential diagnoses and potential complications
table 3: common differential diagnoses for abdominal pain
|Medical Condition||Relevant Findings and Potential Complications|
|Constipation||Infrequent bowel evacuations, difficult or painful defecation, can see blood in stool from anal fissures, low fibre diet, high milk consumption (>2-3 cups per day)|
|Acute appendicitis||Right lower quadrant pain with fever, anorexia, nausea, vomiting, can rupture and lead to sepsis|
|Gastroenteritis||Vomiting and diarrhea with or without fever and nausea, can have bacterial or viral etiologies|
|Irritable bowel syndrome||Change in stool frequency, bloating, abdominal distension, may be associated with certain foods|
|Trauma||History and signs of bruising|
|Ulcerative colitis||Bloody and/or chronic diarrhea, crampy lower abdominal pain, anorexia, weight loss, fever, fecal urgency, can develop to toxic megacolon|
|Crohn’s disease||Intermittent diarrhea, weight loss, crampy right lower quadrant pain, anorexia, weight loss, fatigue|
|Celiac Disease||Abdominal pain, bloating, growth failure, gluten insensitivity|
|Inflammatory Bowel Disease||Associated with diarrhea, bloody stools, weight loss, can lead to significant growth failure if missed.|
|Urinary tract infection||Dysuria, polyuria, hematuria, can progress to pyelonephritis|
|Primary dysmenorrhea||History of menstrual periods and regularity, consider sexual history|
|Pneumonia and Empyema||Consider respiratory history, past medical history and recurrent respiratory tract infections|
Physical exam and investigations
a) physical exam
ABCs; vitals; and growth parameters (is there evidence of failure to thrive).
- Inspection: look for contour, symmetry, pulsations, peristalsis, vascular irregularities, skin markings, wall protrusions (hernias), any signs of trauma (ie. bruising, swelling), and abdominal distension
- Auscultation: auscultate before palpation in the abdominal exam, listen for bowel sounds, abdominal bruits, pressure of the stethoscope also tests for tenderness
- Percussion: assess general tone (tympanic vs non-tympanic), percuss for liver span and spleen tip, assess for ascites (find edge of percussion tone change).
- Palpation: assess tenderness with light and deep palpation, assess for guarding and rebound tenderness, palpate for liver, spleen, kidney and abdominal masses (including fecal mass).
- Digital rectal exam: first exam the anus for fissures and skin tags, then assess for tone, stool, and blood
- Special Tests: there are a number of special tests for each differential diagnosis
table 4: findings on physical exam for common differential diagnoses
|Medical Condition||Findings on Physical Exam|
|Constipation||Abdominal tenderness, palpable fecal mass, look for imperforate anus or stenosis, spina bifida, developmental delay, cerebral palsy|
|Acute appendicitis||Patient avoids movement, rebound tenderness, McBurney sign (pain at 2/3 between umbilicus and right ASIS), Rovsing sign (pain in right lower quadrant on left-sided palpation), Psoas sign (pain in right lower quadrant when child on left and right hip hyperextended), obturator sign (pain in right lower quadrant on internal rotation of flexed right thigh)|
|Gastroenteritis||Diffuse pain with no rebound tenderness, abdominal distension, hyperactive bowel sounds|
|Irritable bowel syndrome||Periumbilical tenderness, no rebound tenderness|
|Trauma||Signs of bruising and tenderness|
|Celiac Disease||Growth failure, distended abdomen, diffuse abdominal tenderness.|
|Inflammatory bowel disease||Appears thin/cachetic, abdominal tenderness, anal skin tags, possible sign of bloody stool on DRE, examine for skin lesions (erythema nodosum, pyoderma gangrenosum), iritis, and joint inflammation|
|Urinary tract infection||Fever, suprapubic and costovertebral angle tenderness, irritability, foul-smeling urine, gross hematuria|
|Primary dysmenorrhea||Lower abdominal tenderness|
|Pneumonia and Empyema||Tachypnea, cyanosis, decreased breath sounds, crackles and rales, dullness on percussion, febrile|
b) Laboratory investigations
table 5: Laboratory investigations for common differential diagnoses
|Medical Condition||Relevant Diagnostic Tests|
|Constipation||None if history does not suggest an alternative diagnosis.|
|Acute appendicitis||CBC (WBC normal or elevated), urinalysis, urine pregnancy|
|Gastroenteritis||Serum electrolytes, stool culture, stool for virology|
|Irritable bowel syndrome||None, based on history and clinical findings|
|Trauma||CBC for blood loss, abdominal CT with contrast|
|Celiac Disease||Anti-TTG, IgA|
|Inflammatory Bowel Disease||CBC, ESR/CRP, electrolytes, albumin, LFTs, Bilirubin, Stool culture, AXR|
|Urinary tract infection||Urine dipstick (for leukocyte esterase and nitrite), urine microscopy, urine culture (best if suprapubic aspirate)|
|Primary dysmenorrhea||None, based on history and clinical findings|
|Pneumonia and Empyema||CBC, Chest x-ray, sputum culture|
a) Uncommon differential diagnoses and potential complications
table 6: uncommon differential diagnosis for abdominal pain
|Medical Condition||Relevant Findings and Potential Complications|
|Intussusception||Colicky pain, flexing of legs, fever, lethargy, vomiting, peak incidence in children at 6 months of age|
|Mekel’s diverticulum||Similar presentation to appendicitis, profuse GI bleeding, can develop to diverticulitis|
|Mesenteric adenitis||Can present like acute appendicitis, recurrent respiratory tract infections|
|Hirschsprung disease||Vomiting, abdominal distension, enterocolitis, primarily in first year of life|
|Small bowel obstruction||Bloating, vomiting, failure to pass flatus or stool, bilious emesis|
|Volvulus||Can present like small bowel obstruction, due to intestinal twisting|
|Large bowel obstruction||Abdominal distension, hard feces and rectal bleeding, can lead to bowel perforation|
|Necrotizing enterocolitis||Feeding intolerance, apnea, lethargy, bloody stools, abdominal distension and tenderness, abdominal erythema, hematochezia, bradycardiac, primarily in premature infants|
|Peptic ulcer disease||Epigastric tenderness, pain related to eating a meal, ulcer can perforate|
|Viral hepatitis||Fever, malaise and jaundice, consider fecal-oral or vertical transmission|
|Acute pancreatitis||Steady and sudden-onset pain radiating to the back, nausea, vomiting, history of cholelithiasis|
|Splenic infarction||Personal or family history of sickle cell disease|
|Nephrolithiasis||Acute renal colic, flank pain radiating to groin|
|Testicular torsion||Testicular pain with acute onset, nausea, vomiting|
|Ovarian torsion||Pain with nausea, vomiting, diarrhea|
|Ruptured ovarian cyst||Bloating, early satiety|
|Pelvic inflammatory disease||Consider sexual history|
|Pregnancy and related complications||Nausea and vomiting, review sexual history and consider ectopic pregnancy and associated ruptures|
table 7: findings on physical exam for uncommon differential diagnoses
|Medical Condition||Findings on Physical Exam|
|Intussusception||Gross or occult blood, abdominal tenderness and palpable abdominal mass|
|Merkel diverticulum||Bloody stools, abdominal tenderness with guarding, rebound tenderness|
|Mesenteric adenitis||Diffuse abdominal tenderness, rhinorrhea and pharyngitis, extramesenteric lymphadenopathy|
|Hirschsprung disease||Abdominal distension, palpable fecal mass, small rectum|
|Small bowel obstruction||Hyperactive or hypoactive bowel sounds|
|Volvulus||Diffuse abdominal distension, no bowel sounds, guarding, rebound tenderness, rigid abdomen, fever, hematochezia|
|Large bowel obstruction||distended abdomen, hyperactive bowel sounds|
|Necrotizing enterocolitis||Abdominal distension, tenderness, abdominal wall erythema, hematochezia, bradycardia|
|Peptic ulcer disease||Epigastric tenderness, melena or occult blood|
|Viral hepatitis||Jaundice, hepatosplenomegaly, lymphadenopathy, wasting, cachexia, ascites, asterixis, caput medusa|
|Acute pancreatitis||Epigastric tenderness, tachycardia, irritability, abdominal distension, Cullen sign (discoloration around umbilicus), Grey-Turner sign (discoloration around flanks)|
|Splenic infarction||Left upper quadrant tenderness|
|Nephrolithiasis||Costovertebral angle and flank tenderness, tachycardia|
|Testicular torsion||Tender, edematous testicle, affected testicle higher than unaffected, absent cremasteric reflex|
|Ovarian torsion||Tender pelvic mass, cervical motion tenderness|
|Ruptured ovarian cyst||Adnexal tenderness|
|Pelvic inflammatory disease||Slight fever, cervical motion tenderness, adnexal tenderness, vaginal or cervical mucopurulent discharge|
|Pregnancy and related complications||Abdominal tenderness, vaginal bleeding|
The differential diagnosis of abdominal pain is extensive making a concise approach sometimes difficult.
1. Determine if abdominal pain is acute or chronic
2. Is the abdomen acute/surgical or benign
3. Are red flags present.
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Neuman MI, Ruddy RM. Emergent evaluation of the child with acute abdominal pain. UptoDate. 2010 [updated 2010 Aug 2; cited 2011 Mar 6].
Shah SK, Allison ND, Tsao K. Evaluation of abdominal pain in children. Epocrates Online: BMJ Group. [Internet] 2011 [updated 2010 Oct 19; cited 2011 Mar 6]. Available from: https://online.epocrates.com/noFrame/showPage.do?method=diseases&MonographId=787
Diaz JJ Jr., Bokhari F, Mowery NT, et al. EAST Practice Parameter Workgroup for Management of Small Bowel Obstruction. Guidelines for small bowel obstruction. J Trauma. 2008;64:1651-1664.
Hackam DJ, Newman K, Ford HR. Pediatric surgery: gastrointestinal tract. In: Schwartz’s principles of surgery. 8th ed. New York: McGraw-Hill; 2005: 1493-1494.
Writer: Christopher Cheung
Edited by: Gaby Yang, Pediatric Resident