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Acute Abdominal Pain - Children (MLA)

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⚡ Acute Abdominal Pain in Children — Causes, History, Clinical Features, Investigations & Management

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.

PLEASE NOTE LEGAL ADVICE: The contents are under continuing development and improvements and may contain errors of omission or fact. Feedback vital and always welcome at drokane at gmail.com. This is not to be used for the assessment, diagnosis or management of patients. It should not be regarded as medical advice. It is only for educational purposes. Please adhere to your local protocols. If you are unwell please seek healthcare advice from your doctor. This does not replace senior or specialist advice. If you do not accept this then please do not use the website. If you need medical advice, please consult a doctor or other appropriate medical professional. If you are a medical professional and you need advice then speak to your senior or colleagues.

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