ED: Children have abdominal pain for mostly non-serious reasons. Duration >12 hours gets alarm bells ringing. Some younger children are reliant on a caregiver’s history. Some common childhood conditions are uncommon in adults.
Pain origin is usually intra-abdominal. However, consider extra-abdominal causes such as pneumonia, tonsillitis with mesenteric adenitis, migraine, or torsion of a testis (male patient – always examine the testicles as a torted testicle can be saved if corrected within six hours of pain onset.) Groin examination is required in both sexes to look for an incarcerated hernia.
Appendicitis is a very common cause of abdominal pain typically commencing in the umbilical region and moving to the right iliac fossa. Vomiting and anorexia may occur. There is usually involuntary guarding in the right iliac fossa. A mild temperature is usually present, as is a raised white cell count and CRP. When in doubt, an abdominal ultrasound can help in diagnosis and if the appendix cannot be visualised, CT scan with oral contrast can assist in the diagnosis.
Colicky abdominal pain may occur with constipation. The usual examination finding is tenderness but no guarding. Faecal masses are usually palpated and plain abdominal X-ray shows faecal overloading of the colon.
Colicky pain also occurs with renal colic. Haematuria, either gross or microscopic, is usually present and the diagnosis is confirmed on ultrasound. If ultrasound fails to show the stone, it will normally be visualised on abdominal CT scan without contrast.
Another common cause of colicky abdominal pain is gastroenteritis. Some viruses can cause abdominal pain and vomiting without diarrhoea. The abdomen is usually generally tender but not distended and there are no masses. Send stool for M.C and S and ova, viruses and parasites.
Malrotation and volvulus, a surgical emergency, is associated with bile stained vomiting and confirmed with upper gastrointestinal contrast study or ultrasound. Intussusception typically occurs in the two to 24 month age range and often presents with colicky abdominal pain, pallor and vomiting and later red currant jelly stools. Females may have ovarian pain from volvulus or ovulation and they can also experience period pain.
Chronic abdominal pain may be caused by lactose or fructose intolerance. On questioning it may become clear that the pain is associated with the ingestion of dairy products or fruit. Breath hydrogen testing is non-invasive and usually very helpful. Gluten intolerance is also common and the diagnosis can be made with a blood test. If either of these conditions is suspected referral to a Paediatric Gastroenterologist, for consideration of endoscopy, is recommended.
Key Messages
- Most abdominal pain in children subsides within 12 to 24 hours with no cause found.
- Appendicitis is a common reason why children require surgery.
- Always examine the testicles in males presenting with abdominal pain
Author competing interests: nil relevant.
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