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Acute Abdominal Pain in Children: Evaluation and Management

Katie L. Buel, DO
James Wilcox, MD
Paul T. Mingo, MD

American Family Physician. 2024;110(6):621-631.

Author disclosure: Dr. Wilcox is a paid instructor for the Global Ultrasound Institute. Drs. Buel and Mingo have no relevant financial relationships.

This clinical content conforms to AAFP criteria for CME.

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 abdominal 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, including 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 systems, such as the Pediatric Appendicitis Score, can be used to help determine the patient's risk of appendicitis.

Acute abdominal pain in children is a common presentation in clinic and emergency department settings and accounts for up to 10% of childhood emergency department visits.1 Most causes of acute abdominal pain are self-limited.1 The most common etiologies that indicate referral for surgery in children younger than 12 months are incarcerated inguinal hernia and intussusception; in those older than 1 year, the most common cause for surgery is acute appendicitis.1 The most common nonsurgical causes of abdominal pain include upper respiratory tract infection with or without otitis media 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 by obesity.2

SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendation Evidence rating Comments
Ultrasonography is the preferred initial imaging modality for children with acute abdominal pain.1,6,7,8,17,20–24 C Systematic reviews of randomized controlled trials with diagnostic accuracy outcomes
Do not routinely perform radiography for the evaluation of abdominal pain in children.3,10,14,21,22,32 A Multiple randomized controlled trials and society guidelines that show no benefit and increased diagnostic error
Use a clinically validated scoring system (eg, the Pediatric Appendicitis Score) for the evaluation of children at high risk of appendicitis in the emergency setting.7,8,13,23,24,36 C Expert opinion

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://www.aafp.org/afpsort.

KATIE L. BUEL, DO, is an assistant professor of Clinical Family Medicine in the Department of Family Medicine at Indiana University School of Medicine, Indianapolis.

JAMES WILCOX, MD, FAAFP, is an assistant professor of Clinical Family Medicine in the Department of Family Medicine at Indiana University School of Medicine.

PAUL T. MINGO, MD, is an assistant professor of Clinical Family Medicine in the Department of Family Medicine at Indiana University School of Medicine.

Address correspondence to Katie L. Buel, DO, at katie.buel@gmail.com.

Author disclosure: Dr. Wilcox is a paid instructor for the Global Ultrasound Institute. Drs. Buel and Mingo have no relevant financial relationships.

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