Abdominal Pain in Children

Abdominal pain in children is very common and there can be many different causes.

It can be a huge cause of concern for both parents and their children so it is important to be able to distinguish between children with abdominal pain that needs to be further investigated and children with abdominal pain that can be reassured.

Important questions for your history

Use SOCRATES to get a good history of pain

  • Site of pain

  • Onset of pain – sudden or gradual, when did it start, what were they doing

  • Character – e.g. crampy, sharp

  • Radiating? E.g. is pain radiating through to the back or to another area of the abdomen

  • Timing of pain – is it coming and going or is it constant?

  • Exacerbating features – is anything exacerbating the pain? E.g. eating, walking *also ask about Relieving features, e.g. lying in a certain position, simple analgesia, opening bowels

  • Severity – if the child is old enough, ask them to rate their pain from 0-10, if not then you will need to subjectively rate the pain by the child’s discomfort

It’s very important to ask about bowel habits. Constipation is a very common cause of abdominal in children.

  • Ensure to ask about symptoms of constipation such as straining when opening bowels and use the Bristol stool chart to ask about the type of stool the child passes.

Ask about blood or mucous in stools.

If there is diarrhoea, has there been blood in the stool? If there’s been bloody diarrhoea be sure to ask about risk factors for e.coli such as recent farm visits or takeaways. The reason for this is bloody diarrhoea secondary to e.coli H157 can progress to haemolytic uraemic syndrome and these children need closer monitoring and follow up.

Have there been any urinary symptoms / fever? UTI is a common cause of abdominal pain. In children too young to complain of urinary symptoms vomiting and fever are the most common symptoms of UTI

Are they eating and drinking okay? (if they’re not eating is it because it exacerbates the pain or is it because they have no appetite?)

Is there a co-existent illness? E.g. a viral URTI

Is there a history of abdominal surgery?

If there’s been vomiting, what colour is the vomit? Be careful to distinguish this as parents will often say their child is vomiting bile, but often just mean water and stomach acid. Clarify whether the colour is dark green or yellow. This is because true bilious vomits which are dark green are indicative of bowel obstruction which is an emergency. Yellow vomits are less worrying.

If the patient is a girl and adolescent, when was her last menstrual period? And is she sexually active

  • ALWAYS think about pregnancy in girls, even if they claim to not be sexually active (all girls are liars and all liars are pregnant)

Also think about sexually transmitted infections and pelvic inflammatory disease, ask about vaginal discharge

In boys ask about testicular pain

Ask about history of recurrent abdominal pain and the pattern for this

  • Often children can present with recurrent abdominal pain as school avoidance and when you specifically ask parents might realise they only complain of pain in the week and not on the weekend

Abdominal migraines can also be a cause of recurrent abdominal pain

Examination:

  • As always, if unwell examine A-E
  • Otherwise, start by looking at the child from the end of the bed, are they comfortable and happily talking to you or are they in pain / crying / vomiting.
  • Do they have a fever?
  • Is there any obvious peripheral or peri-orbital oedema?
  • Auscultate the chest, is there equal air entry bilaterally? Are there crepitations? Any increased work of breathing?
  • Examine for capillary refill, peripheral pulses, are they warm and well perfused?
  • Briefly examine neurology and make sure to check a blood glucose level – patients with DKA can present with abdominal pain  OR patients with abdominal pain and vomiting may have hypoglycaemia
  • Abdominal examination
    • Inspection for scars from previous surgeries, distension, changes in skin colour, any bruising
    • Palpation for tenderness. Prior to this ask for the child to point to where the pain is and start palpating away from the pain. Look at the childs face for signs of pain or discomfort whilst palpating.
    • Examine for rebound tenderness, particularly in the right iliac fossa
    • If suspected appendicitis examine for Rosvings sign (pain in the right iliac fossa on palpation of the left iliac fossa), psoas sign (increased RIF pain caused by passively extending the right leg at the hip with knees extended with the patient lying on their left side) and obturator sign positive (increased RIF pain caused by internally and externally rotating the right leg with the hip flexed while the patient lies supine)
    • Examine for organomegaly
    • If the abdomen is distended and there is oedema then you should examine for ascites, which you can do by looking for shifting dullness or by looking for a fluid thrill
    • Examine the hernial orifices
    • Feel for renal angle tenderness
    • Auscultate for bowel sounds
  • Examine testicles in a boy, look for the cremasteric reflex and swollen / tender testes
  • ENT examination for signs of a illness that could be causing mesenteric adenitis, e.g. viral URTI / tonsillitis
  • Look for any rashes (purpura on the legs / buttocks)
  • Ask the child to do star jumps (this often helps me build a good rapport, and if they can do star jumps without pain then this is a good tool for helping rule out appendicitis)

Differentials (in order of most common to least common)

Constipation

  • Incidence of 0.05-39.3% (Levy EI, 2017)

  • Can have diffuse abdominal tenderness but often are more tender in the left lower quadrant and if the child is very constipated you will feel a faecal mass on palpating which can feel a bit like playdo

Mesenteric Adenitis

  • Around 2-16% of patients presenting with symptoms of appendicitis are found to have mesenteric adenitis. (Otto M, 2023)

  • Caused by inflamed lymph nodes in the abdomen

  • Presents as a vague abdominal pain which can be severe and tends to come in waves

  • Abdomen may be diffusely tender or may be tender more in the lower abdomen
  • There will be signs of a co-comittant illness such as tonsillitis, cervical lymphadenopathy, cough/coryza etc

Gastroenteritis

  • Can occur in age group and presents with vomiting +/- diarrhoea. Causes crampy abdominal pain, worse before opening bowels. If there is excessive vomiting can also cause some gastritis with epigastric pain

  • On examination the abdomen will be tender everywhere but should be soft with no guarding, there may be worse tenderness in the epigastric region.

Urinary Tract Infection (UTI)

  • In younger children may cause fever, vomiting and generalised irritability.

  • In febrile infants of 2 months and younger, 5% of girls and 20% of boys will have a UTI. (Leung AKC, 2019)

  • Parents may say the urine is offensive smelling

  • In older children they may complain of urinary symptoms + fever and suprapubic pain

  • By the age of 16 years, 11.3% of girls and 3.6% of boys will have been treated for a UTI. (Leung AKC, 2019)

  • There may be generalised abdominal tenderness or tenderness localised to the suprapubic region. Make sure to examine for renal angle tenderness and ask about flank pain to rule in /out pyelonephritis

Appendicitis

  •  Most commonly presents between 10-19 years of age with a lifetime risk of 12% for boys and 25% for girls. (Gadiparthi R, 2023)

  • Presents typically with suprapubic / umbilical pain which then migrates to the RIF.

  • Tends to be sharp stabbing pain. Associated with nausea, lack of appetite.

  • Pain exacerbated by walking, jumping, going over speed bumps in the car.

  • The child will often be uncomfortable with tenderness and guarding on palpation of the RIF. They will often have rebound tenderness in the RIF (when you release after palpation it hurts). They may be Rosvings positive, psoas sign positive and/or obturator sign positive.

  • If the appendix has burst the child may be more septic looking with fever, peritonitis, vomiting

  • *Don’t forget, a retrocaecal appendix can present with back pain / flank pain

Pneumonia / Pleural effusion / Empyema

  • Pleural pathology can cause abdominal pain in children as referred pain. A study in 2011 of 258 children admitted to hospital with pneumonia found that 8.5% of patients present initially with acute abdominal pain. (Kirovski I, 2011)

  • It’s important to think about the possibility of an empyema or bad pneumonia in a child with difficulty in breathing, fever and abdominal pain.

  • Generally, whatever side the chest infection is on, the abdomen will be tender on the same side, but there may be diffuse tenderness

  • There may be increased work of breathing, reduced air entry on the side of infection +/- dullness to percussion

Diabetic Ketoacidosis (DKA)

  • Presents with abdominal pain and being generally unwell, usually with a few weeks history of weight loss, polyuria and polydipsia if the child is an undiagnosed diabetic.

  • Abdominal pain is caused by potassium depletion, acidosis and poor splanchic perfusion. It is described in 40-75% of cases of children presenting with DKA. (Frontino G, 2022)

  • There may be kussmal breathing, impaired consciousness level, vomiting

  • The abdomen will be generally tender with no focal area for the tenderness and the child may look very poorly.

Abdominal Migraine

  • A functional abdominal pain disorder which affects 0.2-4.1% of children. (Azmy DJ, 2020)

  • Diagnosis can only be made after recurrent presentations. Causes recurrent episodes of severe, central abdominal pain that occurs for hours – days at a time

  • During episodes the child will report nausea, vomiting, lack of appetite and may appear very pale. May occur with headaches and photophobia.

  • There is usually a family history of migraines.

  • The child will be well in between episodes of pain.

Mittelschmerz

  • (German for “middle pain”) – pain when ovulating, occurs mid-cycle. Typically a crampy intermittent lower abdominal pain. It affects approximately 40% of women. (Brott NR, 2023)

  • The child will look otherwise well and the abdomen will be soft with only mild tenderness to palpation in the lower abdomen with no guarding.

Intussusception

  • Tends to occur in younger age groups (2-24 months) and is the invagination of a proximal segment of bowel into the distal bowel lumen. It causes bowel obstruction, venous congestion and bowel wall ischaemia and therefore causes severe abdominal pain.

  • The most common cause of intestinal obstruction in infants with an incidence of 24.8 per 100,000 (Samad L, 2013)

  • As these patients may be too young to vocalise, they tend to present very irritable, drawing their legs up to their tummy, and inconsolable and the pain is intermittent. Classically they have redcurrant jelly stools but this is often a late sign.

  • During an episode the child will look very unwell, they’ll be pale and may be vomiting. They may present in hypovalaemic shock

  • On examination you may feel a sausage shaped mass in the right side of the abdomen which crosses the midline. The abdomen is usually diffusely tender and there may be distension

Henoch Schoenlein Purpura (HSP)

  • A  vasculitis that presents with a purpuric rash to the lower limbs and buttocks, joint pain and swelling and abdominal pain.

  • The incidence in children is as high as 20 in 100,000 and 50% of these present with abdominal pain. (Bluman J, 2014)

  • The abdominal pain is colicky / crampy, intermittent and diffuse, the child may struggle to point to a single area of pain. It is caused by haemorrhage and oedema within bowel wall and mesentery

  • HSP can cause intussusception which should be suspected if the pain is severe or if there are signs of peritonism.

Inflammatory bowel disease (IBD)

  • Consists of Crohn disease and Ulcerative colitis. Combined incidence in children is 10 per 100,000.

  • 67-86% of children with Crohn disease an 43-62% of children with ulcerative colitis present with abdominal pain. (Rosen MJ, 2015)

  • IBD mostly presents with weight loss, crampy severe abdominal pain which may occur anywhere in the abdomen but frequently in the left lower quadrant and diarrhoea.

  • There will be a history of frequent loose stools + blood and mucous

  • There may be other signs of IBD such as aphthous ulcers, erythema nodosum, anaemia

  • There may be a personal history of juvenile arthritis / episcleritis as these are genetically linked
  • There may be a family history of IBD

Sickle Cell Crisis

  • Around 10% of patients with sickle cell disease are hospitalised for acute abdominal pain.

  • Abdominal pain in sickle cell can be caused by mesenteric lymphadenitis, ischaemia and infarction of abdominal organs such as the spleen, liver, and bowel and cholecystitis.

Ovarian torsion

  • Twisting/ torsion of the ovary / fallopian tube which prevents adequate blood flow and results in ischaemia. The incidence in paediatrics is 4.9 in 100,000, and ovarian torsion accounts for 4% of PED visits for acute abdominal pain in females. (E, 2022)

  • Presents with sudden onset acute severe pelvic/ lower abdominal pain, nausea and vomiting.

  • There will be tenderness on palpation of the lower abdomen and there may be a palpable adnexal mass

Testicular Torsion

  • Presents with sudden onset severe abdominal / testicular pain. The child may not complain of testicular pain!

  • The annual incidence of testicular torsion in boys younger than 18 years is 3.8 per 100,000. Studies have found a 10.7-12.5% incidence of testicular torsion presenting solely with abdominal pain. (S, 2023)

  • The lower abdomen will be tender and then on examination of the testes, the affected side will be red / discoloured, tender, swollen and there will be no cremasteric reflex.

Nephrotic syndrome

  • Incidence of 2-7 per 100,000 children

  • Presents with oedema and proteinuria. Oedema is often peri-orbital first and then progresses to the rest of the body. Testicular swelling can be severe.

  • Abdominal pain is caused by ascites or hypovalaemia which leads to mesenteric ischaemia. It can also be caused by spontaneous bacterial peritonitis which should be suspected if there is also a fever. The incidence of peritonitis in nephrotic syndrome is 1.4-3.7% (Conti G, 2021)

  • There will be significant pitting oedema, abdominal distension, diffuse tenderness, shifting dullness +/- fever

Pelvic Inflammatory Disease (PID)

  • Caused by a sexually transmitted infection in girls e.g. chlamydia, gonorrhoea.

  • Presents with moderate – severe lower abdominal crampy pain diffuse abdominal tenderness +/- guarding, and they may be febrile

  • There may also be a history of dysuria or offensive vaginal discharge.

Ectopic pregnancy

  • Will present with severe pain in either iliac fossae with a history or a recent missed period and being currently sexually active.Will be very tender +/- guarding on the side where the ectopic is

  • If it is a perforated ectopic they may be very unwell with hypovalaemic shock
and severe abdominal pain

Age GroupMedical CausesSurgical Causes
Infant (0-1 year)Gastroenteritis,
Constipation (incl. Hirschprungs),
UTI,
Colic
Intussusception,
Volvulus,
Incarcerated,
Hernia
2-5 yearsGastroenteritis,
Constipation,
UTI,
Mesenteric Adenitis,
HSP,
DKA,
Pneunmonia/Empyema,
Sickle cell crisis
Appendicitis,
Intussusception,
Volvulus,
Trauma
6-11 yearsGastroenteritis,
Constipation,
UTI,
Mesenteric Adenitis,
Abdominal Migraine,
HSP,
DKA,
Pneumonia /Empyema,
Sickle Cell Crisis
Appendicitis,
Trauma,
Bowel Obstruction (in context of previous surgery),
Testicular Torsion,
Ovarian Torsion
12-18 yearsGastroenteritis,
Constipation,
Dysmennorhoea,
DKA,
Mittelschmerz,
PID,
IBD
Appendicitis,
Trauma,
Ovarian Torsion,
Testicular Torsion,
Ectopic pregnancy
Table of most common causes of abdominal pain in children by age group

Investigations:

  • Urine dip is essential +/- pregnancy test
  • If the child is constipated you don’t necessarily need any further investigations, however if they suffer with severe constipation thyroid function and a coeliac screen may be helpful
  • If the child looks acutely unwell with severe pain then bloods will be useful to rule in/out infective causes. Appendicitis generally causes a neutrophilia with a mildly raised CRP although the CRP can be very high in the case of perforation.
  • Bloods are also essential if you suspect nephrotic syndrome or Henoch Schoenlein Purpura. They are also crucial in the case of a painful sickle cell crisis.
  • Ultrasound (USS) should be urgently requested for suspected appendicitis, or ovarian torsion. However there is a 6% false negative rate so if there is a high suspicion of appendicitis a negative USS should not reassure you.
  • USS can be useful for intussusception but you should refer to surgeons immediately rather than waiting for the outcome of a scan if you strongly suspect this.
  • If you suspect testicular torsion there are no investigations necessary, call a urologist / general surgeon as this is a urological emergency

Management:

  • Obviously this depends on the suspected cause for the abdominal pain.
  • If the child has gastroenteritis or mesenteric adenitis and looks well they could be discharged home with safety net advice and reassurance.
  • For constipation manage with laxatives and consider a disimpaction regime and a referral to community nurses
  • For UTI manage with PO Abx as per NICE guidelines
  • If the child has a suspected appendicitis, testicular torsion, intussusception or signs of bowel obstruction you should refer to a surgeon
  • Also, if you have a child with an acute abdomen who appears peritonitic but you don’t know the cause you should refer to a surgeon.
  • If you suspect ovarian torsion you should refer to obs and gynae
  • Ask surgeons for their advice on keeping the child nil by mouth and starting IV fluids.
  • If a child is in pain remember to give them analgesia! This is particularly important in a sickle cell crisis

Bibliography

Azmy DJ, Q. C. (2020). Review of Abdominal Migraine in Children. Gastroenterology & Hepatology, 632-639.

Bluman J, G. R. (2014). Henoch-Schonlein Purpura in Children. Official Publication of The College of Family Physicians of Canada, 1007-1010.

Brott NR, L. J. (2023, June 15). Mittelschmerz. Retrieved from StatPearls: https://www.ncbi.nlm.nih.gov/books/NBK549822/

Conti G, C. N. (2021). Acute Abdominal Pain and Nephrotic Syndrome: Paediatric Case Reports and Review of the Literature. Annals of Paediatric Surgery.

E, S. (2022). Diagnosis and Management of Paediatric Ovarian Torsion in the Emergency Department: Current Insights. Open Access Emergency Medicine, 283-291.

Frontino G, D. T. (2022). Non-Occlusive Mesenteric Ischaemia in Children with Diabetic Ketoacidosis: Case Report and Review of Literature. Fronteirs in Paediatric Endocrinology.

Gadiparthi R, W. M. (2023, June 14). Paediatric Appendicitis. Retrieved from StatPearls: https://www.ncbi.nlm.nih.gov/books/NBK441864/

Kirovski I, M. V. (2011). Abdominal Pain as a Predictor of Pneumonia in Children. European Respiratory Journal, 1152.

Leung AKC, W. A. (2019). Urinary Tract Infection in Children. Recent Patents on Inflammation and Allergy Drug Discovery, 2-18.

Levy EI, L. R. (2017). Functional Constipation in Children: Challenges and Solutions. Paediatric Health, Medicine and Therapeutics, 19-27.

Otto M, N. S. (2023, June 14). Mesenteric Adenitis. Retrieved from StatPearls: https://www.ncbi.nlm.nih.gov/books/NBK560822/

Rosen MJ, D. A. (2015). Inflammatory Bowel Disease in Children and Adolescents. JAMA Paediatrics, 1053-1060.

S, M. (2023, June 14). Testicular Torsion Without Scrotal Pain. Retrieved from Consultant 360: https://www.consultant360.com/articles/testicular-torsion-without-scrotal-pain

Samad L, C.-B. M. (2013). Intussusception Incidence Among Infants in the UK and Republic of Ireland: A Pre-Rotavirus Vaccine Prospective Surveillance Study. Vaccine, 4098-4102.

Written and Edited by Dr Rebecca Evans, Paediatric ST3

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