This is a UKMLA-centred history guide about abdominal pain in children.
Introduction
Primary care, emergency departments, and secondary care encounter paediatric abdominal pain frequently as a presenting symptom. Abdominal pain in children can stem from various causes, ranging from harmless to significant and potentially altering one’s life.
Balancing history taking from both the child and parent is crucial, along with adapting the language to the child’s developmental stage. While parents provide valuable information, it is essential to engage directly with the child and consider their perspective. Adapting the language used ensures effective communication, using age-appropriate terms and explanations.
Presenting Complaint
Site
Left lower quadrant (LLQ) e.g. constipation, Inflammatory bowel disease (IBD), ectopic pregnancy
Right lower quadrant (RLQ) e.g. appendicitis, mesenteric adenitis, gastroenteritis, ectopic pregnancy
Central e.g. abdominal migraine, constipation, appendicitis (later migrates to the RIF), Crohn’s
Testicular pain e.g. testicular torsion, epididymal-orchitis, hydroceles
Suprapubic/ pelvic/ lower abdominal pain e.g. Urinary tract infection (UTI), ovarian torsion, pelvic inflammatory disease (PID)
Flank e.g. pyelonephritis
Radiation/Migration
Radiates from umbilicus to RIF e.g. appendicitis
Radiates through to the back e.g. pancreatitis
Radiating to shoulder tip e.g. ectopic pregnancy ( and other pelvic pathology)
Loin to groin e.g. pyelonephritis, renal calculi
Quality/Character
Colicky e.g. constipation, gastroenteritis, Henoch Schonlein Purpura (HSP), PID, obstruction
Burning (dyspepsia) e.g. reflux
Sharp stabbing e.g. appendicitis
Intensity
Severe e.g. intussusception, ovarian torsion
Onset
Comes and goes e.g. mesenteric adenitis
Sudden e.g. ovarian/ testicular torsion, intussusception, volvulus, incarcerated hernia
Over hours (may suggest inflammatory or infective cause) e.g. appendicitis, gastroenteritis
Timing
Continuous or discrete episodes?
Has the pain changed over time?
How long does the pain last for?
Acute
Gastrointestinal: appendicitis, obstruction, flare of IBD incarcerated hernia
Pancreatic: acute pancreatitis
Genitourinary: UTI, testicular torsion
Gynaecological: ectopic pregnancy, PID, ovarian torsion/cyst
Others: DKA
Chronic (over weeks to months)
Gastrointestinal: IBD, Coeliac, Irritable Bowel Syndrome (IBS), Chronic constipation
Gynaecological: ovarian cyst (s), chronic pelvic pain, endometriosis
Other (medical causes): hypercalcaemia
Recurrent
e.g. abdominal migraines (well between episodes), IBS (often corresponds to stressful life events), functional abdominal pain
Associated Symptoms
Gastrointestinal symptoms
Fever (suggest an infective cause) e.g. gastroenteritis
Vomiting e.g. bowel obstruction/volvulus (bilious i.e. dark green), pyloric stenosis (projectile)
Change in bowel habit (Bristol Stool Chart) e.g. IBD/HUS (bloody diarrhoea), constipation (straining + hard stools), intussusception (red currant jelly stools),
Eating and drinking
Jaundice e.g. breastfeed related, hypothyroidism, rhesus factor disease
Pallor e.g. GI bleed, malnutrition
Urological symptoms
Dysuria, Flank pain, Urinary frequency, Haematuria e.g. UTI/pyelonephritis/nephrotic syndrome, sexually transmitted diseases (STI)Â
Gynaecological symptoms
Vaginal discharge, Pelvic pain, Dyspareunia e.g. PID
Other symptoms:
Shortness of breath, Chest pain, Cough e.g. pneumonia
Weight loss, Polyuria, Polydipsia e.g. Diabetic Ketoacidosis (DKA)
Aggravating Factors
Worse before opening bowels e.g. gastroenteritis
Worse with movements e.g. appendicitis (walking, jumping/ bumps during a car journey)
Worsen by laying down e.g. Gastro-oesophageal reflux (dyspepsia)
Worsen by eating gluten e.g. coeliac disease
Other
– Last menstrual period/ sexually active e.g. ectopic pregnancy, PID
– Ask about coryzal symptoms over the preceding two weeks e.g. mesenteric adenitis
Differentials
There is a large amount of overlap between different causes of abdominal pain in children. Key features of common differentials are summarised in the table below:
| Differential | Features |
|---|---|
| Gastroenteritis (0-18y/o) | Diarrhoea (usually stops within 2 weeks), Vomiting (usually stops within 3 days), Crampy abdominal pain, Fever, headache, aching limbs |
| Constipation (0-18 y/o) | Less than 3 stools a week, Straining and painful passages of hard stools (rabbit dropping), altered perception of the urge to defecate |
| Inflammatory Bowel Disease (12-18 y/o) | Both: Diarrhoea, family history of IBD or autoimmune conditions. Crohn’s disease: non-bloody diarrhoea, weight loss, perineal disease e.g. skin tags or ulcersUlcerative colitis: bloody diarrhoea, tenesmus |
| Intestinal Obstruction(3 months to 6 years/ 6-11 years in the context of previous surgery) | Diffuse, central abdominal pain, bilious vomiting, absolute obstruction with abdominal distension |
| Intussusception (2-5 y/o) | Intermittent, severe, colicky abdominal pain (progressive), infant will exhibit a distinct pattern of knee flexion and pallor during a paroxysm, red-currant jelly stool |
| Appendicitis (2-18 y/o) | Appendicitis: periumbilical abdominal pain radiating to the right iliac fossa, pain worsens on movements e.g. jumping, bumps during a car journey)*Mesenteric adenitis can present similarly: usually associated with URTI |
| Acute Pancreatitis(0-18 y/o) | Severe epigastric pain radiating through to the back, vomiting, abdominal tenderness, systemically unwell |
| Necrotising Enterocolitis (3-12 days after birth) | Generally unwell, intolerance to feeds, bilious vomit, bloody stools, distended/ tender abdomen |
| Cow’s Milk Allergy (first few months of life and before six months) | Diarrhoea and vomiting, bloating, urticaria rash/ eczema, cough/wheeze, angioedema, irritable, crying |
| Ectopic Pregnancy (reproductive years) | Constant lower abdominal pain +/- pelvic tenderness, vaginal bleeding, history of recent amenorrhoea, shoulder tip pain (peritonitis), dizziness or syncope (blood loss) |
| Ovarian torsion(reproductive years) | Sudden onset of constant severe unilateral pelvic pain that gets progressively worse, vomiting and distress |
| Pelvic Inflammatory Disease(reproductive years) | Lower abdominal pain, vaginal/ cervical discharge, pyrexia, deep dyspareunia, intermenstrual/ postcoital bleeding |
| Urinary Tract Infection(0-11 years) | Abdominal/ suprapubic pain, urgency, frequency, dysuria, pyrexia, haematuriaInfants: irritable and crying, poor feeding, vomiting, fevers |
| Diabetic Ketoacidosis(2-18 y/o) | Weight loss, polyuria, polydipsia, Acetone-smelling breath, nausea and vomiting, dehydration, Kussmaul respiration |
Red Flags
It is crucial to show that you are taking into account the possibility of severe causes of abdominal pain in children by asking pertinent red flag questions to assess them.
- Bilious/ Persistent vomiting e.g. Bowel obstructionÂ
- Bloody stool e.g. Necrotising Enterocolitis, Cow’s milk protein allergyÂ
- Abdominal tenderness e.g. Peritonitis (perforation?)Â
- Distended abdomen e.g. bowel obstruction (if associated with absolute constipation)Â
- Weight loss or faltering growth e.g. Cow’s milk intolerance, IBD, Coeliac diseaseÂ
- Not keeping down any feed e.g. pyloric stenosis or intestinal obstructionÂ
Background
When conducting a patient history, it is necessary to inquire about past medical history, medications & immunisations, allergies, prenatal/birth/neonatal history, growth history, family history and social history. In the case of a paediatric abdominal pain history, you can showcase your knowledge of different causes by explicitly probing into the following aspects:
Past Medical History
Abdominal surgery (when, why) e.g. can increase the risk of bowel obstruction secondary to adhesions
Chronic conditions such as IBD, IBS, and constipation (how well controlled, treatments, complications including hospital admissions)
Birth History
Prematurity is a risk factor for certain conditions e.g. Necrotising Enterocolitis, Biliary Atresia
Family History
Coeliac disease, IBD, and Hirschsprung Disease often run in families.
These conditions are also associated with a family history of autoimmune conditions.
Social History
Low fibre diet, poor fluid intake e.g. constipation
Anyone else at home with the same symptoms e.g. infective cause such as gastroenteritis
Examination
While examining the patient, it is important to bear in mind your potential diagnoses and observe for indications that support or contradict them.
Conducting a thorough assessment of a child experiencing abdominal pain necessitates checking vital signs, conducting an abdominal examination, and performing a genital/rectal examination as a minimum requirement.
Additionally, it may be beneficial to consider other straightforward assessments and investigations, such as a nutritional assessment and urinalysis.
Author – Kar Chang Natalie Ko Â
Editor – Dr James Mackintosh
Last updated 06/01/24
