Abdominal pain is one of the most common presentations in the pediatric emergency department.

The most important concern is to decide if the condition requires surgical intervention or can be
managed medically.
What is important is to note whether the pain is constant or colicky and the site and radiation of
pain. Also, other associated features such as nausea, vomiting, bowel or urinary complaints,
vaginal bleeding aid in the diagnosis. Clinical examination findings such as presence of fever,
tenderness, rigidity (indicates peritoneal inflammation), organomegaly, increased/decreased
bowel sounds, pallor, jaundice usually helps to determine the cause of pain.
Causes of acute abdomen
In first few years of life
1. Congenital abnormalities
2. Incarcerated inguinal hernia
3. Intussuception
4. Intestinal volvulus
5. GI perforation
6. NEC in preterm neonates
In older children
1.Trauma
2. Pancreatitis
3. Meckels diverticulum
4. Primary peritonitis
5. Intestinal worm infestation
In adolescents
1. Acute appendicitis
2. Cholecystitis (acalculous)
3. Testicular torsion
4. Rupture of ovarian cyst
Non- surgical causes of abdominal pain
1. Hyperthyroidisin
2. Addisons disease
3. Diabetic ketoacidosis
4. Hypercalcemia
5. Lead poisoning
6. Porphyria

Non-specific abdominal pain

It is the most common cause of abdominal pain in late childhood and early adolescence. It is a
colicky pain with some localization that becomes worse after meals. Bowel sounds may be
increased and a palpable mass of feces may be present in right or left iliac fossa. The causes
commonly are constipation, irritable bowel and chronic spasm.

The treatment consists of antispasmodics.

Investigations in a child with acute abdomen:
1. Abdominal X-Ray/Chest X-Ray erect Look for bowel obstruction
calcification, free air and lower lobe pneumonia. Also soft tissue mass may be
seen
2. Ultrasound of both pelvis and upper abdomen For hepatobiliary, renal
and gynaecological pathology.
3. Complete blood count Increased in case of necrosis, bacterial infection,
abscess
4. Peripheral smear for HUS, Sickle cell.
5. Urine examination for UTI, porphyria
Additional investigations

Serum Amylase/lipase for pancreatitis

Blood cultures
Beta HCG
CT scan for abdomen
Stool examination for worm infestation

Typical presenting clinical characteristics of common abdominal disorders in infants and

children
Diagnosis

Age/Sex

History

Appendicitis

Peak:10-12 Periumbilical
years
pain (early)
M:F=3:2
followed by
vomiting and
localized right
lower quadrant
pain.

Physical
Examination

Lab Analysis

- Fever >100.5
degree F.

Increased WBC X-Ray

(> 10000/cumm) - Concave
curvature of spine
to the right.

- Localized right
lower quadrant
peritonitis

Radiology
(Abdomen)

Treatment

- IV Fluids,
- Antibiotics,
- Antispasmodics
- Appendectomy

- Presence of
faecolith in 510
%
USG
- Pericolic
/appendicea fluid
and/or edema.

Intussuception

59
months
M:F= 3:2

Malrotation /
midgut volvulus

< 1 month

- Paroxymal
crampy
abdominal pain
followed by
periods of calm

- Fever

- Dehydration

X-Ray
Obstructive
pattern
- Distension (late - Pallor
USG "Pseudo
sign)
- Later increased kidney" and
- Right Sided
WBC.
"target" sign
mass (85%)
Contrast enema
- Nonbilious
Intussuception
vomiting (early),
and failure of
later bilious
gas/contrast to
vomiting
reflux in the small
- Currant jelly
bowel
stools.

- Ba enema / Gastrograffin
enema,
- In severe cases:
Operative reduction,
Resection and end-to-end
anastomosis.

Unexpected
- Is normal in early - Dehydration
X-Ray
- Surgical reduction,
bilious vomiting stages
- Anemia
Distended
in an otherwise
- Increased WBC stomach, gasless

healthy infant
M:F=3:2

Incarcerated
inguinal hernia

Cholelithiasis

(late sign).
- There may be
tenderness.
- Distension and
peritonitis may be
late features

<1 year

- Irritability,

F>M

- Crampy,
abdominal pain.
- Early
- Abdominal
nonbilious
distension is seen
vomiting, later
in late stages
bilious vomiting.
- Previously
noted groin
mass.

All

- Associated
illness

abdomen (high
obstruction).

- Adhesionolysis.

Upper GL contrast
Study Abnormal
duodenal sweep
Lower GI contrast
study Caecum in
the left abdomen
or RUQ

- Firm, tender
groin or scrotal
mass.

- Dehydration - X-Ray
Later- Increased Obstructive
WBC
pattern

Surgery and hernitomy.

Minimal physical
findings

Normal

Cholecystectomy

- Fever

- Fever,

- Right upper
quadrant pain
- Nausea,
vomiting

- Right upper
quadrant
tenderness
- Mass

- Increased LFT, USG Gall

bladder
distension,
- Increased WBC thickening,
stones/sludge

USG Gall
bladder
stones/sludge

- Hemolytic
anemia
- Nausea,
vomiting,
- Vague right
upper quadrant
pain
Cholecystitis

All

IV Fluids, IV
antibiotics,Antispasmodics,
Cholecystectomy

- Pericholecystic
fluid
HIDA scan Non
functioning gall
bladder

Management of acute abdomen

Along with treatment of the specific conditions, patients may require intravenous fluids, antibiotics
and antispasmodics. The commonly used antibiotics are ampicillin (100 mg/kg/d), gentamicin (5
mg/kg/d), clindamycin (40 mg/kg/d) or metronidazole (30 mg/kg/d). Other antibiotics such as third
generation cephalosporins are also useful. Surgical treatment would depend on the presenting
cause.