Pediatric Abdominal Pain

Key considerations: Appendicitis, Intussusception, Malrotation with midgut volvulus

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history: Age-specific differential changes significantly; Bilious vs non-bilious vomiting; Stool pattern: bloody, mucoid, constipated; Migration of pain (appendicitis: periumbilical → RLQ); Last menstrual period in adolescent females; Sick contacts, travel, diet changes; exam: Observe child before touching — facial expression, positioning; Hop test or heel drop for peritoneal irritation; RLQ tenderness, Rovsing, psoas, obturator signs; Inguinal exam: hernia; Testicular exam in all males with abdominal pain; Rectal exam only if indicated; labs: CBC with differential; CRP (elevated >10mg/L in appendicitis); Urinalysis (UTI, DKA, kidney stone); Lipase if epigastric pain; Beta-hCG in adolescent females; BMP if vomiting or dehydration; imaging: Ultrasound first: appendicitis, intussusception, ovarian pathology; CT abdomen only if ultrasound non-diagnostic and high clinical concern; Upper GI series if malrotation suspected (emergent); KUB: obstruction pattern, fecal loading; bedside: Point-of-care glucose; Pregnancy test in adolescent females; Ultrasound for right iliac fossa tenderness

immediate: NPO if surgical condition suspected; IV access if ill-appearing or vomiting; Pain control — do NOT withhold analgesia (does not mask surgical findings in children); general: Serial abdominal exams — the trend matters more than a single exam; Adequate pain management improves exam quality; specific: diagnosis: Appendicitis; steps: IV antibiotics: piperacillin-tazobactam or ceftriaxone + metronidazole; Surgical consult for appendectomy; Pain management with IV morphine/fentanyl; NPO, IV fluids; diagnosis: Intussusception; steps: Air or hydrostatic enema (diagnostic AND therapeutic); Surgical consult before reduction attempt; IV access and resuscitation if needed; Post-reduction observation for recurrence (10% risk); diagnosis: Malrotation with volvulus; steps: EMERGENT surgical consult — this is a time-critical surgical emergency; NPO, NG tube decompression; IV fluid resuscitation; Upper GI series confirms diagnosis — do not delay surgery

admit: Appendicitis confirmed or highly suspected; Intussusception requiring reduction or observation post-reduction; Surgical abdomen; Unable to tolerate oral intake; Undifferentiated abdominal pain requiring serial exams; discharge: Constipation after successful disimpaction and bowel regimen education; Viral gastroenteritis with adequate hydration; Functional pain with reliable follow-up; Negative appendicitis workup with return precautions; consults: Pediatric surgery for appendicitis, intussusception, malrotation; Urology for testicular torsion; GI for chronic/recurrent pain

Bilious vomiting in a neonate or infant is MALROTATION WITH VOLVULUS until proven otherwise — this is a surgical emergency
Pain medication does NOT mask physical exam findings — multiple studies show analgesia actually improves exam accuracy
Classic intussusception triad (colicky pain + vomiting + currant jelly stool) is present in <50% of cases
Appendicitis: ultrasound has ~90% sensitivity in experienced hands — avoid unnecessary CT radiation in children

AAP Clinical Report on Appendicitis 2017, ACR Appropriateness Criteria Pediatric, Pediatric Surgery (Coran). Last reviewed: 2024-11-01