Abdominal Pain in Kids

Key Points

• Repeated assessments help track evolving symptoms and response to initial management

• Analgesia should not be delayed, as pain relief does not obscure significant pathology

• Investigations should be targeted according to the most likely diagnosis

• Bilious vomiting (dark green) signals a surgical emergency warranting urgent referral

  
  

Differential Diagnosis

Acute Causes

• Urinary tract infection: May present with upper quadrant pain, consider urine testing even without classic symptoms

• Abdominal migraine: Episodic pain often with a migraine pattern, possible family history of migraine

• Diabetic ketoacidosis: Possible abdominal pain, look for hyperglycaemia and ketonuria

• Pneumonia: Lower lobe consolidation may refer pain to the abdomen

• Sepsis: Can present with diffuse abdominal pain

• Abdominal trauma: Consider accidental or non-accidental injury

• Testicular torsion: Referred pain to the lower abdomen, urgent surgical review

• Toxin ingestion: Varied presentations, always consider accidental ingestion or poisoning

• Volvulus: Twisting of the bowel, often with bilious vomiting and severe pain

Chronic Causes

• Functional abdominal pain: Prevalent in school-age children, no organic findings

• Depression or anxiety: Psychosocial stressors manifesting as somatic complaints

• Abdominal migraine: Intermittent, similar to headache migraine triggers

• Chronic constipation: A frequent cause of recurrent pain

• Inflammatory bowel disease: Chronic pain, altered bowel habits, weight loss

• Coeliac disease: Pain and malabsorption triggered by gluten

• Peptic ulcer disease, gastro-oesophageal reflux disease, gastritis: Upper abdominal pain worsened by acidic foods

• Eosinophilic oesophagitis: Allergic inflammation of the oesophagus, often with feeding difficulties

• Bullying or school refusal: Psychosocial stress may lead to recurrent pain

• Urinary tract infection: Chronic urinary issues causing intermittent abdominal pain

Age-Based Differential Diagnosis (Time-Critical Causes)

Neonates

• Hirschsprung disease, incarcerated hernia, intussusception, necrotising enterocolitis, volvulus

Infants and Children

• Appendicitis, constipation, gastroenteritis, incarcerated hernia, intussusception, Meckel’s diverticulum, ovarian torsion, testicular torsion, volvulus

Adolescents

• Appendicitis, cholecystitis, constipation, ectopic pregnancy, inflammatory bowel disease, ovarian torsion or rupture, renal calculi, testicular torsion

Functional Abdominal Pain Management

• Reassurance that no organic pathology is identified

• Education about functional pain being common and often stress-related

• Encourage maintenance of normal activities, including attending school

• Identify and avoid known food triggers

• Employ relaxation strategies to mitigate stress and anxiety

• Keep a symptom diary to recognise patterns and triggers

• Refer for psychological support or CBT if indicated

Assessment

History

• Determine onset, character, and location of pain (sudden onset could imply testicular or ovarian torsion)

• Note associated symptoms like diarrhoea, fever, or vomiting (bilious vomiting suggests obstruction)

• Identify psychosocial factors including family dynamics and school stress

Examination

• Observe posture and mobility for signs of discomfort

• Palpate all abdominal quadrants, noting rebound tenderness or guarding

• Check for peritonism by assessing the child’s ability to hop or move without pain

• Minimise intrusive examinations, especially rectal or vaginal, unless essential

Investigations

• Most cases do not require extensive testing

• Urinalysis for UTI suspicion

• Blood tests (electrolytes, glucose, inflammatory markers) for suspected DKA or infection

• Imaging with AXR if obstruction is suspected, CXR for pneumonia, ultrasound for intussusception

Specific Conditions

Eosinophilic Oesophagitis

• Allergic inflammation often seen with atopy or food allergies

• Presents with vomiting, feeding difficulties, or dysphagia

• Diagnosis by endoscopic biopsy

• Managed with dietary modification and topical steroid therapy

Non-Specific Abdominal Pain

• Commonly affects 10–15% of primary school-aged children

• Reassure and advise on relaxation, triggers, and maintaining regular routines

Treatment

General Management

• Provide adequate analgesia and hydration

• Refer for surgical evaluation if obstruction or torsion is suspected

• Supportive care with fluid replacement, rest, and antiemetics if needed

When to Refer

• Severe or recurrent pain not responding to conservative measures

• Suspicion of surgical pathology

• Systemic symptoms raising concern for sepsis or malignancy

Notes

• Psychosocial factors such as family issues or bullying can exacerbate or mimic organic pain

• Younger children with suspected surgical issues require stabilisation and possible transfer to a paediatric centre

• Follow-up is vital, especially if symptoms are recurrent or evolve over time