Approach to Abdominal Pain Powerpoint Abdominal Pain Causes Funny Images

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Key points

Repeated examination is useful to look for the persistence or evolution of signs and evaluate response to treatment
Analgesia should be used and will not mask potentially serious causes of pain
Investigations are guided by the most likely cause. Most children do not need investigations
True bilious vomiting is dark green and warrants urgent surgical input

Background

The key consideration in acute abdominal pain is the differentiation between surgical and non-surgical causes
Non-specific abdominal pain is very common but is a diagnosis of exclusion once red flags are considered. See Additional notes section below for more details
Symptoms in neonates may be attributed by parents as abdominal pain. A thorough examination and a broad differential should be considered in this group. See Unsettled baby

Common and time critical causes of abdominal pain by age

Important non-abdominal causes of abdominal pain to consider:
DKA
Headache (Migraine)
Henoch Schonlein Purpura
Hip pathology
Pneumonia

Psychological factors
Sepsis

Sexually transmitted infection
Sickle Cell Disease (vaso-occlusive crisis)
Toxin exposure or overdose
UTI/pyelonephritis

Assessment

History

Symptoms and signs with associated differential diagnoses (the following diagram is not an exhaustive list and presentations can overlap)
Abdominal-pain-flowchart

Relevant past medical history

Underlying condition	Potential complications causing abdominal pain
Hirschprung disease	Enterocolitis (presents with sudden painful abdominal distension and bloody diarrhoea. These children can rapidly deteriorate with dehydration, electrolyte disturbances and systemic toxicity and are at risk of colonic perforation)
Cystic fibrosis
Liver disease and/or ascites	Primary bacterial peritonitis
Nephrotic syndrome
Splenectomy
VP shunt
Chemotherapy	Pancreatitis
On immunosuppressants
PEG / NG / NJ fed
Inflammatory bowel disease (especially if concurrent Clostridium difficile)	Toxic megacolon
Immunocompromised	Toxic megacolon
Sickle cell disease	Vaso-occlusive crisis (acute painful episodes of abdominal pain)

Examination

Observe the child's movements, gait, position and level of comfort
Examine the abdomen for:
- focal vs generalised tenderness
- rebound tenderness*
- guarding or rigidity*
- abdominal masses
- distension
- palpable faeces
Assess for non-abdominal causes (list above)

*Peritonism:

Child will often not want to move in the bed and will be unable to walk or hop comfortably, and will have abdominal tenderness with percussion, internal rotation of the right hip can irritate an inflamed appendix

Rectal or vaginal examination is rarely indicated in a child, this should be discussed with a senior clinician and if needed should only be performed once

Management

Investigations

Most children need no investigations

Investigations to consider, depending on differential diagnosis, may include:

urine analysis (+/- culture +/- pregnancy test if indicated)
electrolytes +/- LFTs
lipase for pancreatitis
venous blood gas
blood sugar for DKA
LFTs, lipase and UEC in abdominal injury
imaging

AXR if obstruction suspected. It isnot helpful in diagnosing constipation
CXR if pneumonia is suspected
Ultrasound may be requested after discussion with a senior clinician (very low yield if used indiscriminately)

It isnot clinically indicated for testicular torsion and may delay time critical surgery
May be appropriate in suspected ovarian torsion
Useful if the history is suggestive of intussusception, even if examination is normal

Treatment

Treatment will be guided by the likely aetiology

Fluid resuscitation may be required (see Intravenous fluids)
Provide adequate analgesia. IV morphine or intranasal fentanyl may be required as initial analgesia in severe pain (see Acute pain management)
Keep children fasting. Consider enteral or intravenous fluids if assessment or diagnosis is delayed (consult local fasting guidelines)
Early referral of children with possible diagnoses requiring surgical or gynaecological management
Consider a nasogastric tube if bowel obstruction is suspected

Consider consultation with local paediatric / surgical team when

Surgical cause suspected
Severe pain not responding to analgesia
Child requiring admission

Consider transfer when

Child requires care beyond the comfort level of the local hospital

Note: Prior to transferring infants or children with possible surgical conditions, ensure the child has adequate analgesia, venous access and intravenous fluids

For emergency advice and paediatric or neonatal ICU transfers, see Retrieval Services .

Consider discharge when

There are no concerning clinical features
Presentation consistent with non-specific abdominal pain (see Additional notes below)
A clear follow-up plan has been arranged, often with a local GP
Parents have been given advice regarding when to seek medical attention

Parent information

Abdominal pain
NSW Children's Hospital Fact Sheets

Additional notes

Appendicitis in young children

Often a late diagnosis
May not present with classical symptoms
Often presents as perforation or sepsis
Requires careful attention to fluid and antibiotic management

Non-specific abdominal pain

Some children suffer recurrent non-specific abdominal pain, with no organic cause identifiable
Occurs in 10-15% of children (usually primary school aged)
Diagnosis can only be made if pain remits completely and there is no associated vomiting, fever and change in bowel habit or oral intake
Psychological factors (eg family, school or other stressful issues) need to be considered in some cases
Investigations are usually not indicated
Non-pharmacological measures (reassurance, relaxation, rubbing and heat packs) can be tried and often help
Follow-up is important. Consider outpatient general paediatric / adolescent referral

Last updated November, 2019

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Source: https://www.rch.org.au/clinicalguide/guideline_index/Abdominal_pain/

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