1. Acute Abdominal Pain in Children
Priya Kantanon, MD.
3rd year Emergency Medicine
Resident, Siriraj Hospital, Mahidol University

2. • Common complaint of children seeking
medical care in the pediatric ED
• <1 week duration

3. Classification of Abdominal Pain
by Age Group
Age Emergent Nonemergent
0–3 mo old Necrotizing enterocolitis Colic
Volvulus Acute gastroenteritis
Testicular torsion Constipation
Incarcerated hernia
Trauma
Toxic megacolon
Tumor
3 mo–3 y old Intussusception Acute gastroenteritis
Testicular torsion Constipation
Trauma Urinary tract infections
Volvulus HSP
Appendicitis
Toxic megacolon
Vaso-occlusive crisis

4. Classification of Abdominal Pain
by Age Group
Age Emergent Nonemergent
3 y old– Appendicitis Constipation
adolescence Diabetic ketoacidosis Acute gastroenteritis
Vaso-occlusive crisis Nonspecific viral syndromes
Toxic ingestion Streptococcus pharyngitis
Testicular torsion Urinary tract infections
Ovarian torsion Pneumonia
Ectopic pregnancy Pancreatitis
Trauma Cholecystitis
Toxic megacolon Renal stones
Tumor HSP
Inflammatory bowel disease
Gastric ulcer disease/gastritis
Ovarian cyst
Pregnancy

6. Clinical Features
• History
• Physical Examination
• Do not forget a genital examination !!!!

7. General management of
abdominal pain in children

8. • Basic labs work up
– POCT glucose
– BUN, Cr, Elyte
– UA, UPT
– Toxico
– CBC not useful for screening
test

9. • Imaging
– Plain film abdomen
– US
– CT (radiation
exposure 600 times of plain
film, risk develop CA)

10. Pain management
• Opiates does not negatively
impact patient care.
• Although physical examination
findings can change after the
administration of opiates
• There is no evidence that this
changes final management or
outcome

11. Common Parenteral Analgesics for
Abdominal Pain in Children
Drug Dose
Morphine 0.05–0.1 milligram/kg/dose IV every 4 h in
sulfate neonates.
0.1 milligram/kg/dose IV every 2–4 h in infants
and children.
Hydromorphone 0.015 milligram/kg/dose IV every 3–6 h if 6 mo
old and <50 kg.
If weighing >50 kg, use adult dosing.
Fentanyl 1–2 micrograms/kg/dose IV every 30–60 min.
Ketorolac 0.5 milligram/kg/dose IV every 6 h (maximum of
30 milligrams per dose) if 6 mo old.

12. • Special Considerations
1. Neonates and Young Infants (0 to 3 Months)
2. Older Infants and Toddlers
(3 Months to 3 Years Old)
3. Children (3 to 15 Years of Age)

13. Neonates and Young Infants (0 to 3 Months)
Other urgent
Life-threatening
conditions include
• Necrotizing enterocolitis • Incarcerated hernias
(NEC) • Testicular torsion
• Malrotation with midgut • Nonaccidental trauma.
volvulus

14. Neonates and Young Infants (0 to 3 Months)
• S&S
• Inconsolability or lethargy associated with
poor feeding
• Constant pain + sudden in onset
• Episodic, paroxysmal pain suggests infant
colic, intussusception, or gastroenteritis.
• Pain related to feeds suggests
gastroesophageal reflux disease.

15. S&S
• Bilious vomiting (bright yellow or green)
 malrotation with volvulus or intussusception
• Any change in stooling pattern
• Timing of passing the first stool

16. PE
• If the infant is crying, one must rely heavily on
observation, though auscultation and
palpation remain important.
• Undress
• Scrotum
• Check for other causes

17. Malrotation and Volvulus
• Life-threatening complication
• Malrotation of the midgut
occurs in 1 in 6000 births
• 90% of complications
occurring in the first year of
life

20. Clinical Features
• No significant past medical
history
• Abrupt onset of constant
abdominal pain, bilious
vomiting, abdominal
distention, and irritability.
• As bowel ischemia
progresses, shock and
peritonitis develop.

21. • Ill appearing
• Shock
• Ominous signs include
tachypnea, grunting
respirations, and jaundice.
• Diffusely tender and distended
and may be rigid
• Rarely, a mass can be palpated.
• Intermittent volvulus may
present with stable vital signs
and focal tenderness on
abdominal examination.

22. Diagnosis
Imaging
• Useful in diagnosing
malrotation with volvulus
• Should not delay surgical
consultation

23. Imaging
• Plain abdominal radiographs
– a loop of bowel overriding the liver
– evidence of obstruction, including air
fluid levels and a paucity of gas
• Upper GI series
– "bird's beak" appearance of the
duodenum at the site twisting, and
may be seen to the right of the spine
• CT scan of the abdomen and pelvis
with oral contrast
– intestinal malrotation

24. Treatment
• Immediate surgical
consultation
• Aggressively resuscitate the
patient in shock

25. Necrotizing Enterocolitis
• Premature and weigh <1500
grams at birth
• Full-term infants at higher
risk
– congenital heart disease
– other disorders that place the
infant under significant stress
(e.g., sepsis, respiratory
distress).

26. S&S
• Poor feeding
• Lethargy
• Abdominal distention, and
tenderness
• Signs of sepsis
• Pneumoperitoneum

27. Investigation
• CBC
• Serum electrolytes
• Septic work up (blood, urine,
and cerebrospinal fluid
cultures)
• A cross-table lateral view of
the abdomen
– dilated loops of bowel
– abnormal gas pattern
– pneumatosis intestinalis

28. Treatment
• Bowel rest (NPO)
• Aggressive IV hydration
• Broad-spectrum antibiotics (to
cover abdominal/gut flora)
• Consultation with a pediatric
surgeon
• Should be admitted to a
neonatal or pediatric intensive
care unit

29. Incarcerated Hernia
• Inguinal hernias occur in up
to 5%
• More common in children
born prematurely
• Incarceration occurs in up to
one third of cases
• Highest in the first year of
life.

30. Clinical Features
• Irritability, poor
feeding, vomiting, and an
inguinal or scrotal mass
• DDx
– Hydrocele of the cord or the
scrotum
– Undescended testicle
– Torsion of the testicle
– Torsion of the appendix testis
– Inguinal lymphadenopathy
– Inguinal node abscess
– Orchitis
– Inguinal or scrotal trauma

31. Treatment
• Medical, and
sometimes, surgical
emergency
• Manual reduction of the
incarcerated hernia is often
possible early in the course
of disease.

32. Manual reduction

33. Manual reduction
• Sedation
• Once the hernia is reduced,
arrange follow-up in 24 to 48
hours with a pediatric
surgeon
• One third of children will
redevelop incarceration

34. Older Infants and Toddlers
(3 Months to 3 Years Old)
DDX
• Intussusception
• Acute gastroenteritis
• Constipation
• Urinary tract infection (UTI)
• Testicular torsion
• Accidental and nonaccidental trauma
• Malrotation with midgut volvulus and appendicitis are rare

35. S&S
• Pulling up of legs in association with episodic
pain followed by periods of normal behavior
or lethargy  Intussusception
• Pain with urinationUTI
• Day care attendance and sick contacts should
be noted when fever, vomiting, and diarrhea
are present together  Infectious
gastroenteritis

36. PE
• Vary greatly in their ability to cooperate with a
physical examination, and stranger anxiety
• Avoiding direct eye contact
• Look first and then feel.
• Non-touch maneuvers and observations
• Ask a parent to palpate the child's abdomen
while you observe

37. Colic
• "rule of threes“
• Crying >3 hours per day for
>3 days per week for >3
weeks
• Starts in the first week of life
• Resolves by 3 to 4 months of
age
• Colic is a diagnosis of
exclusion.

38. Intussusception
• most common cause of
intestinal obstruction in
children between 3 months
and 6 years

39. Pathophysiology
• Leading points
– Lymphoid hyperplasia
– Meckel diverticulum, intestinal
polyps, congenital duplications,
lymphosarcoma, or as a
complication of HSP
Ileum invaginates into the upper colon  bringing the
mesentery with it (ileocolic)  constriction of the
mesentery obstructs venous return engorgement of the
intussusceptum
Bowel ischemia

40. Clinical Features
• Infant aged 6 to 18 months old
• Sudden onset of colicky pain
• Episodes of pain
– shorter with increasing duration
• Vomiting is rare in the first few hours
• The classic "currant jelly" stool is a late
manifestation
• Stool is usually guaiac positive even in the
absence of gross blood

41. Clinical Features
• Apathy or lethargy may be
the only presenting sign
• Sausage-shaped mass on the
right side of the abdomen
• Absence of a mass should
not delay further
investigation
• An ileoileal intussusception
may have a less typical
presentation

42. Diagnosis and Treatment
• Presumptive diagnosis is
usually made by history
alone
• Well-appearing child with a
normal examination does
not exclude the diagnosis

43. Imaging
• Plain films of the abdomen
may suggest a mass or filling
defect in the right lower
quadrant of the abdomen
• US is highly sensitive and
specific for diagnosis.
• Air contrast enema :both
diagnostic and frequently
curative
Pediatric surgeon should be consulted before
diagnostic air enema

44. Air contrast enema
• After successful reduction in
radiology, children are
generally admitted for
observation
• 5% to 10% recurrence rate,
usually within the first 24 to
48 hours after reduction

45. Acute Gastroenteritis
• most common cause of
abdominal pain in children of
all age groups

46. Constipation
• Infrequent, dry, hard stools
• Defects in filling or emptying
the rectum
• May be a sign of either a
pathologic or functional
process

47. • In infancy
– Maternal drugs
– Congenital GI anomalies
– Cystic fibrosis
– Hirschsprung disease
– Poor intake
– Anal fissures
• In older children
– Chronic medical conditions such as anorexia nervosa, cerebral
palsy, neuromuscular disease, spinal cord abnormalities,
depression, sickle cell disease (secondary to opiate use), or
hypothyroidism
– Acute - dehydration, electrolyte abnormalities (hypercalcemia
or hypokalemia), or drug ingestions (diuretics, antihistamines,
anticholinergics, or narcotics)
History is the key to the diagnosis of constipation

48. Questions to Ask about
Constipation
• The frequency and texture of the
stools
• The presence of blood on the stool
• The association of pain with
defecation
• A history of waxing and waning of
hard stools and watery diarrhea
suggesting overflow incontinence

49. • Rectal examination
– presence of stool
– rectal tone sensation
– size of the anal vault
• Palpate the abdomen for the
presence of a mass

50. Treatment
• Disimpaction with a glycerin
suppository in infants and
bisacodyl suppository in
adolescents
• Sodium phosphate (e.g.,
Fleet Enema®) or soap suds
enemas

51. Treatment of Constipation in
Children >1 year of age
Osmotic laxatives: polyethylene glycol (1–2 packs/d with 8 oz of
water or juice)
Lubricants: mineral oil (1–3 cc/kg/d) (should be used with
caution in young children and those at risk for aspiration)
Stool softeners: docusate sodium
Stimulant laxatives
Senna (for 2–6 y olds: sennosides: 3.75 milligrams/d;
maximum of 15 milligrams/d; for 6–12 y olds: sennosides: 8.6
milligrams once a day, maximum of 50 milligrams/d)
Bisacodyl ( if >6 years old): 5–10 milligrams at bedtime or
breakfast

52. Children (3 to 15 Years of Age)
Common cause Less common
• Appendicitis • DKA
• Constipation • Inflammatory bowel disease
• pain secondary to (IBD)
nonspecific viral syndrome • Cholelithiasis
• acute gastroenteritis • Sickle cell anemia
• strep pharyngitis • Henoch-Schönlein purpura
• UTI • Toxic ingestion
• pneumonia • Testicular ovarian
cyst, ectopic
pregnancy, pelvic
inflammatory disease, renal

53. S&S
• Verbalize the time of onset and location of the
pain by age 3 or 4 years old
• Older children may be able to characterize the
frequency and severity

54. PE
• Use verbal and tactile techniques
• Observation remains a key
• Note general appearance, position of comfort,
respiratory effort, and gait.

55. Appendicitis
• most common
• peak ages 9-12 yrs
• M>F
• Perforation rates approach
90% in children <4 years old.

56. • Vomiting may be the first
symptom noted by the parents.
• Peritoneal inflammation in
children can be elicited by asking
patients to walk, hop, or cough
• Assess for hernias in males and
females and perform a testicular
examination in all males
• A pelvic examination may be
needed in adolescent females

57. Diagnosis
• WBC <10,000/mm3 is a
strong negative predictor for
appendicitis
• Ambiguous cases, imaging
with ultrasonography or CT
are useful.

58. Treatment
• Once the diagnosis of
appendicitis is strongly
• NPO, IV hydration
• Antibiotic
– nonperforated 
ampicillin/sulbactam or
cefoxitin
– Perforated 
piperacillin/tazobactam

59. • Appendectomy is definitive
treatment (laparotomy or
laparoscopy)
• In ambiguous cases,
admission for serial
abdominal examination by a
surgeon is reasonable.

60. Nonspecific Abdominal Pain
• Largest single group of children
seen in the ED with acute
abdominal pain
• The key to the establishment
of nonspecific abdominal pain
as a working diagnosis is
reexamination in 24 hours and
repeated examinations over
time if symptoms continue.

61. Clinical features
• Nausea - most common symptom
after abdominal pain.
• Midepigastric or in the Lower half
• Tenderness is not usually severe, is
1/3 absent and 1/3 localized to the
right lower quadrant or
midepigastric
• Laboratory tests are usually normal
• Abdominal radiographs are also
normal.
follow-up is essential

62. Henoch-Schönlein Purpura
• Vasculitic disease of children
between 2 and 11 years
• Elevated IgA levels and IgA
deposits in the glomeruli and
vessel walls.

63. • Triad of acute onset of
– abdominal pain
– purpuric rash
– arthritis
• Diffuse and colicky +
vomiting
• Usually presents after the
rash
• 5% of cases of HSP are
associated with
intussusception

64. Palpable purpuric rash
• 50% of the cases
• typically present on the
lower extremities and
buttocks
Arthralgia or arthritis
• 25%, Joint symptoms are
migratory and usually involve
the knees and ankles with
periarticular swelling and
tenderness
• Painful edema of the feet

65. • Renal involvement
– not common
– any time in the course
– hematuria and hypertension
• Peripheral and central
nervous system, hematologic
system, and testes may also
be involved

66. Investigation
• UA  BUN, Cr
• stool guaiac
• Radiographic imaging

67. Treatment
• Mainly supportive
• Hydration
• NSAIDs, such as ibuprofen
(10 milligrams/kg/dose every
6 to 8 hours) and ketorolac
• Corticosteroids (abdominal,
joint, and scrotal )
• Consultation with a pediatric
rheumatologist or
nephrologist

68. Cholecystitis
• Very rare in children
• Bile stones
– hemolytic disease (e.g., sickle
cell disease)
– total parenteral nutrition

69. • Restless and unable to lie still
• Right upper quadrant
tenderness and a positive
Murphy sign with or without
guarding
• US

70. Treatment
• Any child with evidence of
cholecystitis or cholangitis
should be admitted to the
hospital.
• IV hydration, bowel rest,
analgesics, and antibiotics, if
febrile.

71. • Antibiotics should target
gram-negative organisms and
Enterococcus.
– Ampicillin
– Gentamicin
– Ampicillin/sulbactam
– Piperacillin/tazobactam

72. Pancreatitis
• Extremely rare in infants
• Most commonly a secondary
process in children and
adolescents
• Diverse etiologies

73. Structural anomalies
Idiopathic Pancreas divisum
Hereditary Common channel
Trauma Congenital duodenal stenosis
Blunt Choledochal cysts
Penetrating Stricture
Surgical Sclerosing cholangitis
Systemic Cholelithiasis
Sepsis/shock Ascaris
Viral infection (mumps, coxsackie B, influenza, hemolytic Metabolic
Streptococcus, Salmonella, hepatitis A and B)
Reye syndrome Cystic fibrosis
Collagen vascular disorders (systemic lupus erythematosus, 1-antitrypsin deficiency
periarteritis nodosa, Henoch-Schönlein purpura)
Peptic ulcer Hypercalcemia (hyperparathyroidism)
Uremia Hyperlipidemia (hypercholesterolemia)
Malnutrition Organic acidemias
Vitamin A and D deficiency
Drugs
Steroid
Chlorothiazides
Valproic acid
L-asparaginase

74. Clinical Features
• Acute onset of epigastric
(occasionally periumbilical)
abdominal pain associated
with anorexia, nausea, and
vomiting.
• Dull and constant in the
epigastric region, pain may
radiate to the back
• Worsened by eating or lying
supine

75. • Risk factors
– Recent chemotherapy with L-
asparaginase
– Recent motor vehicle accident
with blunt trauma
– Past medical history of cystic
fibrosis
– Family history of pancreatitis
(hereditary)

76. • The specificity of serum
lipase for pancreatitis is
nearly 100%.
• The severity of the disease
does not correlate with the
degree of enzyme elevation.
• Obtain liver function
studies, as pancreatitis may
be secondary to liver or
biliary disease, and serum
electrolytes, including
calcium.

77. • Abdominal US is the
modality of choice to
visualize the head of the
pancreas and associated
anomalies.

78. • Children with pancreatitis usually undergo a
CT scan to rule out alternative diagnoses.
• ERCP or MRCP may be used for diagnosis and
management once the patient has been
stabilized and admitted to the hospital.
• Treatment is supportive.

79. Pneumonia
• The respiratory component
of the patient's history and
examination may be mild,
and the predominant
complaint may be abdominal
pain
• Several days of mild cough
precede the abdominal pain,
and if the child has emesis, it
is typically post-tussive in
nature.

80. • On physical examination,
specifically look for fever,
tachypnea, or hypoxia.
• The lung examination may
reveal rales, rhonchi, or
decreased air entry at the
base.
• Chest x-ray is needed to
confirm the diagnosis.

81. Group A Streptococcus Pharyngitis
• Typically affects children 4
years of age and older
• Fever, sore throat, tonsillar
erythema, and exudate with
anterior cervical
lymphadenopathy in the
absence of upper respiratory
tract symptoms.

82. • Fever and abdominal pain
with or without vomiting,
and without sore throat
• For this reason, all children
>3 years of age with
abdominal pain, especially if
febrile, deserve a thorough
oropharyngeal examination

83. • The treatment of choice for
Streptococcus pharyngitis
– a one-time IM dose of benzathine penicillin
– Amoxicillin has no advantage over penicillin other
than taste
– Erythromycin can be used in children with a
penicillin allergy.
Treatment reduces the duration of symptoms, time
absent from school, infectivity time, and rheumatic
complications when started within 10 days of
symptoms.

84. Renal Stones
• Melamine-tainted formula
was responsible for an
outbreak of urolithiasis in
children in China
• calcium (most common in
children), uric acid, or
struvite

85. • Unlike adults, children with
renal stones present with
abdominal pain less
frequently (approximately
50% of the time).
• An infant with
nephrolithiases may be
misdiagnosed as having
colic. A preschool child may
present with recurrent UTIs.
Microscopic hematuria may

86. • standard for diagnosis is the
unenhanced helical CT.

87. • Melamine-induced renal stones have feeble or absent
acoustic shadows.38 Although hematuria and plain
abdominal films still appear in many clinical algorithms, the
weak LR of both tests, as shown in Table 124-7, do not
provide strong support for their use as sole predictors of
the presence of renal stones, although they may aid in the
diagnosis when considered along with the history and
physical examination of the child.39
• A basic metabolic panel with calcium, phosphorous, and
uric acid levels may help in identifying the type of stone
and underlying disease. The stone should be analyzed, if
passed, or a 24-hour urine collection for stone evaluation
should be performed.

89. • ED management is centered on pain control. If
the child's pain cannot be controlled with oral
medication, the child is not tolerating oral
fluids, or there is evidence of renal
dysfunction, the child should be admitted to
the hospital. Morphine sulfate (0.1
milligram/kg every 2 to 4 hours, as needed, to
a maximum of 8 milligrams/dose IV) and/or
ketorolac (0.4 to 1.0 milligram/kg/dose every
12 hours, maximum of 30 milligrams/dose IV)
are effective analgesics for renal stones.
Depending on the type of stone, urine
alkalinization or diuretics may be added to the
treatment. Finally, if needed, a urologist may
perform extracorporeal shock wave lithotripsy
or stone removal using a rigid or flexible
endoscope.37

91. Inflammatory Bowel Disease
• older children or teenagers,
and commonly the first
presentation involves severe
acute abdominal pain

92. • colicky and is associated with
diarrhea, which may be
bloody. Abdominal pain is
not the sole presenting
symptom, and IBD is
associated with fever, weight
loss, fatigue, and blood per
rectum.41 For example, 80%
of the patients with Crohn
disease have a history of
weight loss, and 20% have

93. • On physical examination,
tachycardia and hypotension
may be present secondary to
dehydration or anemia from
chronic blood loss.
Abdominal tenderness and
guarding may be localized
(especially to the right lower
quadrant in Crohn disease),
which can mimic
appendicitis. Patients with

94. • An abdominal CT is
commonly obtained to
evaluate for thickening of the
terminal ileum. Definitive
diagnosis requires endoscopy
and biopsy, and a pediatric GI
specialist should be
consulted for further
evaluation and management.

95. THANK YOU