PE23.3 | Abdominal Pain — Summary & Reflection

KEY TAKEAWAYS

Abdominal pain in children requires a systematic, age-stratified approach that prioritises surgical emergency recognition.

• Classify first: Acute vs chronic/recurrent; surgical (peritoneal signs, red flags) vs medical vs functional

• Red flags demanding urgent surgical review: Rebound/guarding/rigidity; bilious vomiting; currant-jelly blood PR; systemic toxicity; progressive worsening; scrotal pain in adolescent males

• Key age-based causes:
• Under 2 years: Intussusception (paroxysmal colic + currant-jelly stool + sausage mass + USG target sign → air enema first-line)
• 5–12 years: Appendicitis (periumbilical → RIF migration + fever + vomiting + Alvarado ≥7 → appendicectomy)
• All ages: UTI (dysuria + leucocytes/nitrites on UA), mesenteric lymphadenitis (after URTI, normal appendix on USG), constipation, lower lobe pneumonia (always examine chest)

• Alvarado score: ≥7 = surgical referral; 5–6 = admit and observe; <4 = discharge with safety net

• Functional abdominal pain disorder (FAPD, ROME IV): ≥4 episodes/month × ≥2 months; no nocturnal pain; linked to stress; diagnose positively; biopsychosocial management

• Do not withhold analgesia pending surgical review — appropriate analgesia does not mask peritoneal signs and is a patient right

REFLECT

Think about what happens when a child with functional abdominal pain undergoes repeated investigations — each negative result fails to reassure the family and can even increase anxiety ('they haven't found anything YET'). How would you structure a consultation to both positively diagnose functional abdominal pain AND reassure the family, without either dismissing the child's pain or inadvertently suggesting that something dangerous might still be lurking?

Now consider the opposite situation: a 6-year-old with diffuse abdominal pain and a temperature of 37.5°C. The parents insist it is 'just his usual tummy aches.' How would you systematically rule out appendicitis, even when the history seems benign? What examination findings, scoring system, and investigation would change your management?