APPROACH TO ABDOMINAL PAIN

Exclude red flags:

- Tumours
Abdominal pain LOW, LOA
Masses
Pallor, lethargy, malaise
- Trauma
GI Non-GI

Diarrhoea Constipationd Others Uro (FUNDISH, haematuria, dysuria) Repro

- Appendicitis - UTI
See approach to diarrhea.See
Commonly - Gastritis, PUD
approach to Constipation - Stone
IBD -
Common: Constipation colic Meckel’s - Tumour
diverticulitis Male Female
GE Red flag: IO - Necrotising Enterocolitis - Torsion - Menses-related
- Tumour - Ectopic pregnancy
HPB (jaundice) - Infection (EO) - PID
- Gallstones - Ovarian
- Hepatitis Ovarian torsion
- Pancreatitis Cyst rupture
- Cholangitis

Medical
- DKA
- HSP
- LL Pneumonia
- HUS
Differentials - HOPC
Age Life-threatening Clinical clues Common Clinical clues  S:
Infant Malrotation/ volvulus 1st days – 1st UTI  Night pain
(0-1) month
Pyloric stenosis 2-8 weeks, Pneumonia  A:
peak 1st  Lethargy
month
 Fever
Hirschsprung Unable to Hernia
pass - Systemic review
meconium in  A: LOW LOA
1st 24h
Meningitis  Bowels: change? Bleed?
Toddler Intussuception 3 mths -3 Constipation  Urine: Polyuria, polydipsia, LOW
(1-3) years colic
Peak 9
 C: colour
months  D: distension?
Medication ileus GE Fever, N&V,  Growth failure, pubertal delay
diarrhea
Assess  Joint pain, rashes
dehydration
Tumor Systemic Choledochal Jaundice, Examination
cysts peritonitis,
+/- Vitals
pancreatitis
RUQ mass General State
Child Appendicitis HSP
(4-10) Adhesion IO Past surgery Meckel’s Bleed, IO - Drowsy - encephalopathy
Ovarian torsion Hepatitis
DKA Mesenteric
- Toxic-appearing – perforated appendicitis, peritonitis, cholangitis
adenitis - Jaundice – hepatitis, HUS, cholangitis
Adolescen Strangulated hernia Pyelonephritis - Dehydrated – severe GE, DKA
t (11-16) Ectopic pregnancy Peptic ulcer
Testicular torsion Cholecystitis - Lung – pneumonia
Pancreatitis
All groups: UTI, pneumonia Abdomen

History - Always full expose

- Site of pain
- Check for abdominal masses  Extramura
 RHC – pyloric stenosis (olive), intussusception (sausage),  Decreased
choledochal cyst  Increased
 RIF – appendiceal abscess, intussusception if RIF empty  Shift of ga
 Inguinal – obstructed/strangulated inguinal hernia  Shift of ga
 Renal / retroperitoneal mass – Wilm’s tumor or neuroblastoma  Caecal gas
 Hepatosplenomegaly – Leukemia  Decreased
 Suprapubic – bladder/ovarian cyst  Solid mass
- Hernia exam  CXR: free air under diaphragm
- Testicular palpation
- +/-DRE
 Anal fissure, intussusception (currant jelly), Meckel’s diverticulum
(fresh blood), faecal loading

Investigations

- Bloods
 FBC – raised WCC, eosinophilia, cytopenia
- Urine
 Urine dipstick / UFEME – UTI, DKA
 Urine Pregnancy test – for all girls after menarche presenting
with abdominal pain Management
- Stool:
 Occult blood - Exclude surgical and traumatic causes
 Stool cultures - Exclude dehydration
- Imaging - Exclude any serious medical causes (e.g. DKA, pneumonia)
 Supine & erect AXR – IO, perforated viscus, foreign body, - Give appropriate laxatives
calcification  <1yr – glycerine supplement
  1-3 yr – microlax supplement
 3-7 yr – half fleet enema
 >7yr – fleet enema
- Discharge
 Panadol/laxatives/infacol (simethicone, anti-foaming agent)
 Discharge advice: return to hospital if
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Indications for admission

- Surgical abdomen (admit all suspected cases referred by GP as early

appendicitis)
- Abdomen difficult to examine despite chloral hydrate (sedative)
- Severe dehydration or inability to retain feeds
- Abdominal pain persisting >4 hours or reattendance
- ALL tender testes

PEARLS

- NEVER discharge a patient if there is still residual abdominal pain

- Intussusception: locally presents early with minimal signs
 Diagnosis frequently from only on history
 Consider in any young child with periodic (5-10min), reccurent
abdominal pain)
- Appendicitis atypical presentation:
 Pyuria: unlike UTI abdominal pain is more severe
 Antibiotic therapy: masks signslooks like GE but severe/
protracted abdominal pain