Introduction

Abdominal pain is a common reason for children to attend an emergency department (ED), occurring in up to 5% of all presentations in some institutions.¹ Most commonly the underlying cause is non-surgical and surgery is required in only 1–7% of children who present with abdominal pain.¹^,² It is not possible to make a definitive diagnosis in all children with abdominal pain. In one study, as many as 15% of children presenting to emergency with abdominal pain did not have a specific diagnosis at their discharge. Some children arrive at the ED soon after the onset of symptoms and it may take time, expectant management and review before a diagnosis becomes clearer or the symptoms of a self-limiting cause resolve. It is important, however, to exclude causes of abdominal pain that may require early surgical consultation, observation or investigations within the ED.

The priorities in managing children presenting with abdominal pain are:

• triage and early appropriate analgesia;

• resuscitation with attention to ABCs as required;

• diagnosis formulation using history, examination and investigation;

• consideration of surgical review and management according to the likely diagnosis.

If a clear diagnosis cannot be reached in the ED, then exclusion of serious/life-threatening diagnoses is the priority. Subsequent disposition and follow up is dependent on various factors including: likelihood of a serious diagnosis; severity of the pain; availability of review; and psychosocial factors that may be contributory.

Pathophysiology

The sensation of abdominal pain is transmitted by either somatic or visceral afferent fibres.³ Visceral pain from visceral peritoneum is poorly localised, whereas somatic pain arising from parietal peritoneum or the abdominal wall is more localised. Referred pain also occurs due to visceral and somatic pathways converging in the spinal column. Two examples of referred pain are diaphragmatic irritation leading to pain at the shoulder tip due to convergence of visceral and somatic pathways at C4, and somatic pain from pneumonia leading to T10–11 pain sensed in the lower abdomen.³ Abdominal pain may occasionally be found to be psychosomatic in origin after a thorough assessment of alternative causes.

Aetiology

There is a broad range of causes of abdominal pain in children and one needs to initially keep an open mind regarding the diagnosis (Table 7.1.1). The age and sex of the child need to be considered, as well as features of the abdominal pain and associated symptoms, and examination findings to determine the diagnostic possibilities.

Table 7.1.1 Causes of acute abdominal pain in children
Inflammatory gastrointestinal
Appendicitis
Meckel’s diverticulum
Mesenteric adenitis
Gastroenteritis
Food poisoning
Peritonitis
Peptic ulcer, gastritis
Hepatitis
Pancreatitis
Inflammatory bowel disease
Non-gastrointestinal
Tonsillitis, pharyngitis
Pneumonia (especially basal)
Pericarditis
Serositis
Pyelonephritis, cystitis
Pelvic inflammatory disease
Intra-abdominal abscess
Epididymitis
Generalised
Infectious mononucleosis
Acute rheumatic fever
Herpes zoster
Intestinal obstruction
Intussusception
Volvulus
Adhesions
Incarcerated hernia
Abdominal trauma
See Section 3
Gall bladder
Cholecystitis, cholelithiasis
Haematological
Leukaemia, lymphoma
Haemolytic crisis
Sickle cell disease
Neuroblastoma, Wilms’ tumour
Endocrine
Diabetic ketoacidosis, hypoglycaemia
Adrenal insufficiency
Hyperparathyroidism
Vasculitic
Henoch–Schönlein purpura
Periarteritis nodosa
Kawasaki disease
Renal
Renal colic
Hydronephrosis
Nephrotic syndrome
Miscellaneous
Constipation
Colic
Toxic ingestion, e.g. lead
Torsion–testicular/ovarian
Ectopic pregnancy
Dysmenorrhea, Mittelschmerz pain
Mesenteric artery occlusion
Hypokalaemia
Acute intermittant porphyria
Familial Mediterranean fever
Abdominal migraine
Psychosomatic – including abuse

Source: Adapted from Rudolph 1996.

Assessment

Each child needs initial assessment and triage with attention to securing the ABCs and providing appropriate early analgesia. This will help achieve a more reliable examination. A detailed history and thorough, gentle, and age-appropriate examination need to be performed.

History

In considering a child who has presented with abdominal pain with no history of trauma, five important questions have to be addressed:

1 The age of the child

The age of the child helps narrow the diagnostic possibilities. The most common diagnoses to consider according to age are:

Neonates and infants

They usually present with a change in behaviour to signify pain.⁴ This may be persistent crying, irritability, inability to be consoled, fussiness, sleeplessness, and poor feeding.⁴ Serious or potentially life-threatening conditions not to miss in this age group are listed in Table 7.1.2.

Table 7.1.2 Serious conditions not to miss in neonates and infants
Surgical causes	Medical causes
Testicular torsion	Diabetic ketoacidosis
Appendicitis	Toxic, e.g. iron ingestion
Peritonitis	Sepsis
Necrotising enterocolitis
Volvulus	Haemolytic uraemic syndrome
Intussusception	Urinary tract infection
Hirschsprung disease
Incarcerated hernia

The diagnoses of acute gastroenteritis or ‘colic’ need to be made after excluding more serious causes.

3 Whether there are other associated symptoms

Generally children with abdominal pain have other associated symptoms. A full symptom review is required, with particular reference to gastrointestinal symptoms. This includes vomiting, and whether it is bilious or blood stained, and the timing and quality of stool, including the presence of blood or mucus. The child with fever, voluminous diarrhoea and vomiting is likely to have gastroenteritis. However, particularly in young children, one must keep an open mind to other possibilities that can mimic or complicate gastroenteritis (see Chapter 7.8 pp. 172–175 on Diarrhoea and vomiting).

More general questions should assess the child’s constitution – whether the child is febrile, lethargic, irritable, anorexic or has associated pallor. It is unusual for children with appendicitis to be hungry. The child with intussusception is often lethargic and pale. The presence of upper respiratory tract infection (URTI) or viral symptoms may suggest mesenteric adenitis. Dysuria or frequency may be reported in older children with a urinary tract infection. A typical rash or sore joints may indicate Henoch–Schönlein purpura as the cause of related vasculitic abdominal pain.

4 Whether there are any relevant pre-existing conditions

The child’s past medical and surgical history should be fully explored. In older females an adolescent approach (see Chapter 30.1) and a menstrual and sexual activity history may be important. Family history and racial background may be relevant, along with a psychosocial history that may contribute if there is a suggestion of somatisation.

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