🧸 Acute abdominal pain in children is common and can range from benign self-limiting conditions to life-threatening emergencies. Early recognition, thorough assessment (including genital exam), and judicious use of imaging are key. ⚠️ Always apply ABCDE principles and resuscitate first if the child is unstable.

🧸 General Approach

⚖️ Stabilisation first: Assess and manage airway, breathing, circulation, disability, exposure (ABCDE) before detailed assessment if unwell.
📖 History: Include both child and carer input. Ask about feeding, bowel/urine habits, systemic features (fever, rash, lethargy, weight loss).
🕐 Onset & progression: Sudden vs gradual, intermittent vs continuous, associated vomiting, diarrhoea, recent infections.
🧪 Associated features: Urinary symptoms, testicular pain, menstrual history in adolescents, systemic signs (polyuria, rash, arthralgia).
🚨 Red flags: Shock, bilious vomiting, peritonitis, severe pain with minimal signs, blood in stool/urine, altered consciousness.

🩺 Examination Principles

🧸 Child-friendly approach: Sit at eye level, explain gently, use distraction/toys.
👀 Inspection: Distension, scars, hernias, posture (lying still vs writhing in colic).
🤲 Palpation: Start away from pain; gentle, warm hands; observe facial expression for pain cues.
👂 Auscultation: Bowel sounds (hyperactive in obstruction, hypoactive in peritonitis).
🎯 Special checks: Always examine genitalia in boys; PR exam only if essential and under senior guidance.
🧠 Whole-child assessment: Hydration, systemic signs, chest exam (pneumonia may present as abdominal pain).

💡 Clinical Pearl: Children often have non-specific presentations; irritability, refusal to feed, or quiet withdrawal may indicate serious pathology.

Cause	History & Clinical Features	Investigations	Management
Appendicitis 🟠	Periumbilical → RLQ pain, anorexia, nausea, vomiting, fever Rebound tenderness, guarding, Rovsing’s sign Children may present late with perforation	FBC ↑WCC, CRP Urinalysis to exclude UTI US abdomen (appendix diameter, free fluid) CT only if diagnosis unclear (minimise radiation)	IV fluids, analgesia, antibiotics pre-op Appendicectomy (laparoscopic preferred) Drain/peritoneal washout if perforated
Mesenteric Adenitis 🦠	Post-viral, mild fever, diffuse/central pain Less localised than appendicitis Self-limiting	FBC, CRP (mildly raised) US: enlarged mesenteric nodes, normal appendix	Supportive care: fluids, analgesia Observation; avoid unnecessary surgery
Intussusception 🎯	6 months–2 years, paroxysmal colicky pain, knees drawn up, inconsolable crying “Red currant jelly” stools, palpable sausage-shaped mass Shock if prolonged	US abdomen: “target/doughnut” sign AXR: obstruction or perforation signs FBC, U&E, lactate if shocked	IV access, fluids, NG decompression Air or contrast enema (diagnostic & therapeutic) Surgical referral if enema fails or perforation suspected
Testicular Torsion ⚠️	Acute lower abdominal/groin ± scrotal pain, vomiting High-riding, tender testis, absent cremasteric reflex Surgical emergency	Clinical diagnosis – do not delay Colour Doppler US only if uncertain and testis salvage window exists	Immediate surgical exploration and detorsion Bilateral orchidopexy to prevent recurrence
Gastroenteritis 🤢	Diffuse crampy pain, vomiting, diarrhoea Dehydration signs: dry mucosa, tachycardia, ↓ urine output	Clinical diagnosis Stool culture if bloody/prolonged U&E if severe dehydration	Oral rehydration therapy IV fluids if oral not tolerated Ondansetron if persistent vomiting
Constipation 🚽	Recurrent pain, palpable faecal mass Infrequent, hard stools, straining	Clinical diagnosis AXR if diagnosis uncertain or severe impaction	Oral laxatives (macrogol first-line) High-fibre diet, hydration, bowel retraining
Henoch–Schönlein Purpura 🌈	Colicky abdominal pain, vomiting Purpuric rash on legs/buttocks, arthralgia May cause intussusception	FBC, U&E Urinalysis for haematuria/proteinuria US abdomen if intussusception suspected	Supportive care (fluids, analgesia) Steroids if severe abdominal/renal involvement
Diabetic Ketoacidosis (DKA) 🍬	Abdominal pain, nausea, vomiting Polyuria, polydipsia, weight loss Kussmaul breathing, dehydration, altered consciousness	Capillary blood glucose, blood ketones Venous blood gas: metabolic acidosis	IV fluids, insulin infusion Potassium monitoring and replacement Monitor for complications

✅ Paediatric Pearls

Always examine the genitalia in boys with abdominal pain.
Use US as first-line imaging; minimise CT unless necessary.
Early surgical referral for suspected acute abdomen.
Maintain high suspicion: children may present late with perforation in appendicitis.
Consider systemic causes (HSP, DKA, pneumonia, UTI) if GI causes are excluded.

👶 Key Case Scenarios

Appendicitis: 12yo boy, periumbilical → RLQ pain, raised CRP, neutrophilia → urgent laparoscopic appendicectomy.
Intussusception: 2yo girl, colicky pain, currant-jelly stool, “target sign” on US → air enema reduction successful.
Mesenteric adenitis: 9yo boy, post-viral, diffuse mild pain, US shows enlarged mesenteric nodes → supportive care only.
Testicular torsion: 13yo boy, suprapubic pain, swollen tender testis, absent cremasteric reflex → urgent scrotal exploration and bilateral orchidopexy.

🧑‍⚕️ Teaching Commentary

Acute abdominal pain in children has a broad differential. Appendicitis is the most common surgical cause; intussusception is characterised by colicky pain and “currant jelly” stool. Mesenteric adenitis often mimics appendicitis but is self-limiting. Always examine the scrotum in boys, as testicular torsion may present primarily with abdominal pain. Rapid recognition of surgical emergencies while avoiding unnecessary surgery in benign conditions is the key.

📌 NICE / NHS Resources for Paediatric Abdominal Pain

📄 NICE CG84: Diarrhoea and vomiting caused by gastroenteritis in under 5s – diagnosis, red flags, rehydration, and escalation advice.
📄 NICE CG99: Constipation in children and young people – background and management of chronic constipation as a cause of abdominal pain.
📄 NICE NG12: Suspected cancer – abdominal alarm features in children – urgent referral criteria for masses or persistent symptoms.
📄 NHS Clinical Constipation Pathway (England) – pathway for assessment and management of constipation and related abdominal pain; useful for systematised assessment.
📄 GIRFT Paediatric Acute Abdominal Pain & Appendicectomy Pathway – best practice pathway used across UK paediatric surgical units.
📄 Healthier Together: Acute Abdominal Pain Pathway – NHS‑aligned clinical pathway for frontline assessment and safety‑netting.

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Acute Abdominal Pain - Children ✅