Urgent considerations
See Differentials for more details
Although the causes of abdominal pain in children are frequently benign (e.g., constipation), there is always the potential for life- or organ-threatening conditions, which require urgent intervention.
Absent bowel sounds, bilious vomiting, bloody diarrhoea or occult blood in stool, fever (≥38.0°C [≥100.4°F]), rebound tenderness, rigidity, and guarding indicate a possible need for surgery.
Gastrointestinal (GI) emergencies
Acute appendicitis resulting in perforation
Untreated acute appendicitis may progress to ischaemia, necrosis, and eventually perforation. The clinician may encounter a range of presentations. Patients often complain of abdominal pain localised to the right lower quadrant; in more severe cases the pain may be diffuse (e.g., if perforation results in generalised peritonitis).
Perforation should be considered when a patient presents with a longer duration of symptoms and/or suspected appendicitis with marked systemic signs of illness (e.g., high fever [>38.3°C, >101°F]), tachycardia, and anorexia), localised or generalised peritonitis with guarding, distended abdomen with absent bowel sounds. There may be a palpable mass if a peri-appendiceal abscess is present due to perforation.
Refer all children with suspected appendicitis to the paediatric surgery team on call, if available. Where no paediatric surgery team is available, joint care should be managed between paediatrics and surgical teams.
Ultrasound (US) is usually the preferred initial diagnostic study (due to low cost and lack of radiation exposure).[76][77][78] In children, specificity and sensitivity of ultrasound is similar to that of computed tomography (CT) (specificity 92.0% vs. 94.2%; sensitivity 90.3% vs. 93.0%); for MRI the specificity is 96.5% and sensitivity 96.9%.[78] However, all imaging modalities have limitations in differentiating perforated from non-perforated appendicitis.[76][78][79]
Treatment (antibiotics and possibly surgery) of acute or perforated appendicitis should be instituted promptly, but the condition is more urgent than emergent. Once antibiotics are administered, appendectomy for out-of-hours cases selected for operative management can be safely deferred until the following day.[13][14]
Appendectomy can be done with an open approach or laparoscopically. Laparoscopic appendectomy is associated with lower postoperative pain, lower incidence of surgical site infection, and higher quality of life in children.[13] Referral to a children’s hospital or a paediatric surgeon should be considered for children younger than 5 years of age.[80]
Intestinal obstruction
Urgency of intervention is dependent on the clinical severity of the obstruction.
Strangulated obstructions are usually complete obstructions in which the blood supply to the bowel is cut off as a result of oedema, twisting of the bowel, or adhesions. These usually demonstrate diffuse or local peritonitis, fever, and leukocytosis. Untreated, they progress to intestinal necrosis and/or perforation. Urgent surgical treatment is mandatory.
Non-strangulated obstructions involve a loop of bowel that is partially or completely obstructed but has an adequate blood supply and is not necrotic. This type of obstruction is usually not associated with peritonitis, fever, or leukocytosis, but may be associated with abdominal distension, nausea, and vomiting. Although surgical intervention may be necessary, it is usually not urgent. However, prolonged delay may progress to strangulation.
Intussusception
May lead to venous obstruction and bowel-wall oedema and can progress, if untreated, to bowel necrosis, perforation, and, rarely, death.[81][82] Treatment should be initiated at the time of diagnosis. The goal is correction of hypovolaemia and electrolyte abnormalities, and antibiotic administration, followed by urgent reduction.
Reduction can be accomplished with a radiographic enema study (air is preferred over contrast reagent) or by surgery.[83]
There is a risk of recurrence of intussusception after reduction, especially within the first 48 hours, so prompt re-evaluation is necessary if symptoms recur.[84]
Volvulus
Malrotation with mid-gut volvulus is a surgical emergency, and bilious vomiting in any child should prompt concern for this condition until confirmed otherwise.
With a corresponding history and physical examination (bilious vomiting and feeding difficulty, especially in infants during the first month of life), no further diagnostic intervention is necessary, and prompt surgical exploration is recommended.
Ambiguous cases may proceed to an upper GI contrast study (the gold standard test). However, this should not preclude surgical intervention if clinical suspicion is high.
Incarcerated hernia
Prompt attention should be paid to an incarcerated inguinal or umbilical hernia due to the danger of bowel strangulation (compromise of blood flow to the bowel with consequent bowel ischaemia and gangrene). Incarceration, with or without strangulation, occurs if intra-abdominal contents become trapped in the protruding hernia sac.
Clinically, the hernia is irreducible and tender. Associated symptoms may include nausea, vomiting, and generalised abdominal pain. In severe cases, fever, abdominal distension, and skin changes may be present.
Peritonitis is a contraindication to attempted non-operative reduction.
If strangulation is evident, surgery is required urgently to resect the gangrenous segment of bowel.
Necrotising enterocolitis
The most common medical/surgical emergency affecting neonates, particularly premature infants, especially those weighing less than 1500 g.[35]
Signs and symptoms include feeding intolerance, apnoea, lethargy, bloody stools, abdominal distension, tenderness, abdominal wall erythema, and bradycardia.
Early intervention is mandatory to prevent morbidity and mortality due to multiple organ impairment. Treatment may be medical or surgical, and is determined by severity of the clinical presentation. [
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Abdominal trauma
Genitourinary emergencies
Ruptured ectopic pregnancy
If undiagnosed or incorrectly managed, a ruptured ectopic pregnancy may lead to maternal death due to rupture of the implantation site and intraperitoneal haemorrhage.
The classic presentation includes lower abdominal pain, amenorrhoea, and vaginal bleeding. Patients with a positive urine pregnancy test and the absence of an intrauterine pregnancy on transvaginal ultrasound are considered to have an ectopic pregnancy until confirmed otherwise.
A quick and focused ultrasonographic examination to assess for the presence of free fluid or blood may be helpful when this diagnosis is suspected, but this should not delay other care.
Haemodynamic instability associated with a ruptured ectopic pregnancy results from severe hypovolaemia secondary to blood loss. As such, the management of these patients involves stabilisation with emergency fluid resuscitation and immediate transfer to theatre. Rapid volume repletion with isotonic solution and blood products is of paramount importance to avoid ischaemic injury and multi-organ damage.
Urgent laparoscopy with salpingectomy or salpingostomy is performed for a ruptured ectopic pregnancy.
Ovarian torsion
Twisting or torsion of the ovary compromises the arterial inflow and venous outflow, producing ischaemia, which, if not relieved, can affect the viability of the ovary.
It presents with acute-onset lower abdominal pain and, frequently, nausea and vomiting. Symptoms may be intermittent and fluctuate in severity.
Doppler ultrasound is of only variable reliability in the diagnosis of ovarian torsion.[87][88]
It is not known how long an ovary can withstand ischaemia without permanent damage (it may be up to 72 hours or even longer), but definitive operative intervention should be undertaken as soon as possible.[89][90] A delay in the timing of surgery is associated with a reduction in the possibility of ovarian salvage.[91]
Conservative management with detorsion is highly recommended regardless of appearance of ovary.[60][92][93]
Testicular torsion
Should be ruled out in any male child presenting with abdominal pain. The twisting of the testis and spermatic cord causes obstruction of arterial inflow and venous drainage from the testis.
It typically presents with sudden-onset testicular pain; however, younger boys may only complain of abdominal tenderness, nausea, and/or vomiting.
Physical findings suggestive of testicular torsion include loss of the cremasteric reflex, diffuse testicular tenderness, raised testes, and a horizontal rather than vertical position of the testes.
Prompt recognition and early surgical intervention are necessary to prevent testicular loss. Manual detorsion may be attempted while preparations for surgery are being made.
Duplex Doppler ultrasound is the definitive test for testicular torsion and should be obtained unless the test would unnecessarily delay intervention in a child for whom there is a high index of suspicion.[94][95]
Sepsis
Sepsis and septic shock
Patients with intra-abdominal sepsis may present with abdominal pain.[96]
Sepsis is a spectrum of disease where there is a systemic and dysregulated host response to an infection.[97]
Presentation ranges from subtle, non-specific symptoms (e.g., feeling unwell with a normal temperature) to severe symptoms with evidence of multi-organ dysfunction and septic shock. Patients may have signs of tachycardia, tachypnoea, hypotension, fever or hypothermia, poor capillary refill, mottled or ashen skin, cyanosis, newly altered mental state, or reduced urine output.[98]
Sepsis and septic shock are medical emergencies.
In children, risk factors for sepsis include: age under 1 year, impaired immunity (due to illness or drugs), recent surgery or other invasive procedures, any breach of skin integrity (e.g., cuts, burns), and indwelling lines or catheters.[98]
Early recognition of sepsis is essential because early treatment improves outcomes.[98][99][Evidence C] However, detection can be challenging because the clinical presentation of sepsis can be subtle and non-specific. A low threshold for suspecting sepsis is therefore important.
The key to early recognition is the systematic identification of any patient who has signs or symptoms suggestive of infection and is at risk of deterioration due to organ dysfunction. Criteria to identify sepsis and septic shock in children and young people under the age of 18 years have been developed.[100] Several other risk stratification approaches exist. All rely on a structured clinical assessment and recording of the patient's vital signs.[98][100][101][102][103] It is important to check local guidance for information on which approach your institution recommends.
The timeline of ensuing investigations and treatment should be guided by this early assessment.[103]
Treatment guidelines have been produced by the Surviving Sepsis Campaign and remain the most widely accepted standards.[99] Within the first hour:[99]
Follow institutional protocols for management of sepsis/septic shock in children; these improve the speed and reliability of care.
Obtain blood cultures before administering antibiotics (provided this does not substantially delay antibiotic administration).
Administer broad-spectrum antibiotics.
Administer crystalloid fluids titrated to clinical signs of cardiac output and stopped if there is evidence of volume overload. Consult local protocols.
Use trends in blood lactate levels to guide resuscitation. If the child's hypotension is refractory to fluid resuscitation, consider use of vasopressors.
For more information on sepsis, please see our topic Sepsis in children.
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