Acute abdominal pain in children is common, often non-specific, and ranges from benign to life-threatening. A careful history, thorough examination (including genitalia), and judicious use of imaging are key. Always assess ABCDE and resuscitate if unstable.

🧸 General Approach to Acute Abdominal Pain in Children

⚖️ Stabilisation first: Apply ABCDE — airway, breathing, circulation. Resuscitate before detailed history/exam if the child is unwell.
📖 History: Involve both child and parent/carer. Younger children may not localise pain well. Ask about feeding, bowel/urine habits, systemic symptoms (fever, rash, weight loss).
🕐 Onset & progression: Sudden vs gradual, intermittent vs continuous, associated vomiting or diarrhoea, preceding infections.
🧪 Associated features: Urinary symptoms, testicular pain, menstrual history in adolescents, systemic signs (polyuria, rash, arthralgia).
🚨 Red flags: Shock, bilious vomiting, peritonitis (guarding, rigidity), severe pain with minimal signs (possible mesenteric ischaemia), blood in stool or urine.

🩺 Examination Techniques & Advice

🧸 Child-friendly approach: Sit at the child’s level, use toys or parents for distraction. Warm hands, explain gently.
👀 Inspection first: Observe the child lying still (peritonitis) vs writhing in pain (colic). Look for distension, scars, visible peristalsis, hernias.
🤲 Palpation: Start away from the pain. Use gentle, warm hands. In younger children, palpate while they sit on a parent’s lap. Watch the face for grimacing more than words.
👂 Auscultation: Bowel sounds (↑ in obstruction, ↓ in peritonitis).
🎯 Special checks: Always examine the genitalia in boys (torsion can mimic abdominal pain). Do a gentle per rectal exam only if essential and with senior advice.
🧠 Whole-child assessment: Hydration status, rash (HSP, meningococcal), chest exam (pneumonia can present as abdominal pain).

💡 Clinical Pearl: Children may not present with “classic” textbook signs. Non-specific irritability, refusal to eat, or quiet withdrawal may be the only clues to serious intra-abdominal disease.

Cause	History & Clinical Features	Investigations	Management
Appendicitis 🟠	Periumbilical pain migrating to RLQ Anorexia, nausea, vomiting, fever Rebound tenderness, guarding, Rovsing’s sign May present late with perforation/peritonitis in children	FBC (↑ WCC), CRP Urinalysis to exclude UTI US abdomen (appendix diameter, free fluid) CT reserved if equivocal (minimise radiation)	IV fluids, analgesia, antibiotics Appendicectomy (laparoscopic preferred) Drain/peritoneal washout if perforated
Mesenteric Adenitis 🦠	Often post-viral infection Generalised or central abdominal pain, less localised than appendicitis Low-grade fever, tender mesenteric lymph nodes Usually self-limiting	FBC, CRP (mild inflammatory changes) US abdomen: enlarged mesenteric lymph nodes, normal appendix	Supportive: fluids, analgesia, reassurance Observation; avoid unnecessary surgery
Intussusception 🎯	6 months – 2 years most common Paroxysmal colicky pain, drawing knees up, inconsolable crying “Red currant jelly” stools (blood + mucus) Palpable sausage-shaped mass in abdomen May cause shock if prolonged	US abdomen: “target” or “doughnut” sign AXR: bowel obstruction features, pneumoperitoneum if perforated Bloods: FBC, U&E, lactate if shocked	IV access, resuscitation, NG tube decompression Air or contrast enema (diagnostic & therapeutic) Paediatric surgical referral if enema reduction fails or perforation suspected
Meckel’s Diverticulum 🌟	Painless rectal bleeding (bright red/maroon) May mimic appendicitis if inflamed Occasional obstruction from volvulus/intussusception	Technetium-99m pertechnetate (Meckel’s) scan FBC: check for anaemia US/CT if obstruction suspected	Surgical resection if symptomatic or complicated Blood transfusion if severe bleeding
Testicular Torsion ⚠️	Acute lower abdominal or groin pain ± scrotal pain Vomiting common in children Tender, high-riding testis, absent cremasteric reflex Surgical emergency	Clinical diagnosis – do not delay Colour Doppler US if uncertain and testis salvage window allows	Immediate surgical exploration and detorsion Bilateral orchidopexy to prevent recurrence
Gastroenteritis 🤢	Diffuse crampy pain, vomiting, diarrhoea Signs of dehydration: dry mucosa, tachycardia, ↓ urine output May mimic surgical abdomen if severe	Clinical diagnosis Stool culture if bloody/prolonged U&E if severe dehydration	Oral rehydration therapy (first-line) IV fluids if unable to tolerate oral Ondansetron for vomiting if persistent
Constipation 🚽	Recurrent abdominal pain, palpable faecal mass Infrequent, hard stools, straining May cause overflow diarrhoea	Clinical diagnosis AXR if diagnosis uncertain or faecal impaction suspected	Oral laxatives (macrogol first-line) Dietary fibre and hydration advice Bowel retraining with family support
Henoch–Schönlein Purpura (HSP) 🌈	Colicky abdominal pain, often with vomiting Palpable purpuric rash (legs, buttocks), arthralgia Can cause intussusception	FBC, U&E Urinalysis: haematuria/proteinuria US abdomen if intussusception suspected	Supportive management (fluids, analgesia) Steroids for severe abdominal or renal involvement
Diabetic Ketoacidosis (DKA) 🍬	Abdominal pain, nausea, vomiting Polyuria, polydipsia, weight loss Kussmaul breathing, dehydration, altered consciousness in severe cases	Capillary blood glucose (high) Blood ketones Venous blood gas: metabolic acidosis	IV fluids (initial bolus, then maintenance) IV insulin infusion Careful potassium monitoring and replacement

✅ Paediatric Pearls

Always examine genitalia in boys with abdominal pain.
Use US as first-line imaging — avoid CT unless essential.
Early surgical consultation is vital in suspected acute abdomen.
Children often present late with perforation in appendicitis — maintain a high index of suspicion.
Consider systemic causes (HSP, DKA, pneumonia, UTI) if GI causes excluded.

👶 Case Scenarios — Acute Abdominal Pain in Children

Case 1 (Appendicitis): A 12-year-old boy presents with 24 hours of periumbilical pain that has migrated to the right iliac fossa. He has anorexia, low-grade fever, and tenderness with rebound on exam. Bloods show raised CRP and neutrophilia. The clinical picture is typical of acute appendicitis. He is admitted for IV antibiotics and urgent appendicectomy, with good recovery post-op.
Case 2 (Intussusception): A 2-year-old girl is brought in with intermittent episodes of severe crying and drawing up of her legs, alternating with periods of lethargy. Parents report red “currant jelly” stool. On exam, a sausage-shaped mass is palpable in the right abdomen. Abdominal ultrasound shows the “target sign,” confirming intussusception. She undergoes air enema reduction under radiology, which successfully resolves the obstruction.
Case 3 (Mesenteric adenitis): A 9-year-old boy presents with fever, diffuse abdominal pain, and recent sore throat. Examination shows mild tenderness in the right iliac fossa but no guarding. Ultrasound excludes appendicitis and shows enlarged mesenteric lymph nodes. Diagnosis of mesenteric adenitis is made. He is treated supportively with fluids and analgesia, and his symptoms settle within 48 hours without surgery.
Case 4 (Testicular torsion masquerading as abdominal pain): A 13-year-old boy presents with sudden onset lower abdominal pain and vomiting. Abdominal exam is non-specific but reveals some tenderness in the suprapubic region. Genital exam reveals a swollen, tender, high-riding left testis with absent cremasteric reflex. The diagnosis is testicular torsion, a surgical emergency. He is rushed to theatre for scrotal exploration and bilateral orchidopexy; the testis is salvaged as intervention was within 4 hours.

🧑‍⚕️ Teaching Commentary

Acute abdominal pain in children has a wide differential. Appendicitis is the most common surgical cause. Intussusception presents with colicky pain and “currant jelly” stools. Mesenteric adenitis is a common mimic of appendicitis following viral infection. Always examine the scrotum in boys, as testicular torsion can present primarily with abdominal pain. 🌟 The key is rapid recognition of surgical emergencies while avoiding unnecessary laparotomy in benign conditions.

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Acute Abdominal Pain - Children