Acute Abdominal Pain in Children

CARIN E. REUST, MD, MSPH, and AMY WILLIAMS, MD, MSPH, University of Missouri–Columbia, Columbia, Missouri

Acute abdominal pain accounts for approximately 9% of childhood primary care office visits. Symptoms and signs
that increase the likelihood of a surgical cause for pain include fever, bilious vomiting, bloody diarrhea, absent bowel
sounds, voluntary guarding, rigidity, and rebound tenderness. The age of the child can help focus the differential
diagnosis. In infants and toddlers, clinicians should consider congenital anomalies and other causes, including mal-
rotation, hernias, Meckel diverticulum, or intussusception. In school-aged children, constipation and infectious
causes of pain, such as gastroenteritis, colitis, respiratory infections,
and urinary tract infections, are more common. In female adoles-
cents, clinicians should consider pelvic inflammatory disease, preg-
nancy, ruptured ovarian cysts, or ovarian torsion. Initial laboratory
tests include complete blood count, erythrocyte sedimentation rate
or C-reactive protein, urinalysis, and a pregnancy test. Abdominal
radiography can be used to diagnose constipation or obstruction.
Ultrasonography is the initial choice in children for the diagnosis
of cholecystitis, pancreatitis, ovarian cyst, ovarian or testicular tor-
sion, pelvic inflammatory disease, pregnancy-related pathology,
and appendicitis. Appendicitis is the most common cause of acute

ILLUSTRATION BY SCOTT BODELL

abdominal pain requiring surgery, with a peak incidence during ado-
lescence. When the appendix is not clearly visible on ultrasonogra-
phy, computed tomography or magnetic resonance imaging can be
used to confirm the diagnosis. (Am Fam Physician. 2016;93(10):830-
836. Copyright © 2016 American Academy of Family Physicians.)

A
More online cute abdominal pain accounts for about in discomfort, active). The child’s age
at http://www.
approximately 9% of childhood can help in narrowing potential causes of
aafp.org/afp.
visits to primary care.1 The initial abdominal pain (Table 16,7).
CME This clinical content
assessment of acute abdominal History regarding abdominal pain should
conforms to AAFP criteria
for continuing medical pain should focus on the severity of illness include associated symptoms, previous epi-
education (CME). See and whether there is a potential surgical sodes of abdominal pain, and the intensity
CME Quiz Questions on cause of abdominal pain. For this article, of the pain. Important associated symptoms
page 822. surgical cause refers to a condition that may are bilious vomiting (bowel obstruction),
Author disclosure: No rel- require surgical intervention. In children bloody stool (bowel ischemia), and fever.
evant financial affiliations. presenting to the emergency department Fever at the onset of acute illness is less likely
with acute abdominal pain, the incidence of to indicate a surgical abdomen, whereas
appendicitis or other causes needing surgi- fever after the onset of vomiting or pain
cal intervention ranges from 10% to 30%2-5 ; is consistent with developing peritonitis.
however, in general, the incidence of surgical Chronic, intermittent acute abdominal pain
acute abdominal pain is 2%.1 is less likely to be related to a surgical cause
than a first episode of acute pain.
History Poorly localized pain that improves with
The approach to a child with acute abdomi- movement is more likely visceral pain. Vis-
nal pain should begin with an overall assess- ceral pain receptors are located in the muscles
ment of the child’s appearance (lethargy, and mucosa of hollow organs. Stretching or
eye contact, comforted by family member, twisting of these receptors through obstruc-
interactive), food and fluid intake (decreased tion or volvulus of organs causes pain. Visceral
intake or urine output, normal intake and pain receptors in the stomach, lower esopha-
output), and activity level (lying still, moving gus, or duodenum cause epigastric pain;

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 SORT: KEY RECOMMENDATIONS FOR PRACTICE

Evidence
Clinical recommendation rating References

Urinalysis, complete blood count, pregnancy test, and erythrocyte C 15-18

sedimentation rate or C-reactive protein should be the initial laboratory
tests in the evaluation of acute abdominal pain in children.
Ultrasonography is the imaging choice for acute abdominal pain in children. C 23-28
Opiates may be safely used in children with acute abdominal pain without A 34-36
delaying or affecting the accuracy of diagnosis.

A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence;

C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the
SORT evidence rating system, go to http://www.aafp.org/afpsort.

receptors in the small intestine cause perium- mal menstrual bleeding with pain can indi-
bilical pain; and in the colon, lower abdomi- cate pelvic inflammatory disease.
nal pain. Pain that is sharp, localized, and
worsens with movement has most likely origi- Physical Examination
nated from somatoparietal receptors found in A complete examination with attention to
the parietal peritoneum, muscle, and skin. pharyngeal erythema or exudate and focal
It is important to ask about other asso- consolidation in the lungs should be per-
ciated symptoms because a variety of eti- formed in children with acute abdominal
ologies cause abdominal pain in children pain. An abdominal examination in a sick,
(Table 21,8-14). Abdominal pain with cough, crying child can be difficult to perform. A
shortness of breath, or sore throat can be family member can assist by placing his or
due to respiratory infection. Urinary symp- her hands on the abdomen with the exam-
toms can indicate a urinary tract infection or iner’s hands on top of them until the child
pyelonephritis. In pubertal girls, it is impor- allows the examination. Asking the child to
tant to ask about menstrual history and point to the part of the abdomen that hurts
sexual activity. Vaginal discharge, with or the most, and then initially avoiding that
without fever, irregular spotting, or abnor- area, can also facilitate the examination.

Table 1. Selected Differential Diagnosis of Acute Abdominal Pain in Children by Age

All ages Infants and toddlers (0 to 4 years) School age (5 to 11 years) Adolescents (12 to 18 years)

Appendicitis Hirschsprung disease Abdominal migraine Ectopic pregnancy

Bowel obstruction Infantile colic Functional pain Functional pain
Child abuse Inguinal hernia Henoch-Schönlein purpura Inflammatory bowel disease
Constipation Intussusception Intussusception Irritable bowel syndrome
Dietary indiscretions Lactose intolerance Lead poisoning Menstrual-related condition
Gallbladder disease Lead poisoning Mononucleosis Mononucleosis
Gastroenteritis Malrotation of the midgut Volvulus Omental infarction
Hemolytic uremic syndrome Meckel diverticulum Other pregnancy issues
Mesenteric adenitis Volvulus Ovarian or testicular torsion
Pancreatitis Pelvic inflammatory disease
Sickle cell crisis Sexually transmitted infection
Trauma
Upper respiratory infection
Urinary tract infection

Information from references 6 and 7.

May 15, 2016 ◆ Volume 93, Number 10 www.aafp.org/afp American Family Physician 831
Acute Abdominal Pain
Table 2. Clinical Features of Selected Causes of Acute Abdominal Pain in Children

Condition Clinical findings Age Comments

Abdominal migraine Anorexia, nausea, vomiting, 3 to 10 years Boys and girls equally affected8
headache, photophobia
Colic Persistent crying without Younger than 3 months Nonacute abdominal examination
apparent cause
Constipation Hard, infrequent stooling All age groups May be most common cause of
abdominal pain1
Gastroenteritis or colitis Diarrhea, with vomiting or All age groups Campylobacter, Cryptosporidium,
fever Escherichia coli, Salmonella, Shigella,
rotavirus
Hirschsprung disease Constipation, severe Infant Delayed passage of meconium (more than
diarrhea, bowel 24 hours) in about 57% of cases9
obstruction, perforation,
sepsis
Inflammatory bowel Bloody diarrhea Primarily adolescents Childhood prevalence of Crohn disease
disease is 43 per 100,000; of ulcerative colitis,
28 per 100,00010
Omental infarction Lower abdominal pain, School-aged, Self-limiting, diagnosed on computed
vomiting, diarrhea overweight males11 tomography12
Ovarian cyst Lower abdominal pain Adolescent females Types include hemorrhagic, ruptured, and
ovulatory, and torsion of a cyst
Pneumonia Cough, shortness of breath, All age groups Lower lobe pneumonia
fever, tachypnea
Pyelonephritis Flank tenderness, fever, All age groups Oral antibiotics for 10 to 14 days as
nausea and vomiting effective as intravenous antibiotics13
Sexually transmitted Vaginal or penile discharge, Adolescent Chlamydia trachomatis, Neisseria
infection fever gonorrhoeae
Streptococcal pharyngitis Sore throat, fever Older than 3 years Rapid strep test or culture
Urinary tract infection Dysuria, urinary frequency, All age groups, Point prevalence in children older than
urinary urgency, hematuria primarily females and one year is 7.8%14
uncircumcised infants

Information from references 1, and 8 through 14.

Auscultation of bowel sounds can help a for pregnancy complications and sexually
clinician understand where the abdomen is transmitted infections; scrotal examination
painful because the child may try to block is indicated in boys.
the stethoscope from that area. Absent
bowel sounds can indicate ileus or peritoni- Diagnostic Evaluation
tis, whereas hyperactive bowel sounds may LABORATORY
indicate obstruction. Beginning palpation Initial laboratory tests should include a com-
just above the iliac crest in the lower quad- plete blood count, erythrocyte sedimenta-
rants of the abdomen will help identify an tion rate or C-reactive protein, a pregnancy
enlarged liver, spleen, or other abdominal test, if indicated, and urinalysis.15-18 A clean
mass. Gentle palpation can elicit guard- void urinalysis is as accurate as a suprapubic
ing, and percussion without deep palpa- aspiration15 ; the accuracy of a bag, diaper,
tion can elicit rebound pain. Guarding and or pad specimen is inconsistent.19,20 A urine
rebound pain can be consistent with peri- dipstick positive for leukocytes, esterase,
tonitis. Signs suggestive of the possible need and nitrite is concerning for a urinary tract
for surgery for acute abdominal pain are infection (pooled positive likelihood ratio
listed in Table 3. Rectal examination may of 28.2 in children younger than five years
be necessary to identify a pelvic abscess or [95% confidence interval, 17.3 to 46.0]).15,21
occult blood in the stool. Pelvic examina- Other tests may include liver function
tion is required in pubertal girls to evaluate tests; amylase, lipase, or both for pancreatitis;

832  American Family Physician www.aafp.org/afp Volume 93, Number 10 ◆ May 15, 2016
 Acute Abdominal Pain
BEST PRACTICES IN EMERGENCY MEDICINE:
RECOMMENDATIONS FROM THE CHOOSING WISELY CAMPAIGN

Recommendation Sponsoring organization

sexually transmitted infection testing (Chla- Computed tomography is not necessary in the American Academy
mydia trachomatis, Neisseria gonorrhoeae); routine evaluation of abdominal pain. of Pediatrics
and stool studies (Escherichia coli and Cam- Do not do computed tomography for the American College
pylobacter, Cryptosporidium, Salmonella, and evaluation of suspected appendicitis in of Surgeons
Shigella species), including evaluation for children until after ultrasonography has been
occult blood. considered as an option.

IMAGING Source: For more information on the Choosing Wisely Campaign, see http://www.
choosingwisely.org. For supporting citations and to search Choosing Wisely recom-
Radiation exposure is an important consid- mendations relevant to primary care, see http://www.aafp.org/afp/recommendations/
eration before imaging in children. Radia- search.htm.

tion dose is dependent on the child’s size.

The cumulative effect of exposure over a
lifetime of imaging needs to be assessed. lecystitis, pancreatitis, renal calculi, ovar-
Computed tomography (CT) of the abdo- ian cysts, ovarian torsion, and pregnancy
men and pelvis exposes a child to the equiv- complications.27,28
alent of more than 100 chest radiographs. Ultrasonography is the imaging tool of
The risk of a radiation-induced solid cancer choice for evaluation of appendicitis, fol-
is estimated to be one per 300 to 390 CT lowed by CT or magnetic resonance imag-
scans of the abdomen and pelvis for girls, ing (MRI) for equivocal findings.30,31 The
and one per 670 to 760 scans for boys.22 sensitivity of ultrasonography is decreased
The American College of Radiology Appro- in centers where it is used less often, when
priateness Criteria offer recommenda- the appendix is not clearly visualized, and
tions for imaging children with abdominal when there is shorter duration of pain; sen-
pain (http://www.acr.org/Quality-Safety/ sitivity is also dependent on the child’s body
Appropriateness-Criteria). habitus.30,31 Ultrafast 3T magnetic resonance
Ultrasonography is relatively inexpensive imaging requires only six minutes, does
and does not expose the patient to radiation. not require sedation, and has no radiation
It is the first-line imaging choice for undif- exposure.32
ferentiated acute abdominal pain, unless Abdominal radiography is more likely
history or physical examination identifies a to be diagnostic in patients with previous
specific diagnosis.23-28 Ultrasonography can abdominal surgery, abnormal bowel sounds,
be used to evaluate for bowel thickening in abdominal distension, or peritoneal signs.
inflammatory bowel disease, focal intramu- Radiography may identify a renal or ureteric
ral bowel hematomas in Henoch-Schönlein calculus, abdominal mass, ingested foreign
purpura, and bowel “target” or “donut” sign body (including bezoars), bowel perforation
in intussusception.27,29 It is also the primary with free air, and constipation.12,27,33
imaging choice for pyloric stenosis, cho- CT of the abdomen may be required to
diagnose complications such as necrosis
from pancreatitis or abscess formation in
Table 3. Signs Indicating the appendicitis27,33 and may be used for the
Possible Need for Surgery in diagnosis of omental torsion or mesenteric
Patients with Acute Abdominal Pain lymphadenitis.33

Absent bowel sounds Management of Acute Abdominal Pain

Bilious vomiting A quick workup is needed for a sick-
Bloody diarrhea or occult blood in stool appearing child, with attention to hydration
Elevated temperature (≥ 100.4°F [38.0°C]) status and pain control. For severe pain,
Rebound tenderness opiates should be used and will not delay or
Rigidity (involuntary guarding) affect the accuracy of diagnosis.34-36 Urgent
Voluntary guarding surgical consultation should not be delayed
while awaiting diagnostic workup. If a child

May 15, 2016 ◆ Volume 93, Number 10 www.aafp.org/afp American Family Physician 833
Acute Abdominal Pain
Evaluation and Diagnosis of Acute Abdominal
Pain in Children
Bilious vomiting, bloody diarrhea,
or fever, with rebound tenderness,
rigidity, or voluntary guarding? SURGICAL CAUSES OF ACUTE ABDOMINAL PAIN
Appendicitis can occur at any age but has a
peak incidence during adolescence because
Yes No
of lymphoid follicular hyperplasia.16 Clinical
Consider surgical Diarrhea Bloody diarrhea? examination does not distinguish appendi-
consultation
citis from mesenteric lymphadenitis.38 There
are a variety of clinical prediction rules for
No Yes
Obtain laboratory appendicitis. The best validated systems
results (CBC, ESR If mild to moderate Consider dysentery, are the Pediatric Appendicitis Score and
or CRP, urinalysis, presentation, infectious enteritis or
β-hCG), and perform most likely viral colitis, inflammatory
the Alvarado score, which uses the mne-
imaging as indicated gastroenteritis bowel disease monic MANTRELS for the characteristics
by clinical presentation including rotavirus it evaluates (Table 4).39 In general, predic-
tion rules overestimate appendicitis by 30%
Constipation Abdominal radiography and miss 3% to 5% of cases. A child with
Consider appendicitis,
bowel obstruction, bowel fever, rebound tenderness, a history of mid-
perforation, incarcerated abdominal pain migrating to the right lower
Consider constipation,
hernia, intussusception,
malrotation of the
bowel obstruction quadrant, and an elevated white blood cell
midgut, ovarian torsion, count, erythrocyte sedimentation rate, or
testicular torsion, volvulus Risk factors for β-hCG measurement, C-reactive protein level should be evaluated
pregnancy or STI gonorrhea and chlamydia
testing, pelvic or trans­
for appendicitis16,40 (eTable A).
vaginal ultrasonography
INFANTS AND TODDLERS

In infants and toddlers, acute abdominal

Consider pregnancy-
or STI-related disease
pain may be caused by intussusception and
or complication congenital anomalies, including Meckel
diverticulum, malrotation of the midgut,
Urinary symptoms Urinalysis and inguinal hernias. Intussusception usu-
ally occurs before two years of age.41 Infants
and toddlers may present with right lower
Consider urinary
tract infection quadrant tenderness, a sausage-shaped
mass in the abdomen, and red currant
Respiratory symptoms Chest radiography jelly stool caused by venous congestion of
Rapid strep test intussuscepted bowel.41 However, the clas-
sic triad of colicky abdominal pain, vomit-
If the diagnosis is undetermined
and not acute, consider
ing, and bloody stool is found in less than
Consider pneumonia,
observation, with monitoring streptococcal pharyngitis, 50% of cases.29,41 In children, 90% of cases
instructions for parents, and other upper respiratory of intussusception are idiopathic, with
repeating the examination in infection
24 to 48 hours
10% of cases resulting from a lead point or
sticky spot in the colon.41 Air or contrast
enema can be diagnostic and therapeutic for
Figure 1. Algorithm for the evaluation and diagnosis of acute abdomi-
nal pain in children. (β-hCG = beta human chorionic gonadotropin; intussusception.
CBC = complete blood count; CRP = C-reactive protein; ESR = erythro- Symptomatic Meckel diverticulum can
cyte sedimentation rate; STI = sexually transmitted infection.) present with gastrointestinal bleeding,
diverticulitis, bowel obstruction, peritoni-
does not have an acute surgical abdomen tis, intussusception, or volvulus. One-half
and the diagnosis is undetermined, the of such cases occur in children younger than
examination should be repeated in 24 to four years.12,41 Malrotation of the midgut
48 hours. Up to 30% of children will have a leading to volvulus causes bilious vomiting,
change in their diagnosis.37 Figure 1 outlines pain, diarrhea, and bloody stools in more
the approach to the evaluation and diagno- advanced cases. Incarcerated inguinal her-
sis of acute abdominal pain. nias present with a tender groin mass.

834  American Family Physician www.aafp.org/afp Volume 93, Number 10 ◆ May 15, 2016
 Acute Abdominal Pain
Table 4. Validated Prediction Scores for Appendicitis
in Children

Alvarado Pediatric
ADOLESCENTS (MANTRELS) Appendicitis
Clinical variable score* Score†
In adolescents, acute abdominal pain may
result from a gonad- or pregnancy-related Migration of pain 1 1
pathology. Ovarian torsion presents with Anorexia 1 1
intermittent, nonradiating unilateral lower Nausea/vomiting 1 1
abdominal pain with an enlarged adnexa Tenderness in right lower quadrant 2 2
on ultrasonography or CT.42 Testicular tor- Rebound pain 1 —
sion commonly presents with a tender scro- Elevation in temperature (≥ 100.4°F 1 1
tum and enlarged testis in adolescents, but [38.0°C])
boys may present with a complaint of hip or Leukocytosis > 10,000 per mm3 (10.00 × 2 1
abdominal pain with nausea or vomiting. 109 per L)
Ectopic pregnancy and early pregnancy Shift to the left of white blood cell count 1 1
(> 75% polymorphonucleocytes)
loss must be considered in adolescent girls.
Cough/percussion/hopping causes pain in — 2
Both conditions may present with vaginal the right lower quadrant
bleeding, cramping pain, and abdominal ten-
derness. An intrauterine pregnancy should be *—Score < 4 = low risk of appendicitis, no imaging required; 4 to 8 = intermediate risk
visualized with transvaginal ultrasonogra- of appendicitis; ≥ 9 = high risk of appendicitis.
†—Score < 4 = low risk of appendicitis, no imaging required; 4 to 7 = intermediate risk
phy when the beta human chorionic gonad-
of appendicitis; ≥ 8 high risk of appendicitis.
otropin level is 1,500 to 2,000 mIU per mL
Adapted with permission from Ebell MH, Shinholser J. What are the most clinically
(1,500 to 2,000 IU per L).43 Early pregnancy useful cutoffs for the Alvarado and Pediatric Appendicitis Scores? A systematic review.
loss may be seen as an empty gestational sac Ann Emerg Med. 2014;64(4):366.
or gestational sac without fetal heart activity
on transvaginal ultrasonography.44 Repeat
ultrasonography and serial beta human cho- bia, MO 65212 (e-mail: [email protected]).
rionic gonadotropin testing may be required Reprints are not available from the authors.
to confirm pregnancy loss.
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quarterly/Abstract/publishahead/ACR_Appropriateness_ diverticulum. Surg Clin North Am. 2012;​92(3):​505-526, vii.
Criteria_R__Acute_Pelvic_Pain.99880.aspx. Accessed 42. Appelbaum H, Abraham C, Choi-Rosen J, Ackerman M.
January 23, 2016. Key clinical predictors in the early diagnosis of adnexal
25. Karmazyn B, Coley BD, Binkovitz LA, et al. American Col- torsion in children. J Pediatr Adolesc Gynecol. 2013;​26(3):​
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836  American Family Physician www.aafp.org/afp Volume 93, Number 10 ◆ May 15, 2016
 Acute Abdominal Pain

eTable A. Likelihood Ratios Related to Appendicitis

LR+ (95% CI) LR– (95% CI)

Signs and symptoms

Fever A1 3.4 (2.4 to 4.8) 0.32 (0.16 to 0.64)
Rebound tendernessA2 3.0 (2.3 to 3.9) 0.28 (0.14 to 0.55)
Mid-abdominal pain migrating 1.9 (1.4 to 2.5) 0.72 (0.62 to 0.85)
to right lower quadrant A3
Laboratory tests
Erythrocyte sedimentation rate 3.8 (1.8 to 8.1) 0.68 (0.56 to 0.81)
> 20 mm per hour A4
C-reactive protein > 10 mg per L 3.6 (2.1 to 6.2) 0.44 (0.33 to 0.59)
(95.24 nmol per L) A4
White blood cell count > 10,000 2.0 (1.3 to 2.9) 0.22 (0.17 to 0.30)
per mm3 (10.00 × 109 per L) A2
Prediction scores
Alvarado (MANTRELS) ≥ 7A2 4.0 (3.2 to 4.9) 0.20 (0.09 to 0.41)
Pediatric Appendicitis Score ≥ 6A5 2.4 (2.0 to 2.8) 0.27 (0.20 to 0.37)

CI = confidence interval; LR+ = positive likelihood ratio; LR– = negative likelihood ratio.
Information from:
A1. O’Shea JS, Bishop ME, Alario AJ, Cooper JM. Diagnosing appendicitis in children
with acute abdominal pain. Pediatr Emerg Care. 1988;4(3):172-176.
A2. Bundy DG, Byerley JS, Liles EA, Perrin EM, Katznelson J, Rice HE. Does this child
have appendicitis? JAMA. 2007;298(4):438-451.
A3. Kharbanda AB, Taylor GA, Fishman SJ, Bachur RG. A clinical decision rule to iden-
tify children at low risk for appendicitis. Pediatrics. 2005;116(3):709-716.
A4. Pelota H, Ahlqvist J, Rapola J, et al. C-reactive protein compared with white blood
cell count and erythrocyte sedimentation rate in the diagnosis of acute appendicitis in
children. Acta Chir Scand. 1986;152:55-58.
A5. Schneider C, Kharbanda A, Bachur R. Evaluating appendicitis scoring systems
using a prospective pediatric cohort. Ann Emerg Med. 2007;49(6):778-784.e.1.

May 15, 2016

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