CME

Acute Abdominal Pain in Children:​

Evaluation and Management
Katie L. Buel, DO;​James Wilcox, MD;​and Paul T. Mingo, MD

Acute abdominal pain in children is a common presentation in the clinic and emergency department settings and
accounts for up to 10% of childhood emergency department visits. Determining the appropriate disposition of abdom-
inal pain in children can be challenging. The differential diagnosis of acute abdominal pain, including gastroenteritis,
constipation, urinary tract infection, acute appendicitis, tubo-ovarian abscess, testicular torsion, and volvulus, and the
diagnostic approach vary by age. Most causes of acute abdominal pain in children are self-limited. Symptoms and signs
that indicate referral for surgery include pain that is severe, localized, and increases in intensity;​pain preceding vomiting;​
bilious vomiting;​hematochezia;​guarding;​and rigidity. Physical examination findings suggestive of acute appendicitis in
children include decreased or absent bowel sounds, psoas sign, obturator sign, Rovsing sign, and right lower quadrant
rebound tenderness. Initial laboratory evaluation may include urinalysis;​ complete blood cell count;​ human chorionic
gonadotropin, lactate, and C-reactive protein levels;​and a comprehensive metabolic profile. Ultrasonography, includ-
ing point-of-care ultrasonography, for the evaluation of acute abdominal pain in children is the preferred initial imaging
modality due to its low cost, ease of use, and lack of ionizing radiation. In addition to laboratory evaluation and imaging,
children with red-flag or high-risk symptoms should be referred for urgent surgical consultation. Validated scoring sys-
tems, such as the Pediatric Appendicitis Score, can be used to help determine the patient’s risk of appendicitis.

Am Fam Physician. 2024;​110(6):​621-631. Copyright © 2024 American Academy of Family Physicians.

A cute abdominal pain in children is a common presenta-

tion in clinic and emergency department settings and
accounts for up to 10% of childhood emergency department
or sinusitis (23.7%), gastroenteritis (15.4%), uncertain etiology
(15.4%), constipation (9.4%), and urinary tract infection (8%).1
Cases of pancreatitis are increasing due to gallstones caused
visits.1 Most causes of acute abdominal pain are self-limited.1 by obesity.2
The most common etiologies that indicate referral for surgery
in children younger than 12 months are incarcerated inguinal HISTORY
hernia and intussusception;​in those older than 1 year, the Narrowing the differential diagnosis can be done by using the
most common cause for surgery is acute appendicitis.1 The age and symptoms of the patient. Table 1 shows the differen-
most common nonsurgical causes of abdominal pain include tial diagnosis of acute abdominal pain in children by age.1,3
upper respiratory tract infection with or without otitis media Table 21,3,4 and Table 31,3,5 outline the clinical features of com-
mon causes of acute abdominal pain in infants and toddlers and
school-aged children and adolescents, respectively. Because of
KATIE L. BUEL, DO, is an assistant professor of Clinical the visceral nature of many etiologies of acute abdominal pain,
Family Medicine in the Department of Family Medicine at the pain is often generalized on initial presentation. Children
Indiana University School of Medicine, Indianapolis. younger than 5 years may struggle to localize pain;​therefore,
JAMES WILCOX, MD, FAAFP, is an assistant professor obtaining a comprehensive history is important.6 Although
of Clinical Family Medicine in the Department of Family history alone is rarely sufficient to determine the source of the
Medicine at Indiana University School of Medicine. pain, it is critical in determining which cases are high risk
and require urgent evaluation or intervention.1 A pain history
PAUL T. MINGO, MD, is an assistant professor of Clinical
should include when the pain started, where it is located, if it
Family Medicine in the Department of Family Medicine at
radiates, its association with eating, if it is constant or parox-
Indiana University School of Medicine.
ysmal, and provoking or alleviating factors.
Author disclosure:​Dr. Wilcox is a paid instructor for the Symptoms of acute abdominal pain may include fever,
Global Ultrasound Institute. Drs. Buel and Mingo have no anorexia, nausea, emesis, or changes in urinary and stooling
relevant financial relationships. patterns. Symptoms and signs that indicate referral for surgery
Address correspondence to Katie L. Buel, DO, at katie. include pain that is severe, localized, and increases in inten-
buel@​gmail.com. sity;​pain preceding vomiting;​bilious vomiting;​hematochezia;​
guarding;​and rigidity. Patients who have mild to moderate

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 SORT:​KEY RECOMMENDATIONS FOR PRACTICE

Evidence
Clinical recommendation rating Comments

Ultrasonography is the preferred initial imaging modality for C Systematic reviews of randomized controlled
children with acute abdominal pain.1,6,7,8,17,20-24 trials with diagnostic accuracy outcomes

Do not routinely perform radiography for the evaluation of A Multiple randomized controlled trials and
abdominal pain in children.3,10,14,21,22,32 society guidelines that show no benefit and
increased diagnostic error

Use a clinically validated scoring system (eg, the Pediatric C Expert opinion
Appendicitis Score) for the evaluation of children at high risk
of appendicitis in the emergency setting.7,8,13,23,24,36

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 https://​w ww.
aafp.org/afpsort.

midline pain without worsening inten-

sity and vomiting tend to have a benign TABLE 1
etiology.1
Differential Diagnosis of Acute Abdominal Pain in Children
PHYSICAL EXAMINATION by Age
The assessment of acute abdominal
pain in children should begin with an Infants and toddlers School-aged children Adolescents
evaluation of vital signs and general
Constipation Abdominal migraine Abdominal migraine
appearance. The abdominal examination
should include inspection, auscultation, Gastroenteritis Appendicitis Appendicitis
palpation, and additional tests based on Gastroesophageal Constipation Constipation
differential diagnosis. High-risk or red- reflux Diabetic ketoacidosis Ectopic pregnancy
flag signs include abdominal distention, Hirschsprung disease Functional abdominal Functional abdominal
rigidity, peritoneal signs, unstable vital
Incarcerated hernia pain pain
signs, and focal tenderness. Findings
suggestive of acute appendicitis in chil- Infantile colic Gastroenteritis Gastroenteritis
dren include absent or decreased bowel Ingestion of a foreign Inflammatory bowel Inflammatory bowel
sounds, psoas sign, obturator sign, body disease disease
Rovsing sign, and right lower quadrant Intussusception Mononucleosis Irritable bowel syndrome
rebound tenderness 7 (Table 48).
Meckel diverticulum Pneumonia Mononucleosis
Children and adolescents with male
anatomy should receive a genitourinary Necrotizing Streptococcal Pancreatitis
examination because testicular torsion enterocolitis pharyngitis Pelvic inflammatory
can present with abdominal pain as the Trauma Testicular or ovarian disease
only symptom. Findings consistent with torsion
Urinary tract infection Kidney or ureteral stone
testicular torsion include scrotal pain and
Volvulus Urinary tract infection Sexually transmitted
swelling, loss of the cremasteric reflex,
and abnormal position of the testicle.9 infection

In children and adolescents with female Streptococcal

anatomy and lower abdominal pain, a pharyngitis
pelvic examination may be necessary, Tubo-ovarian abscess
including a bimanual examination and
Urinary tract infection
swabs, to test for sexually transmitted
infections (STIs) if indicated. Suspected Information from references 1 and 3.
or reported sexual abuse is an indication

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 ABDOMINAL PAIN IN CHILDREN

TABLE 2

Clinical Features of Common Causes of Acute Abdominal Pain in Infants and Toddlers

Condition Clinical findings Comments

Emergent causes
Bowel obstruction Fever and abdominal tenderness with bilious Multiple imaging modalities exist for diagnosis, with
vomiting and possibly bloody stools from isch- preference for ultrasonography as initial modality,
emia;​decreased or absent bowel sounds followed by magnetic resonance imaging, CT with
oral contrast media, and plain radiography

Child abuse or Typical mechanisms of trauma include motor Suspect child abuse when caregiver story does not
trauma vehicle crashes, falling, and child abuse match developmental milestones, if a child has mul-
tiple injuries, or is seen multiple times for injuries

Intussusception Classic triad of symptoms includes intermit- 60% of cases occur in the first year of life;​ultraso-
tent, colicky abdominal pain, vomiting, and nography can identify the “target sign” for bowel
bloody mucoid stools (also known as red cur- wall within bowel lumen;​an enema may be diagnos-
rant jelly stools) and is present in only 20% to tic and therapeutic
40% of cases;​at least two of these findings are
present in approximately 60% of patients

Malrotation with Typically presents with bilious and nonbilious Ultrasonography can be performed as initial evalua-
volvulus vomiting, possibly with abdominal distention;​ tion, but an upper gastrointestinal series or CT may
pain is often inconsistent, but typically present be needed for diagnosis;​this condition is a surgical
emergency;​necrotic bowel requiring resection can
manifest in hours

Meckel Painless or minimally painful rectal bleeding;​ Rule of 2’s:​it is present in 2% of the population, only
diverticulum abdominal pain and other clinical presentations 2% of affected patients become symptomatic, and​
may mimic appendicitis or diverticulitis almost one-half of patients are < 2 years

May ulcerate and perforate, presenting as a bowel

perforation, or act as a lead point in intussusception
or volvulus

Necrotizing Severe abdominal pain and lethargy;​may be Can be managed medically or surgically;​requires
enterocolitis accompanied by unstable vital signs urgent surgical consultation

Pneumonia Cough, fever, and leukocytosis Best evaluated with history and physical examina-
tion;​ultrasonography or radiography of the lungs
can provide diagnostic accuracy in unclear cases

Pyelonephritis Urinary symptoms (eg, dysuria, frequency, Ultrasonography can rule out kidney abscess
urgency) with leukocytosis, fever, and flank pain

Pyloric stenosis Projectile vomiting and losing weight;​some- Ultrasonography can identify stenotic pylorus
times an olive-sized mass can be palpated

Urinary tract For infants, the only presenting sign may be Fever in infants < 3 months requires extensive evalu-
infection fever, especially in those < 3 months ation, including urinalysis, laboratory tests, imaging,
and possibly lumbar puncture
continues ➤

CT = computed tomography.

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for a pelvic examination performed by a trained clinician. Uni- and cervical discharge on direct inspection suggests an infec-
lateral pelvic pain should raise suspicion for ovarian torsion, tious cause.

TABLE 2 (continued)

Clinical Features of Common Causes of Acute Abdominal Pain in Infants and Toddlers

Condition Clinical findings Comments

Nonemergent causes
Constipation May present with a long history of difficulty History of soft to loose bowel movements does not
defecating, with infrequent bowel movements;​ exclude the possibility of constipation because con-
size and consistency may be large and hard or stipation with overflow may be present;​radiography
small and pebbly;​withholding behavior may be is not recommended for diagnosis
present

Foreign body Coughing, gagging, or history consistent with Perform imaging to determine placement of the for-
aspiration swallowed object eign body starting with radiography for radiopaque
objects;​could be an emergent cause if object is
obstructing the airway

Gastroenteritis or Acute vomiting, followed by diarrhea within Usually caused by viruses, typically rotavirus;​often
colitis 12-24 hours;​no focal tenderness;​associated self-limited but other causes should be ruled out,
with mild fever;​no guarding especially in younger infants;​bloody, mucoid diar-
rhea could suggest a bacterial cause

Henoch-Schönlein Diagnosed when at least two of these four Most cases occur between 3 and 5 years of age;​
purpura criteria are present:​palpable purpura (slightly ultrasonography can identify long segments of char-
raised hemorrhagic skin lesions not related acteristic bowel wall thickening;​self-limiting and
to thrombocytopenia);​symptom onset at usually lasts 1-4 weeks
≤ 20 years;​bowel angina (diffuse abdominal
pain that is worse after meals) or the diagnosis
of bowel ischemia, usually with bloody diarrhea;​
and wall granulocytes on biopsy

Infantile colic Severe pain and paroxysmal crying;​infants will Presents in the first 3-4 weeks of life and is usually
sometimes draw their knees to their abdomen relieved with passing stool or flatus

Inflammatory Growth failure, abdominal pain, or blood in Laboratory markers may show anemia, elevated
bowel disease stool;​symptomatology is chronic in nature erythrocyte sedimentation rate and C-reactive
protein level, low albumin, and high fecal calprotec-
tin;​stool infectious studies are negative

Mesenteric Fever, nausea, vomiting, diarrhea, and diffuse Self-limited and can be caused by viral, bacterial, and
adenitis or right lower quadrant abdominal pain and mycobacterial infections;​imaging is performed to
tenderness;​can mimic appendicitis rule out other emergent causes, such as appendicitis

Streptococcal Sore throat, usually with fever and lack of cough Diagnosed with a combination of Centor criteria
pharyngitis and throat swab

Urinary tract infec- Urinary frequency, dysuria, incontinence, and Urinalysis positive for leukocytes or nitrites;​confir-
tion in older infants urgency mation with urine culture
and toddlers

CT = computed tomography.

Information from references 1, 3, and 4.

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 ABDOMINAL PAIN IN CHILDREN

DIAGNOSTIC EVALUATION diagnosis and management of generalized abdominal pain or

One study found that history and physical examination alone right lower quadrant pain in children with and without red-
had a sensitivity of 25% and a specificity of 92% for identi- flag signs.5,11-15 If a patient does not have red-flag signs but the
fying cases that need urgent intervention.10 Laboratory test- treating clinician still has high suspicion for a more serious
ing and imaging are needed for higher-risk abdominal pain cause, further laboratory or diagnostic testing should be initi-
presentations. Figure 1 outlines a suggested pathway for the ated (Figure 25,11-15).

TABLE 3

Clinical Features of Common Causes of Acute Abdominal Pain in School-Aged Children

and Adolescents

Condition Clinical findings Comments

Emergent causes
Appendicitis Fever, right lower quadrant rebound tender- Initial clinical evaluation may miss the diagnosis in
ness, with pain migrating to McBurney point, 28%-57% of children ≤ 12 years and approximately 100%
guarding, and vomiting;​children < 2 years may in those < 2 years
have diarrhea as the presenting symptom

Child abuse or Typical mechanisms of trauma include motor Child abuse should be suspected if a child has multiple
trauma vehicle crashes, falling, and child abuse injuries or is seen multiple times for injuries;​older chil-
dren might need to be separated from their caregiver to
provide accurate information

Diabetic May present as lethargy, abdominal pain, and Laboratory evaluation may demonstrate critically ele-
ketoacidosis vomiting in the setting of diabetes vated blood glucose, widened anion gap, and decreased
potassium

Ectopic Abdominal pain and positive urine pregnancy Intrauterine pregnancy almost exclusively rules out ecto-
pregnancy test;​may be accompanied by vaginal bleeding pic pregnancy, but if no fetus is seen in the uterus, it does
not rule in ectopic pregnancy

Gallstones or Children typically present with nonspecific, Classic signs of right upper quadrant pain with vomiting
cholecystitis poorly localized pain;​fever, leukocytosis, exacerbated by eating fatty foods is rare in children
vomiting, or jaundice should raise suspicion for
cholecystitis

Ovarian or tes- Acute pelvic pain, lower abdominal pain, nau- More common in those 13-16 years of age and < 1 year
ticular torsion sea, vomiting; or acute testicular pain, lower
abdominal pain, and loss of cremasteric reflex

Pancreatitis Abdominal or back pain, nausea and vomiting, Cases of pancreatitis are rising in children;​although
amylase or lipase levels greater than three gallstones and alcohol use are common causes in adults,
times the upper limit of normal, and imaging most cases in children are idiopathic
findings consistent with pancreatitis

Pneumonia Productive cough, fever, and leukocytosis, Best evaluated with history and physical examination,
often with night sweats but ultrasonography or radiography of the lungs can
provide diagnostic accuracy in unclear cases

Pyelonephritis Urinary symptoms, such as dysuria, frequency, Ultrasonography can rule out kidney abscess
and urgency;​leukocytosis;​fever;​and flank pain
continues ➤

STI = sexually transmitted infection.

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Laboratory Testing should also be ruled out in females of childbearing age by
For patients with red-flag signs, complete blood cell count, obtaining human chorionic gonadotropin levels. Stool studies
comprehensive metabolic profile, type and screen, and lipase should be considered if infectious diarrhea is suspected. The
and C-reactive protein levels should be obtained.8,16 Pregnancy predictive value of signs, symptoms, examination, and basic

TABLE 3 (continued)

Clinical Features of Common Causes of Acute Abdominal Pain in School-Aged Children

and Adolescents

Condition Clinical findings Comments

Nonemergent causes
Constipation May present with a long history of difficulty History of soft to loose bowel movements does not
defecating, and infrequent bowel movements;​ exclude the possibility of constipation because con-
consistency may be large and hard or small and stipation with overflow may be present;​functional
pebbly;​withholding behavior may be present constipation is the most common cause but because
there are several other causes, evaluation with complete
blood cell count, C-reactive protein, electrolytes, and
possibly ultrasonography may be warranted

Gastroenteritis Acute vomiting, usually followed by diarrhea Usually caused by viruses, typically rotavirus;​often
or colitis within 12-24 hours;​no focal tenderness;​associ- self-limited but other causes should be ruled out, espe-
ated with mild fever;​no guarding cially in younger infants;​bloody, mucoid diarrhea could
suggest a bacterial cause

Irritable bowel Abdominal pain that improves with bowel Could have constipation, diarrhea, or mixed component
syndrome movements

Kidney stone Abdominal pain, flank pain, and vomiting;​pres- Urinalysis usually shows hematuria;​consider ultrasonog-
ents less often as colicky pain that patients raphy of the kidneys to find signs of obstruction;​if stone
usually describe as constant does not pass with medication management, computed
tomography and surgical treatment should be considered

Mononucleosis Sore throat, tonsillar exudates, unilateral ante- Complete blood cell count with differential and rapid
rior cervical lymphadenopathy, and fatigue heterophile antibody test;​comprehensive metabolic
panel for the evaluation of elevated liver enzymes, espe-
cially in the setting of jaundice;​discuss precautions for
splenomegaly

Ovarian cyst Unilateral pelvic pain Similar symptoms to ovarian torsion;​transvaginal

ultrasonography may be needed to distinguish the two
conditions

STI Urinary discharge, sores or rash on genitalia, or If one STI is identified, testing for other STIs should be
flulike symptoms considered;​if partner tests positive, the patient should
be tested

Streptococcal Sore throat, usually with fever and lack of Diagnosed with a combination of Centor criteria and
pharyngitis cough throat swab

Urinary tract Urinary symptoms, including frequency, Urinalysis positive for leukocytes or nitrites;​confir-
infection dysuria, incontinence, and urgency mation with urine culture;​if sexually active, testing for
additional STIs should be considered

STI = sexually transmitted infection.

Information from references 1, 3, and 5.

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 ABDOMINAL PAIN IN CHILDREN

laboratory tests for appendicitis is poor.17

TABLE 4
Although C-reactive protein is 96% sensi-
tive for appendiceal perforation and a nega-
Examination Findings in Children With Acute Appendicitis
tive test effectively rules that out, laboratory
tests alone cannot rule out nonperforated Finding Sensitivity (%) Specificity (%) LR+ LR–
appendicitis.8,18
For patients without red-flag signs, uri- Absent or decreased 40 87 3.06 0.69
nalysis and tests for STIs, if indicated, bowel sounds
should be obtained. For the evaluation of
children with suspected peptic ulcer disease, Psoas sign 38 88 3.15 0.75
Helicobacter pylori fecal antigen testing is
highly sensitive and specific.19 Obturator sign 34 90 3.52 0.73

Imaging Rovsing sign 35 90 3.52 0.72

Ultrasonography is the preferred initial

Right lower quadrant 34 95 6.8 0.69
imaging modality for evaluating acute
rebound tenderness
abdominal pain in children because of the
low cost, ease of use, and lack of ionizing Note:​ The psoas sign is performed by placing a hand just above the patient’s right knee
radiation and because sedatation is rarely while supine and asking the patient to raise their right thigh against your hand. A positive
needed for an accurate scan.1,6,7,8,17,20-24 A result is increased abdominal pain. The obturator sign is performed while the patient is
supine and flexing the patient’s right thigh at the hip with the knee bent while rotating the
diagnostic accuracy study that involved leg internally at the hip. A positive result is right hypogastric pain. A positive Rovsing sign is
1,021 emergency department patients with pain in the right lower quadrant when applying deep, even pressure to the left lower quad-
nontraumatic abdominal pain for more rant. Right lower quadrant rebound tenderness is increased pain on quick withdrawal of
examiner’s hand after palpation of right lower quadrant.
than 2 hours and less than 5 days who had
imaging with ultrasonography or computed LR+ = positive likelihood ratio;​LR– = negative likelihood ratio.

tomography (CT) or were assessed with Information from reference 8.

clinical examination alone found that CT

FIGURE 1
Acute abdominal pain in children 5-18 years of age with
generalized abdominal pain or right lower quadrant pain

Red-flag signs (ie, abdominal distention, rigidity,

peritoneal signs, unstable vital signs, or focal tenderness)?

No Yes

No red-flag signs or other symptoms Obtain CBC, comprehensive

based on history: use PAS metabolic panel, type and screen,
and CRP and HCG levels
Immediate surgical consultation
Obtain immediate imaging (abdominal
ultrasonography is first line). If
If patient has a low- If patient has an intermediate- If patient has
ultrasonography is equivocal or
risk PAS, risk PAS, perform abdominal high-risk PAS, refer
negative, consider additional imaging
consider other ultrasonography for urgent surgical
causes (Figure 2) consultation

If there are trauma or abuse concerns,

follow institutional protocols
If ultrasonography is positive If ultrasonography is
for appendicitis, refer for equivocal or negative,
surgical consultation consider additional imaging

CBC = complete blood cell count; CRP = C-reactive protein; HCG = human chorionic gonadotropin; PAS = Pediatric Appendicitis Score.

Suggested pathway for the diagnosis and management of generalized abdominal pain or right lower quadrant pain in children.
Information from references 5 and 11-15.

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 ulcer disease, cholelithiasis, pancreatitis,
FIGURE 2 hepatic abscess, intussusception, small
If positive for leukocytes and bowel obstruction, inflammatory bowel
nitrites, treat for urinary tract disease, Henoch-Schönlein purpura,
infection and obtain urine culture infectious colitis, and ovarian or testic-
Perform urinalysis for
urinary symptoms ular torsion.20,25
If positive for blood, consider Some clinicians use bedside point-of-
ultrasonography of the kidneys,
care ultrasonography (POCUS) to iden-
ureter, and bladder and refer to
urology if imaging is abnormal tify common diagnoses more rapidly.23
Studies have shown that the diagnostic
If negative HCG test, perform accuracy of POCUS for appendicitis was
ultrasonography of the pelvis to
rule out ovarian torsion, tubo-
higher when performed by a radiologist
Obtain HCG levels ovarian abscess, and ovarian cyst (89%) compared with an emergency
and consider sexually physician (80%), with neither being
transmitted infection excellent.26 Other studies found that the
testing for pelvic pain If positive HCG test, perform
ultrasonography of the pelvis to rule out sensitivity and specificity of ultrasonog-
ectopic pregnancy and consult gynecology raphy for acute appendicitis is 85.5% to
91% and 84.4% to 97%, respectively.
Urgent urology consultation Although POCUS is more accurate
Perform ultrasonography if results are positive than white blood cell count, C-reactive
of the testicles and protein, or procalcitonin alone, CT
genitourinary examination
for testicular pain Treat medically if cause does not require should be used in equivocal cases.8,24,27
surgery, consider alternative diagnosis Table 5 shows the sensitivity and spec-
ificity for common ultrasound findings
If negative results, consider additional
for appendicitis.28-31
Screen for ova and
parasites in stool, test for testing for inflammatory bowel disease Radiography is not routinely used
Clostridioides difficile, in the evaluation of abdominal pain
obtain stool culture in children.10,14,22,32 It can be used as a
for bloody diarrhea If positive results, treat underlying cause
quick test to evaluate for bowel obstruc-
tion or free air from bowel perforation,
Perform rapid antigen test or in postsurgical cases.3 It may be used
for streptococcus, rapid for identifying swallowed objects or
heterophile antibody test, and If positive, treat underlying cause
chest radiography for upper bezoars.3 Magnetic resonance imaging
respiratory tract symptoms is an alternative to CT for definitive
imaging. Evaluation with magnetic res-
onance imaging can be limited due to
If no improvement, consider
Initiate a trial of alternative medication regimen and cost, speed of image acquisition, and the
polyethylene glycol referral to gastroenterology need for sedation in younger children,
3350 in patients with a Consider obtaining CBC, comprehensive but it is preferred for the evaluation of
history of constipation metabolic panel, ESR, CRP, TSH, tissue
transglutaminase IgA, and total IgA
pancreatitis.20,21

MANAGEMENT
CBC = complete blood cell count; CRP = C-reactive protein; ESR = erythrocyte sedimentation
Management of acute abdominal pain
rate; HCG = human chorionic gonadotropin; IgA = immunoglobulin A; TSH = thyroid stimulat-
ing hormone. depends on the clinical setting. Patients
with the inability to eat or drink, signs
Suggested pathway for the diagnosis and management of acute abdominal pain of acute abdomen on examination, fever,
in children with no red-flag signs and selected symptoms. or acutely ill appearance should be trans-
Information from references 5 and 11-15.
ferred to the emergency department for
further management. For those already
in the emergency department, history,
only after negative or inconclusive ultrasonography yielded the physical examination, and laboratory and imaging studies
highest sensitivity, missing only 6% of urgent cases. Based on are used to determine disposition. In all cases, pain should be
this strategy, only 49% (95 % CI, 46%-52%) of patients will appropriately treated, including the use of opioid pain medi-
have a CT scan.22 Ultrasonography is a good initial imaging cations if needed, because this does not decrease the accuracy
modality for many diagnoses, including gastric and peptic of diagnosis and improves patient comfort.33,34

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 ABDOMINAL PAIN IN CHILDREN

Infants and Toddlers School-Aged Children

History should include prenatal history, birth course, and any The differential diagnosis in this age group includes gastro-
admission to the neonatal intensive care unit. In the clinic enteritis, acute appendicitis, constipation, urinary tract infec-
setting, infants and toddlers who are ill appearing, have poor tion, pancreatitis, and testicular torsion. Appendicitis remains
weight gain, are not tolerating feedings, or have associated the most common surgical emergency in children, with
vomiting should be referred to the emergency department a median age of onset of 10 to 11 years.36 Many prediction
for further workup. If the patient has a fever, an appropriate scores have been developed to identify children who are at
workup should be initiated per established protocols, especially high risk. The most common are the Alvarado score for Acute
in infants younger than 90 days.35 For those with bilious eme- Appendicitis (https://​w ww.mdcalc.com/calc/617/alvarado-
sis, projectile vomiting, or red-flag signs, imaging is indicated score-acute-appendicitis) and the Pediatric Appendicitis Score
in close consultation with a pediatric surgeon.3 (https://​w ww.mdcalc.com/calc/3926/pediatric-appendicitis-
The differential diagnosis for this age group includes con- score-pas).5,7,8,13,23,24 A score of 6 or more using the Pediatric
genital anomalies not seen as often in school-aged children Appendicitis Score has a positive likelihood ratio of 2.01 (95%
and adolescents (eg, Meckel diverticulum, malrotation of the CI, 1.64-2.45).8 Both scoring systems can be used to determine
midgut, hernias).11 If intussusception is suspected, an air or low-, intermediate-, or high-risk patients and the appropriate-
contrast enema can be diagnostic and therapeutic.12 Appen- ness of referral to the emergency department.
dicitis often does not have typical symptoms in infants and In the clinic setting, if there are no red-flag symptoms,
toddlers;​therefore, early imaging should be considered.6 constipation, functional abdominal pain, and urinary tract

TABLE 5

Common Ultrasound Findings for Appendicitis

Finding Description Sensitivity Specificity

Noncompressible appendix Appendix does not deform laterally with compression 99% 65%

Increased color Doppler flow Color Doppler evaluation of the appendiceal wall 52% 96%
within the appendiceal wall shows increased flow in the wall compared with normal
appendix

Increased intra-abdominal fat Increased signal of hyperechoic fat stranding sur- 73% 98%
echo rounding the appendix

Maximal mural thickness > 3 mm Largest width of a single appendiceal wall 62% 82%

Maximal outer diameter > 6 mm Largest diameter of the appendix in the anterior to 95% 65%
posterior direction

Round appendix in transverse Circular, round appearance of the appendix, rather 68% 94%
view than an oblong, flatter appearance

Secondary findings
Any secondary findings Secondary findings typically seen adjacent to the 40% 91%
appendix or in the abdomen
Abscess 6% 100%

Fat stranding 11% 98%

Fat stranding and free fluid 2% 100%

Lymph nodes 0% 99%

Moderate or large free fluid 21% 94%

Information from references 28-31.

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