This document discusses the diagnosis and management of abdominal pain in pediatric patients through a series of case studies and discussions. It begins with an introduction on abdominal pain in children and objectives. It then presents 5 case studies of children presenting with abdominal pain and asks the reader to make a diagnosis. Following this, it discusses the causes, history, examination, investigations and management of abdominal pain in children at different ages. It provides details on recognizing red flag signs, systemic causes, and approaching the diagnosis of acute abdominal pain.

1. Dr. ZAHEEN ZEHRA N
FIRST YEAR MD PAEDIATRICS
MGMCRI

2. OUTLINE
1. Introduction
2. Case Scenarios.
3. History and Examination.
4. Recognition of Red flag Signs.
5. Investigations.
6. Management

3. INTRODUCTION
 Abdominal pain is a diagnostically and therapeutically
challenging complaint.
 At least, 20% of children seek attention for it, out of
which 5% seek hospitalization.
 Abdominal pain might be a single acute event, a
recurring acute problem or a chronic problem.

4. OBJECTIVE
 How to Diagnose serious cause of Abdominal Pain.
 Causes in Various age groups .
 Recognition of Red Flag Signs.

5. CASE 1
 An eight-year-old boy presents with his third episode of
abdominal pain in three months.
 He has griping abdominal pains centred on the umbilicus,
flatulence and repeated visits to the toilet with Ocassional Semi
Solid stools. Defecation seems to ease the pain for a short period.
 You note that he went through a similar phase six months ago.
FBC, renal function, LFTs, ESR, serum glucose, coeliac screen,
urine and stool microscopy, and faecal calprotectin were normal
and he had continued to gain weight satisfactorily.
 His mother wants him to have a ‘scan’ as ‘something must be
wrong’. These episodes are affecting his school attendance and
causing stress at home. Examination reveals a systemically well
child with a soft abdomen. What would your diagnosis be?

6. CASE 2
 A 11year old girl is brought to the emergency
department with a 2 day history of right sided
abdominal pain, fever and vomiting. On the way to the
hospital, each time the vehicle bumped at a speed
breaker, she could not bear the pain.
 She has a temperature of 37.6 C and heart rate of 112
bpm. On examination, child is stooping forward and
holding her hand against right lower abdomen.
Abdominal examination revealed tenderness in the
right iliac fossa.

7. CASE 3
 A 5 year old girl is brought to casualty with abdominal
pain and vomitting. She is in altered sensorium and
breathing fast. On Examination, child is thin looking,
drowsy with dry tongue. Deep breathing is noticed.
Chest and Abdomen shows no abnormality.
 No significant illness except passing very frequent
urine and frequent thirst even at nights of late,
according to the mother.

8. CASE 4
 5 year female child was brought with the complaints of
cough and cold for 6 days, fever for 3 days and
Abdominal pain for 4 days.
 On Examination, Child had bilateral crepitations in
the lower lobe of the lungs. Subcostal Retractions were
present. Tenderness of the Right Hypochondrium.
 What would the diagnosis be?

9. CASE 5
 10 year old male child was brought with the complaints
of Abdominal pain since last night. Complaints of
cough and cold for 5 days, complaints of body pain
since 3 days. History of Fever for 5 days which subsided
yesterday.
 On Examination, child had rashes all over his chest
and upperlimbs. Hepatomegaly was present.
 Thrombocytopenia + and Raised Hematocrit levels.
 Diagnosis?

10. CAUSES OF ACUTE ABDOMINAL
PAIN
 Neonate:
Necrotizing Enterocolitis.
Obstruction.
Malrotation with volvulus.
 Infant:
Urinary Tract Infection.
Incarcerated Hernia.
Intussusception.
Gastroenteritis.

11. Causes of Acute Abdominal Pain
 CHILD (2-11 years):
Appendicitis.
Gastroenteritis.
Trauma.
Idiopathic.
 Adolescent:
Appendicitis.
Trauma.
Pelvic Inflammatory Disease.
Idiopathic.

13. Causes of Chronic And Recurrent
Abdominal Pain.
 Infant:
Colic
Malabsorption.
 Child:
Constipation.
Functional Pain.
Giardiasis.
 Adolescent:
Irritable bowel syndrome.
Psychogenic factors.
Dysmenorrhea.
Peptic Ulcer disease.

14. Systemic Causes Of Abdominal Pain
 Porphyrias.
 Lead Poisoning.
 DKA
 Abdominal Epilepsy.

15. Approach to Acute Abdominal Pain
 History.
 Physical Examination.
 Lab Evaluation.
 Radiological Evaluation.
 Management.

16. HISTORY
 TIME OF ONSET:
Duration
Timing of Progression.

17. HISTORY cont…
 LOCATION:
- IBS: Periumblical.
- Gastroenteritis: Periumblical.
- Urolithiasis: Loin and Back.
- Intestinal Obstruction: Epigastric/Hypogastric
- Appendicits: Right lower quadrant
- Functional- Periumblical.
- Intusussception: Periumblical
- Cholelithiasis: Right upper quadrant

18. HISTORY cont…
 CHARACTER:
- IBS: Dull, crampy.
- Gastroenteritis: Dull, crampy.
- Duodenal Ulcer: Severe burning.
- Intestinal Obstruction: Alternating crampy
- Appendicitis: Sharp, steady
- Intusussception: Cramping (painless periods)
- Cholelithiasis: Severe colicky.
- Functional: Dull, Crampy, Intermittent.
-Urolithiasis- Severe Colicky Pain.

19. HISTORY cont…
 SEVERITY
- The severity of the pain is indicated by the child’s
activity level.
- If the pain is sufficiently severe to awaken the child
from sound sleep, it is of more significance than one
that occurs in school.

20. HISTORY cont…
 GASTROINTESTINAL SYMPTOMS:
Anorexia.
Nausea.
Vomiting.
Diarrhoea.
Constipation.

21. Gastrointestinal Symptoms
Yes No
Intestinal Problems Intraabdominal Problems
Appendicitis.
Gastroenteritis Ovarian Disease.
Cholecystitis Abdominal wall pain.

22. VOMITING:
Intestinal Disease Non Intestinal Disease
Recurring. Non Recurring.
Prominent. Non Prominent.
(Gastroenteritis (Testicular Torsion)
Acute problems of GIT)
Appearance:
Feculent or Dark Green- Intestinal Obstruction.
Dark Brown or Frankly Bloody- Gastritis

23.  Vomiting During or After Pain:
Intestinal Obstruction.
Appendicitis.
Cholecystitis.
 Vomiting Before Pain:
Gastroenteritis.

24. Diarrhoea
Intestinal Diseases NonIntestinal Diseases
Stool Volume Large Stool Volume- Small
Preceded by Pain Constant Pain.
Pain alleviated by Diarrhoea. Not Alleviated.

25.  Nausea and Anorexia:
- Caused by specific gastrointestinal disorders or
systemic illnesses.
- Often difficult for the child to describe.
 Constipation:
- Can alone cause acute abdominal pain.
- May indicate other gastrointestinal dysfunction.
- May be present with Appendicitis.
 Gas stoppage sign

26.  Family History & Personal Medical History:
- Viral Gastritis, Food Poisoning, Viral Syndromes, etc.
- Sickle Cell Anemia, Diabetes Mellitus, Hereditary
Spherocytosis, Familial Mediterranean Fever,
Porphyria.

27. PHYSICAL EXAMINATION
 Observe the child’s activity and demeanor.
 Lethargic/ Restless: Shock/ Dehydration
 Crying: Gastroenteritis with cramping abdominal
pain.
 Mildly ill/ Moves with great care: Acute Appendicitis/
Incarcerated Hernia.
 Wither in Discomfort: Renal stones, gall stones,
pancreatitis.
 Examination of Head, Neck, Chest and Ear.

28. ABDOMINAL EXAMINATION
 INSPECTION:
- Distension
- Inguinal masses
- Peristaltic waves
- Scars
- Point to the pain.

29.  PALPATION & PERCUSSION:
- Soft/ tense/ guarding rigidity.
- Area of tenderness.
- Rebound tenderness
- Palpable masses.
- Organomegaly.
- Shifting dullness/ Fluid thrill.
- Psoas sign/ Obturator sign.

31.  AUSCULATION:
Bowel Sounds
- Nonspecific
- High-pitched tinkling sounds or rushes: Obstructive
pathologies.
- Active and loud: Gastroenteritis
- Absent: Peritonitis
- Clue to true tenderness

32. LAB EVALUATION
 COMPLETE BLOOD COUNT:
- Anemia (Ulcers, IBS, Meckel’s, Lupus)
- TLC:
Normal or High- Appendicitis
High- Intestinal Gangrene, Perforation, Peritonitis,
Abscess, Bacterial Gastroenteritis, PID.

33.  URINE ANALYSIS:
- Ketones (+): Poor food intake an dehyration/ DKA
- White cells and Bacteria: UTI
- Hematuria: Nephrolithiasis
 OTHERS:
- Amylase, Lipase, Electrolytes, CRP, Pregnancy.

34. IMAGING EVALUATION
 Plain Radiography: CXR, KUB
 Ultrasonography
 Computed Tomography
 Magnetic Resonance Imaging
 Contrast studies

36. MANAGEMENT ALGORITHM

37. THANK YOU