Makindo Medical Notes

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.

✅ 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.