Rob Beatty, MD FACEP
Pediatric patients and teenagers often experience abdominal pain, which can vary from mild discomfort to also including severe debilitating pain. Determining if the pain is emergent or non-emergent is crucial for addressing it. Non-emergent pain often results from indigestion, constipation, or menstrual cramps and can be treated with over-the-counter medication and home remedies. However, emergency abdominal pain stems from serious conditions like appendicitis or a ruptured ovarian cyst and requires immediate medical attention.
Differential Diagnosis by Age
| Age group | Diagnoses |
| any age | intestinal malrotation/volvulus mechanical bowel obstruction – adhesive – intraluminal – foreign body (non-neonate/infant), distal intestinal obstruction syndrome (cystic fibrosis), constipation Meckel diverticulitis neutropenic enterocolitis perforated viscus |
| newborn | neonatal obstruction congenital lesion internal hernia/volvulus– omphalomesenteric duct remnant duplication cyst mesenteric cyst necrotizing enterocolitis incarcerated inguinal hernia |
| infant | intussusception incarcerated inguinal hernia nonaccidental abdominal trauma Hirschsprung associated enterocolitis abdominal/retroperitoneal neoplasm |
| toddler | intussusception appendicitis– complicated non-accidental abdominal trauma Hirschsprung associated enterocolitis abdominal/retroperitoneal neoplasm pneumonia |
| pre-adolescent child | appendicitis – acute – complicated gallstone complications – pigment gallstones – cholecystitis – choledocholithiasis – gallstone pancreatitis epiploic fat torsion/infarction omental torsion/infarction Henoch-Schonlein purpura viral gastroenteritis ovarian torsion (female) |
| adolescent | appendicitis gallstone complications – pigment and cholesterol gallstones – cholecystitis – choledocholithiasis – gallstone pancreatitis – biliary dyskinesia gastroesophageal reflux inflammatory bowel disease – Crohn disease– partial obstruction/stricture, phlegmon/abscess, fistula, perforation – ulcerative colitis- megacolon ovarian pathology (female) – torsion – ruptured cyst pelvic inflammatory disease(female) perforated gastric/duodenal ulcer epiploic fat torsion/infarction omental torsion/infarction Henoch-Schonlein purpura urinary tract infection urolithiasis |
Narrowing Down Pediatric and Adolescent Abdominal Pain
The type of abdominal process causing the patient’s pain can be broken down into four general categories. These include obstruction, inflammation, obstruction and inflammation, and others. When categorized into the likely type of pain a patient is experiencing, narrowing down the diagnosis can be easier.
| Abdominal pain pattern | Diagnoses |
| obstruction | Congenital intestinal malrotation/volvulus internal hernia/volvulus omphalomesenteric duct remnant/Meckel diverticulum intestinal duplication cyst mesenteric cyst incarcerated inguinal hernia intraluminal obstruction -distal intestinal obstruction syndrome functional obstruction -Hirschsprung associated enterocolitis Acquired intussusception adhesive bowel obstruction Crohn disease partial obstruction, stricture superior mesenteric artery syndrome intraluminal obstruction -foreign bodies -Henoch-Schonlein purpura -constipation |
| inflammation | appendicitis -acute – complicated/perforated gallstone complications – cholecystitis – choledocholithiasis/cholangitis pancreatitis pelvic inflammatory disease other intestinal – Meckel diverticulitis – Crohn disease – phlegmon/abscess, fistula, perforation – necrotizing, neutropenic enterocolitis perforated viscus peptic ulcer disease foreign bodies nonaccidental abdominal trauma pneumonia viral mesenteric adenitis/gastroenteritis |
| obstruction and inflammation | intestinal obstruction with ischemic/infarcted bowel complicated appendicitis inflammatory bowel disease – Crohn disease – phlegmon/abscess, fistula, perforation – ulcerative colitis- megacolon functional obstruction – Hirschsprung associated enterocolitis |
| other | abdominal/retroperitoneal neoplasm ovarian pathology – torsion – ruptured cyst epiploic fat torsion/infarction omental torsion/infarction (male>female) biliary dyskinesia gastroesophageal reflux |
Labs
When evaluating a teen patient with abdominal pain, a healthcare provider may order a variety of lab tests to help make a diagnosis. The specific tests that are ordered will depend on the patient’s symptoms and the suspected cause of the pain. However, some common lab tests that may be ordered include:
- Complete Blood Count (CBC): This test measures the number of white blood cells, red blood cells, and platelets in the blood. An elevated white blood cell count can indicate an infection or inflammation, while a low red blood cell count may indicate anemia.
- Blood cultures: These test are typically ordered if the healthcare provider suspects an infection is causing the abdominal pain. Blood cultures can help to identify the specific type of bacteria or fungus that is causing the infection.
- Liver function tests (LFTs): These tests are used to evaluate the function of the liver and can help to detect any underlying liver disease or damage.
- Renal function tests (RFTs): These tests are used to evaluate the function of the kidneys and can help to detect any underlying kidney disease or damage.
- Urinalysis: This test is used to evaluate the presence of any abnormalities in the urine. It can help detect urinary tract infections, kidney stones, and other conditions.
- Stool test: This test is used to evaluate
Imaging Children and Teenagers
Recognizing the difference between non-emergent and emergency abdominal pain is crucial. Non-emergent pain can be treated with at-home remedies and rest. Emergency abdominal pain requires immediate medical attention. Imaging can also reveal the cause of the pain.
Imaging, such as X-rays, CT scans, and ultrasounds, is an effective tool in identifying the cause of abdominal pain. These tests provide a clear picture of what’s happening inside the body, and assist in accurate diagnosis. It’s important to remember that these tests may not always be necessary, and they carry risks such as radiation exposure.
Common Imaging Findings
| Image modality | Key findings | Associated diagnoses |
| abdominal radiograph | normal bowel gas pattern | constipation appendicitis malrotation with volvulus |
| gastric distension | gastroenteritis superior mesenteric artery syndrome | |
| loss of psoas shadowfocal ileusscoliosisfecalith | appendicitis | |
| bowel dilation predominantly left upper quadrant | proximal small bowel obstruction gastroenteritis pancreatitis | |
| bowel dilation except right lower quadrant | distal small bowel obstruction | |
| paucity of gas in right lower quadrant/ascending colonadipose rose sign | intussusception | |
| displacement of bowel loops | abdominal/retroperitoneal mass | |
| diffuse bowel dilation | gastroenteritis or other ileus (pneumonia, urinary tract infection) | |
| colonic air fluid levels | gastroenteritis colitis | |
| pneumatosis | necrotizing enterocolitis neutropenic enterocolitis | |
| colon cut off sign | Hirschsprung associated enterocolitis appendicitis | |
| pneumoperitoneum | perforated viscus (gastric/duodenal ulcer, Meckel diverticulum, intestinal perforation due to non-accidental trauma, perforated appendicitis (rare)) | |
| Upper gastrointestinal series +/- small bowel follow through | delayed passage of contrast from stomach | gastroenteritis |
| bird beak in proximal duodenum | malrotation with volvulus | |
| dilated proximal duodenum, delayed contrast passage across vertebral body | superior mesenteric artery syndrome | |
| Contrast enema | inspissated stool | distal intestinal obstruction syndrome (DIOS) |
| saw toothing of colon | colitis | |
| Ultrasound | target sign | intussusception |
| non-compressible tubular structure in right lower quadrant (greater than 7 mm diameter) | appendicitis | |
| loculated/complex pelvic fluid with hyperemia | complicated appendicitis pelvic inflammatory disease | |
| inversion of mesenteric vessels | malrotation | |
| gall bladder wall thickening, pericholecystic fluid, sonographic Murphy sign | cholecystitis | |
| bile duct dilation | choledocholithiasis | |
| pancreatic edema, peripancreatic fluid | pancreatitis | |
| pelvic fluid, decompressed ovarian cyst | ruptured ovarian cyst | |
| ovarian enlargement, hypoperfusion | ovarian torsion | |
| cystic lesion (thick walled – bowel signature) | intestinal duplication cyst | |
| echogenic fat – ovoid | epiploic fat torsion | |
| echogenic fat – swirling blood vessels anterior to bowel, right greater than left | omental torsion | |
| Computerized tomography/magnetic resonance imaging | pancreatic edema, hypoperfusion, peripancreatic fluid | pancreatitis |
| bowel wall thickening, phlegmon, abscess | Crohn disease | |
| small bowel dilation, transition zone | intestinal obstruction | |
| whirlpool sign | intestinal volvulus |
Signs and Symptoms in Teens
Healthcare providers should look for a variety of different signs when identifying the symptoms of abdominal pain in teenagers. For example, non-emergent abdominal pain may be accompanied by symptoms such as bloating, gas, and constipation. Additionally, patients may report cramping or a dull ache in the lower abdomen. These symptoms may be more pronounced during menstruation for girls. Emergency abdominal pain may be accompanied by more severe symptoms such as severe cramping, nausea and vomiting, and a high fever.
Patients may also report pain that is concentrated in a specific area of the abdomen, such as the right lower quadrant (where the appendix is located) or the pelvic area. Additionally, patients may experience a rapid heartbeat, sweating, and a general feeling of being unwell. Healthcare providers should also pay attention to other signs such as changes in bowel habits or urination patterns, as well as any signs of vomiting or nausea. Patients may also report a loss of appetite or difficulty eating.
Appendicitis is a common pediatric and adolescent diagnosis. There are scoring criteria available that consider the presentation of the patient to help you determine your diagnosis. Below are two examples:
| Alvarado | PAS | ||||
| Predictor | Detail | Value | Detail | Value | |
| symptoms | migration | 1 | 1 | ||
| anorexia | 1 | 1 | |||
| nausea-vomiting | 1 | 1 | |||
| signs | tenderness right lower quadrant | 2 | 2 | ||
| rebound pain | rebound | 1 | cough/ percussion/ hopping | 2 | |
| fever | ≥37.3 ○C | 1 | ≥38.0 ○C | 1 | |
| laboratory | leukocytosis | ≥10,000/mm3 | 2 | ≥10,000/mm3 | 1 |
| neutrophilia | ≥75% | 1 | ≥7500/mm3 | 1 | |
| total | 10 | 10 | |||
Treatment
Treatment options for teenagers vary depending on the underlying cause of the pain. For example, a high-fiber diet and regular exercise can alleviate symptoms caused by constipation. More serious conditions like appendicitis may require surgery.
Teenagers should be aware of their bodies and seek medical attention if they experience abdominal pain. Parents should also be informed of the possible causes of abdominal pain and recognize the signs of an emergency. With the help of a doctor and appropriate imaging, the cause of the pain can be accurately identified and treated.
Indications for Operative Exploration
Indications for operative exploration can be categorized in the context of presenting symptoms and suspected diagnosis:
- Evidence of complete bowel obstruction, intestinal volvulus, or vascular compromise of abdominal structures
- malrotation with bilious emesis
- closed loop bowel obstruction (e.g. postoperative adhesions, omphalomesenteric duct remnant, intestinal duplication cyst)
- non-reducible intussusception
- ovarian torsion
- Acute abdomen/peritonitis, intestinal perforation
- perforated duodenal ulcer
- intestinal perforation/necrosis
- perforated appendicitis, Meckel diverticulitis with diffuse peritonitis
- perforated Crohn disease
- toxic megacolon (ulcerative colitis, antibiotic-associated colitis)
- Diagnosis of surgical etiology
- appendicitis
- cholecystitis, complicated gallstone disease (choledocholithiasis, gallstone pancreatitis)
- Meckel diverticulitis
- intestinal mass (duplication cyst, mesenteric cyst, intussusception with suspected pathologic lead point)
Surgical intervention for omental epiploic fat torsion/infarction is controversial.
The nonoperative treatment of acute appendicitis is currently being evaluated. The need for interval appendectomy after nonoperative treatment of complicated appendicitis is also under investigation.
Summary
In conclusion, abdominal pain is a common concern among teenagers and can range from mild discomfort to severe, debilitating pain. It is important for healthcare providers to recognize the difference between non-emergent and emergency abdominal pain, as the treatment and management of each type of pain is different. Imaging is an important tool in determining the cause of the pain and making an accurate diagnosis. The treatment options will depend on the underlying cause of the pain and may include at-home remedies, medication, surgery, or a combination of these. Parents and teenagers should be aware of the possible causes of abdominal pain and seek medical attention when necessary. With the help of a healthcare provider, the cause of the abdominal pain can be accurately identified and treated.
References
HCUP Nationwide Emergency Department Sample (NEDS) 2013. Healthcare Cost and Utilization Project (HCUP), Agency for Healthcare Research and Quality. Available at: https://hcupnet.ahrq.gov/HCUPnet.jsp; accessed Dec. 31, 2015
Thongprachum A, Takanashi S, Kalesaran AF, et al. Four-year study of viruses that cause diarrhea in Japanese pediatric outpatients. J Med Virol. 2015;87(7):1141-8. [PMID:25881021]
Sahni LC, Tate JE, Payne DC, et al. Variation in rotavirus vaccine coverage by provider location and subsequent disease burden. Pediatrics. 2015;135(2):e432-9. [PMID:25583918]
American College of Radiology ACR Appropriateness Criteria. Right Lower Quadrant Pain—Suspected Appendicitis. Available at: https://acsearch.acr.org/docs/69357/Narrative; accessed Dec. 31, 2015
Alvarado A. A practical score for the early diagnosis of acute appendicitis. Ann Emerg Med. 1986;15(5):557-64. [PMID:3963537]
Samuel M. Pediatric appendicitis score. J Pediatr Surg. 2002;37(6):877-81. [PMID:12037754]
