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Abdominal Pain

The evaluation of abdominal pain is problematic because the pain is often difficult to localize, and the history in children is often nonspecific. In children the differential diagnosis of abdominal pain is 

Localization of Abdominal Pain

Generalized pain in the epigastrium usually comes from the stomach, duodenum, or the

Pain in the midgut (small bowel and colon or spleen) usually localizes to the periumbilical region.

Inflammation (parietal pain) is usually well localized.

Referred abdominal pain occurs when poorly localized visceral pain is felt at a distant location.

Pancreatitis, cholecystitis, liver abscess, or a bleeding spleen cause diaphragmatic irritation, which is referred to the ipsilateral neck and shoulders.

Intraabdominal fluid may produce shoulder pain on reclining.


The history and physical exam, including rectal (and pelvic exam in females), are diagnostic of appendicitis in 80% of the cases. Perforation often follows the onset of symptoms in 24-48 hours. Beyond the neonatal period, but <2 years old, gastroenteritis and intussusception are also part of the differential diagnosis of abdominal pain.

Fever, vomiting, irritability, lethargy with right lower quadrant (RLQ) tenderness and guarding are diagnostic of

Differential Diagnosis of Appendicitis by Age

All Ages

Acute gastroenteritis

Mesenteric lymphadenitis


Urinary tract infection (UTI)

Basilar pneumonia

Older Children and Adolescents



Inflammatory Bowel Disease (IBD)


Infants and Very Young Children

Midgut volvulus

Choledochal cyst


Adolescent Females

Pelvic Inflammatory Disease (PID)

Ectopic pregnancy


Toddlers and Younger Children

Intestinal duplications

Meckelís diverticulum

Hemolytic-uremic syndrome (HUS)

Primary peritonitis

Henoch-Schönlein purpura (HSP)

Unusual Childhood Diseases


Ureteral stones

Pain from Sickle Cell anemia

Leukemic ileocecal syndrome


Intussusception is the most common cause of bowel obstruction between 2 months and 5 years of age. The most vulnerable age group is 4-10 months old, but children up to 7 years old may be at risk.

Intussusception is characterized by vomiting, colicky abdominal pain (85%) with drawing up of the legs, and currant jelly stools (60%). Fever is common. Lethargy, dehydration, obtundation and/or coma may occur in

Midgut Volvulus

Midgut volvulus results from the improper rotation and fixation of the duodenum and colon (malrotation) resulting in a long, narrow mesenteric base. Obstruction of the superior mesenteric artery may cause ischemic necrosis of the gut, which may be fatal.

Infants in the first month constitute the majority of the cases. Symptoms usually begin about 5 days before diagnosis. The first sign of volvulus is bilious vomiting, followed by abdominal distention and GI bleeding. Peritonitis, hypovolemia, and shock follow as the ischemia continues.

Abdominal x-ray reveals a classic double bubble caused by duodenal obstruction, but this finding is

Gallbladder Disease

Cholecystitis in children occurs most commonly in the adolescent female, but it may affect infants who are only a few weeks of age. Cholecystitis is suggested by RUQ pain, back pain, or epigastric pain, radiating to the right subscapular area, bilious vomiting, fever, RUQ tenderness, and a RUQ mass. Jaundice is 

Hydrops of the gallbladder is characterized by massive gallbladder distention in the absence of stones, infection, or congenital malformations. It usually is preceded by another systemic disease (viral syndrome),

Acalculous cholecystitis accounts for about 10-30% of gallbladder disease in children. It may occur with severe illnesses, such as burns, sepsis, or

Cholelithiasis may be a concomitant of hemolytic diseases in children. Fifty percent of children with spherocytosis develop gallstones. Sickle cell anemia and Thalassemia are the next 

Ectopic Pregnancy

Ectopic pregnancy must be considered in any postmenarchal, sexually active adolescent with abdominal pain. It is uncommon and usually seen in late adolescence. Ectopic pregnancy occurs in 0.5-3% of all

Gonadal Pain in Males

In males with lower abdominal pain, the scrotum and its contents must be examined. Testicular torsion is a surgical emergency and must be treated within 6 hours of the onset of the pain to save the testicle.

Testicular torsion may present as lower abdominal pain, which may be associated with recent trauma or

Gonadal Pain in Females

The leading causes of gonadal pain in females are ovarian cysts and torsion of uterine adnexal structures. Ovarian tumors are often associated with precocious puberty or virilization.

Ovarian cysts are responsible for 25% of childhood ovarian tumors. They are most common in adolescents.

Torsion of Uterine Adnexal Structures

Torsion is associated with unilateral, sudden, severe pain with nausea and vomiting. However, the patient may have subacute or chronic symptoms, with intermittent pain for days. The pain is usually diffuse and periumbilical in younger patients, but in older children and adolescents, the pain may radiate initially to the anterior thigh or ipsilateral groin. Torsion is more

Abdominal Pain From Abdominal Scars

Adhesive small bowel obstruction occurs in 2-15% of children following a laparotomy. Seventy five percent of such patients present with adhesive obstruction between 2 weeks and 3 months after their operation. Eighty percent will occur within 2 years of operation. The disorder is treated with 

Meckel Diverticulum

Meckel diverticulum are present in 2% of the population. It presents as a tender left lower quadrant mass, associated with blood in the stool. Occasionally, technetium nuclear scans are positive for Meckelís in the


Pancreatitis is a rare cause of abdominal pain in children. Trauma is the most frequent cause of this disorder in children.

Symptoms include mid-epigastric abdominal pain, nausea and vomiting, jaundice, and