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Emergency evaluation of the child with acute abdominal pain

Emergency evaluation of the child with acute abdominal pain
Literature review current through: Jan 2024.
This topic last updated: Apr 07, 2023.

INTRODUCTION — The emergency evaluation of children with acute abdominal pain, including a brief description of life-threatening and common causes, will be discussed here.

The evaluation and management of children with chronic abdominal pain is reviewed separately. (See "Chronic abdominal pain in children and adolescents: Approach to the evaluation" and "Functional abdominal pain in children and adolescents: Management in primary care".)

GOALS OF EVALUATION — Among children, abdominal pain is a frequent, nonspecific symptom that is typically associated with self-limited conditions such as gastroenteritis, constipation, and viral illnesses. The challenge for the clinician is to identify patients with serious causes of abdominal pain that require specific intervention:

Acute abdomen from appendicitis or bowel obstruction (as can occur from volvulus, intussusception, or adhesions); acute manifestations of inflammatory bowel disease, pancreatitis, hepatitis, myocarditis, or intra-abdominal mass

Extra-abdominal infections such as streptococcal pharyngitis, urinary tract infection, or pneumonia

Unusual manifestations of less common diseases such as Hirschsprung disease or primary bacterial peritonitis with nephrotic syndrome

Diabetic ketoacidosis

CAUSES — The causes of acute abdominal pain in children are summarized in the table with clinical features discussed in detail separately (table 1). (See "Causes of acute abdominal pain in children and adolescents".)

EVALUATION — The first goal of the evaluation of children with abdominal pain is to identify life-threatening conditions that require emergency interventions. Subsequently, other causes of abdominal pain can often be identified through deliberate evaluation with careful attention to the clinical features of the illness (such as the child's age and sex, history of trauma, pattern of the pain, related symptoms with attention to the time sequence, physical findings based on single or repeated examinations, and selected diagnostic studies) (algorithm 1 and algorithm 2).

Unavoidably, a small number of patients who may present early in the course of an illness (such as appendicitis) or with subtle and/or atypical signs do not receive the definitive diagnosis on the initial evaluation [1]. Consequently, repeat examination and reliable follow-up are essential components of the evaluation and management of children with acute abdominal pain.

History — Key historical variables that may assist in identifying a specific cause of abdominal pain include the patient's age, history of trauma, prior abdominal surgery, fever, vomiting, location, and character of the abdominal pain, and the pattern of symptoms. A gynecologic history (including last menstrual period and sexual activity) should be obtained for pubertal girls.

Age — Conditions that cause abdominal pain in children may vary with the age of the child (table 1).

For example, serious etiologies of abdominal pain that present with obstruction and/ or peritonitis according to age include:

Neonates – Volvulus (as a complication of malrotation) and necrotizing enterocolitis.

Two months to two years – Intussusception (invagination of a part of the intestine into itself, causing obstruction), incarcerated hernia, and complications of Hirschsprung disease.

Children – Appendicitis (most commonly in children >5 years of age) and, less commonly, primary bacterial peritonitis (usually as a complication of nephrotic syndrome) or obstruction due to adhesions from a prior surgery.

Adolescents – Appendicitis and, less commonly, obstruction caused by adhesions from previous surgery or inflammation, perforated ulcer, or primary bacterial peritonitis.

Among postmenarchal females, serious conditions within the reproductive tract that can cause abdominal pain include ovarian torsion, pelvic inflammatory disease with tubo-ovarian abscess, and ruptured ectopic pregnancy.

Trauma — Abdominal trauma (typically sustained in motor vehicle crashes, auto-pedestrian collisions, or falls) can cause life-threatening injuries (such as solid organ injury or perforated viscus). Typical mechanisms include motor vehicle crashes, falls, and child abuse. However, a history of trauma may not be forthcoming for infants and children who have sustained inflicted injuries. (See "Pediatric blunt abdominal trauma: Initial evaluation and stabilization" and "Physical child abuse: Recognition", section on 'Visceral injuries'.)

Although symptoms of abdominal injury typically occur immediately, they may be delayed with some injuries (such as left shoulder pain from a slowly expanding splenic hematoma, vomiting from obstruction as the result of a duodenal hematoma, or bowel perforation associated with a lap seatbelt injury). (See "Pediatric blunt abdominal trauma: Initial evaluation and stabilization", section on 'Specific injuries'.)

Infection — Children with intra- and extra-abdominal infections may present with a primary complaint of abdominal pain. Common conditions that are associated with acute abdominal pain include:

Viral gastroenteritis

Systemic viral illness

Streptococcal pharyngitis

Lobar pneumonia

Urinary tract infections

Exacerbation of chronic condition — Acute abdominal pain may also represent an exacerbation of a chronic condition. Frequent causes of chronic or recurrent abdominal pain include constipation, functional abdominal pain, gastroesophageal reflux, and dietary intolerance. In one- to three-month-old infants, abdominal pain and fussiness may be signs of colic (although other etiologies should be excluded). Acute abdominal pain may also represent an exacerbation of a chronic condition in older children and adolescents, such as inflammatory bowel disease, abdominal migraine, or gastrointestinal dysmotility.

(See "Causes of acute abdominal pain in children and adolescents", section on 'Common causes'.)

Characteristics of abdominal pain — Infants and children younger than two years of age with abdominal pain usually cannot describe or localize pain. This limitation leads to both over and under attribution of symptoms to "abdominal pain." Parents/primary caregivers may infer that the child has abdominal pain from symptoms such as drawing the legs up or inconsolability. The preschool child may be able to describe pain and other symptoms, although descriptions may not be consistently reliable. Above five years of age, children can typically characterize the onset, frequency, duration, and location of their symptom.

Specific diagnoses may be associated with the following characteristic patterns of pain:

Appendicitis – Periumbilical, migrating to the right lower abdomen

Appendiceal rupture (early), ovarian torsion – Acute, severe, focal

Intussusception – Intermittent, colicky

Gastroenteritis – Diffuse or vague

Hepatitis and cholecystitis – Right upper quadrant

Gastritis, gastric ulcer disease – Epigastric

Pancreatitis – Steady periumbilical and/or subxiphoid pain, often radiating to the back

Renal stone – Flank pain radiating to mid to lower lateral abdomen

Constipation – Intermittent, often left sided

For children with localized peritoneal irritation (as with advanced/complicated appendicitis), pain can be aggravated by movement (such as, coughing, hopping, traveling in the car or walking). In comparison, patients with visceral pain may writhe with discomfort. Improvement in pain after a bout of emesis may occur with conditions localized to the small bowel [2]. Pain relief after a bowel movement suggests a colonic condition including chronic constipation, or bowel inflammation from a host of causes.

Associated symptoms

Fever – In an observational series describing children evaluated for abdominal pain in outpatient settings, 64 percent had a history of fever [1]. Patients with appendicitis often have fever, which may be initially low grade. Most children with abdominal pain and fever, however, have infectious etiologies such as gastroenteritis, urinary tract infection, or pharyngitis [1,3].

Bacterial infections that may be associated with abdominal pain include:

Streptococcal pharyngitis (often with sore throat, headache, and vomiting), although children with viral pharyngitis can also have abdominal pain (see "Group A streptococcal tonsillopharyngitis in children and adolescents: Clinical features and diagnosis", section on 'Clinical features')

Urinary tract infections (sometimes with vomiting or, less often, diarrhea in younger children) (see "Urinary tract infections in infants and children older than one month: Clinical features and diagnosis", section on 'Clinical presentation')

Lower lobe pneumonia (usually with respiratory symptoms such as tachypnea or cough, but without abdominal tenderness on examination) [4] (see "Community-acquired pneumonia in children: Clinical features and diagnosis", section on 'Clinical presentation')

Pelvic inflammatory disease (in postmenarchal, sexually active females) (see "Pelvic inflammatory disease: Clinical manifestations and diagnosis", section on 'Clinical features')

Vomiting – Vomiting is frequently reported among children with abdominal pain. In the previously noted series, 42 percent of patients had a history of vomiting [1].

Children with vomiting and abdominal pain (particularly in the absence of diarrhea) should be carefully evaluated for life-threatening conditions such as bowel obstruction or appendicitis with peritonitis.

Volvulus must be excluded as the cause of bilious emesis and apparent abdominal pain in a neonate (see "Intestinal malrotation in children", section on 'Clinical presentation')

With intussusception, vomiting (initially nonbilious, but often becoming bilious as the obstruction progresses) may occur following episodes of pain (see "Intussusception in children", section on 'Clinical manifestations')

Small bowel obstruction may develop as the result of many conditions, including postoperative or postinflammatory adhesions. Worldwide, ascaris infection is a common cause of small bowel obstruction (see "Ascariasis", section on 'Complications')

Nausea and vomiting are typically present among children with appendicitis, ovarian and testicular torsion, pancreatitis, and severe inflammatory bowel disease (see "Acute appendicitis in children: Clinical manifestations and diagnosis", section on 'Clinical manifestations')

Diarrhea – The following conditions can be associated with diarrhea (see "Diagnostic approach to diarrhea in children in resource-abundant settings"):

Children with diarrhea and abdominal pain usually have viral gastroenteritis

Urinary tract infections can cause diarrhea

Children with appendicitis occasionally present with diarrhea (typically mucoid stools, rather than profuse, watery diarrhea)

Children with intussusception may have bloody stools, sometimes mixed with mucus (currant jelly). In addition, intussusception may be preceded by viral gastroenteritis (particularly from adenovirus) (see "Intussusception in children", section on 'Clinical manifestations' and "Intussusception in children", section on 'Pathogenesis')

Bloody diarrhea with abdominal pain suggests infectious enteritis, hemolytic uremic syndrome (HUS), Meckel's diverticulum (may be gross blood only), or inflammatory bowel disease (see "Clinical manifestations and diagnosis of Shiga toxin-producing Escherichia coli (STEC) hemolytic uremic syndrome in children" and "Clinical presentation and diagnosis of inflammatory bowel disease in children")

Other symptoms that may suggest the etiology of abdominal pain include cough (pneumonia), sore throat (pharyngitis), dysuria (urinary tract infection), polyuria (diabetic ketoacidosis), and hematuria (urinary tract infection, urolithiasis, hemolytic uremic syndrome, immunoglobulin A vasculitis [IgAV; Henoch-Schönlein purpura (HSP)]).

Past medical history

Bowel obstruction from adhesions can occur among children who have had abdominal surgery. (See "Causes of acute abdominal pain in children and adolescents", section on 'Adhesions with intestinal obstruction'.)

Children with Hirschsprung disease can develop complications such as obstruction and fulminant enterocolitis. (See "Emergency complications of Hirschsprung disease", section on 'Enterocolitis'.)

Cholecystitis may be the cause of abdominal pain for older adolescents or children with predisposing conditions such as sickle cell disease or cystic fibrosis. (See "Cystic fibrosis: Clinical manifestations and diagnosis", section on 'Hepatobiliary disease' and "Overview of the clinical manifestations of sickle cell disease", section on 'Hepatobiliary complications'.)

Abdominal pain may be the manifestation of vasoocclusive crisis (VOC) for children with sickle cell disease. Other emergency conditions should be considered as suggested by specific findings (such as peritoneal signs or focal right lower quadrant pain), by a pattern of pain that is not typical of VOC for this patient, or for a child whose symptoms do not improve with hydration and analgesia. (See "Overview of the clinical manifestations of sickle cell disease", section on 'Acute painful episodes'.)

Children with diabetic ketoacidosis may have abdominal pain. (See "Diabetic ketoacidosis in children: Clinical features and diagnosis", section on 'Signs and symptoms'.)

Primary bacterial peritonitis may occur in children with nephrotic syndrome or may present in patients with chronic ascites (eg, chronic liver disease, portal vein obstruction, or chylous ascites). (See "Complications of nephrotic syndrome in children", section on 'Infection'.)

Physical examination — A comprehensive physical examination, including vital signs, a detailed abdominal examination, and a focused extra-abdominal examination are essential for the evaluation of the child with acute abdominal pain.

Appearance — Appearance and hydration should be noted. Patients with hypovolemia (as with abdominal injury, volvulus, or intussusception) or peritonitis (as from perforated appendicitis) may have signs of poor perfusion (see "Assessment of systemic perfusion in children"). Children with peritonitis typically prefer to lie still, while those with biliary or renal colic may writhe in pain. Children with jaundice may have hepatitis or hemolysis. However, children with intussusception early in the course of their disease may appear quite well in between painful episodes of peristalsis.

Vital signs — Abnormal vital signs may provide a clue to the diagnosis:

Fever suggests infection (such as gastroenteritis, urinary tract infection, pneumonia, or pharyngitis). Although many children with appendicitis are febrile, fever is neither sensitive nor specific for this condition [5].

Tachypnea can be a sign of respiratory illness (such as pneumonia) or hyperventilation with metabolic acidosis (causing deeper and sometimes rapid breathing in children with dehydration from gastroenteritis, diabetic ketoacidosis, peritonitis, or intestinal obstruction).

Hypotension in a child with acute abdominal pain can develop from intravascular volume loss (as with hemorrhage from injury, gastroenteritis, or capillary leak from bowel obstruction with volvulus or intussusception) or septic shock with peritonitis (as with perforated appendicitis).

Abdominal examination — The abdomen should be examined when the child is quiet and cooperative, in a position of comfort (such as a caretaker's lap), and before more anxiety provoking or uncomfortable parts of the examination (such as ears and throat). (See "The pediatric physical examination: Chest and abdomen", section on 'Abdomen'.)

The following features should be noted:

Distention may be the result of obstruction or a mass.

Bowel sounds may be decreased (as with an ileus in response to peritoneal irritation from appendicitis) or increased (as with gastroenteritis or bowel obstruction).

Pain may be localized with gentle palpation performed in all four quadrants. Considerations include:

Children can be asked to point with one finger to the spot that hurts the most.

Reproducible focal tenderness suggests an intra-abdominal inflammatory process.

Serious causes of abdominal pain are less likely for otherwise healthy children who are not uncomfortable with deep palpation throughout the abdomen, who have no focal tenderness, and who have no extra-abdominal findings.

Among older children, tenderness can sometimes be localized to the abdominal wall by demonstrating that tenderness to palpation is exacerbated when the child lifts her head off of the table.

Percussive tenderness, rebound, and involuntary guarding are most often signs of peritoneal irritation (as with appendicitis or cholecystitis). Other findings that may be noted with percussion include increased tympany (as with distended bowel), dullness (as with a mass), and shifting dullness (as with ascites).

Rectal examination (to assess for local tenderness, mass, constipation, and hematochezia) may be considered as part of the evaluation for abdominal pain. However, it is uncomfortable and may be of low yield to identify serious conditions. For example, observational evidence suggests that rectal examination may have low utility either for diagnosing appendicitis among children with abdominal pain or for identifying injuries among trauma patients [3,6-10].

If performed, findings on rectal examination that should be noted include:

Hard stool in the rectal vault supports the diagnosis of constipation but does not prove that this common condition is responsible for a given episode of acute abdominal pain.

Blood in the stool (gross or occult) may occur in a variety of conditions, including intussusception, inflammatory bowel disease, inflamed Meckel's diverticulum, dietary protein allergy, infectious enteritis, and constipation with anal fissure.

Uterine or adnexal tenderness or masses (suggesting a gynecologic source for abdominal pain) may rarely be noted on rectal examination.

General examination — Extra-abdominal findings on physical examination can provide important information regarding the cause of abdominal pain.

Pharyngeal erythema and/or exudate can be seen with pharyngitis.

Crackles (Rales), focal, decreased breath sounds, or egophony on auscultation of the chest are suggestive of pneumonia.

Muffled heart sounds or a rub may be seen with pericarditis, a gallop rhythm may occur in myocarditis, and tachycardia is typically a feature of both conditions.

Flank tenderness may be a sign of pyelonephritis or urolithiasis.

Tender scrotal swelling suggests testicular torsion or incarcerated hernia. A careful genitourinary examination should be performed among all males presenting with abdominal pain.

Bruising suggests trauma. Petechiae and/or purpura may be seen with IgAV (HSP) and can present with abdominal pain prior to presence of the characteristic rash.

The sandpapery erythematous rash with perioral sparing occurs with scarlet fever.

Jaundice may be observed in children with hepatitis, gall bladder disease with obstruction, or hemolysis (as with sickle cell disease).

Sexually active females with lower abdominal pain should generally receive bimanual pelvic examinations to look for signs of pelvic inflammatory disease, adnexal masses or cysts, uterine pathology, or ectopic pregnancy. (See "The gynecologic history and pelvic examination".)

Ancillary studies — Children with abdominal pain who are otherwise healthy, well appearing, and have normal physical examinations typically do not require ancillary studies. Those whose repeat examinations continue to be unremarkable and who tolerate feeding can usually be discharged with reliable medical follow-up.

Laboratory and radiographic studies should be performed when history and/or physical examination demonstrate focal findings or suggest concerning diagnoses (such as intra-abdominal injury, appendicitis, bowel obstruction, or infection). The choice of tests should be based upon the age of the child and the diagnoses under consideration.

Laboratory studies — Specific studies that may be considered include:

White blood cell count (WBC) – An elevated WBC suggests infection or inflammation (such as appendicitis), although a normal WBC does not exclude these processes (see "Acute appendicitis in children: Clinical manifestations and diagnosis", section on 'Laboratory testing'). WBC >20,000 suggests perforated appendicitis, appendiceal abscess, or lobar pneumonia [11,12].

Hematocrit – For children with bleeding, hematocrits that are initially normal establish baselines for serial measurements but may be misleading (eg, in situations of dehydration). Anemia with abnormal red cell morphology can be seen with hemoglobinopathies (sickling) and hemolytic uremic syndrome (microangiopathic changes). Children with hemolytic uremic syndrome also have thrombocytopenia. (See "Overview of the clinical manifestations of sickle cell disease" and "Clinical manifestations and diagnosis of Shiga toxin-producing Escherichia coli (STEC) hemolytic uremic syndrome in children", section on 'Typical course'.)

Serum chemistries – Among children with upper abdominal pain, abnormal liver enzyme tests, lipase or amylase measurements suggest hepatitis, cholecystitis, or pancreatitis, respectively. Metabolic acidosis can occur with dehydration, intestinal obstruction, peritonitis, or diabetic ketoacidosis (DKA). An elevated blood glucose in the setting of acidosis is also consistent with DKA. (See "Diabetic ketoacidosis in children: Clinical features and diagnosis".)

A urine dipstick evaluation (for blood, nitrites, leukocyte esterase, glucose, ketones, and protein) should be obtained for most children with abdominal pain. A formal urinalysis should be sent when the dipstick is abnormal. Hematuria can occur with urolithiasis, IgAV (HSP), hemolytic uremic syndrome, and urinary tract infection (UTI). Pyuria usually indicates a UTI, but a small number of WBCs (10 to 20 WBCs/hpf) can be seen with appendicitis (presumably when inflammation irritates the bladder wall). Children with DKA have glucosuria and ketonuria. A child with nephrotic syndrome and bacterial peritonitis typically has proteinuria.

Urine pregnancy testing should be performed for postmenarchal females with abdominal pain. (See "Clinical manifestations and diagnosis of early pregnancy", section on 'Urine pregnancy test'.)

Rapid streptococcal antigen testing or bacterial throat culture – Children with abdominal pain and pharyngeal findings should usually receive rapid screening tests and/or throat cultures for group A beta hemolytic Streptococcus. (See "Group A streptococcal tonsillopharyngitis in children and adolescents: Clinical features and diagnosis", section on 'Diagnosis'.)

Imaging — Imaging is an essential component of the evaluation of some children with acute abdominal pain who have concerning clinical features such as trauma, peritoneal irritation, signs of obstruction, masses, distension, or focal tenderness and/or pain. Children with a typical clinical presentation for acute appendicitis are likely to have appendicitis. In this circumstance, we encourage clinicians to consult a surgeon with experience caring for children prior to obtaining imaging studies. (See "Acute appendicitis in children: Clinical manifestations and diagnosis", section on 'Imaging'.)

Plain radiography – In most instances, plain images are not helpful for providing a specific diagnosis for abdominal pain. They may serve a limited role in some children as follows:

Abdominal films may demonstrate signs of obstruction (such as air fluid levels, distended bowel, or sentinel bowel loops) or perforation (such as free air) (image 1).

Fluid-filled loops of small bowel can be seen with gastroenteritis.

A fecalith in the right lower quadrant of a child with abdominal pain suggests the diagnosis of appendicitis, although this finding is not frequently observed. (See "Acute appendicitis in children: Diagnostic imaging", section on 'Plain radiographs'.)

Although not routinely indicated for the evaluation of functional constipation, children with acute abdominal pain due to constipation may have increased stool noted with abdominal radiography. The absence of at least moderate amounts of stool excludes this diagnosis as an explanation for acute abdominal pain. (See "Constipation in infants and children: Evaluation", section on 'Imaging'.)

For children who may have midgut volvulus, an upper GI contrast series is the best examination for diagnosis (image 2 and image 3). (See "Intestinal malrotation in children", section on 'Diagnosis'.)

Although obstruction or mass effect may be seen on plain film, ultrasound is the best diagnostic test for intussusception. In addition, contrast enema (air or barium) can diagnose and often reduce an intussusception (image 4 and image 5). (See "Intussusception in children", section on 'Nonoperative reduction'.)

A chest radiograph may reveal basilar pneumonia or signs of myocarditis (cardiomegaly) as the cause of abdominal pain.

Ultrasonography (US) – Because it has the advantage of no radiation exposure, is less impacted by patient motion, and can be performed at the bedside, ultrasonography may be useful for several conditions that cause abdominal pain in children including the following:

Gallstones.

Genitourinary conditions (eg, ovarian torsion, ruptured ovarian cyst, and testicular torsion). (See "Ovarian and fallopian tube torsion", section on 'Ultrasound' and "Causes of scrotal pain in children and adolescents", section on 'Role of imaging' and "Evaluation and management of ruptured ovarian cyst", section on 'Laboratory findings'.)

Nephrolithiasis – Ultrasonography is the recommended primary imaging modality for suspected nephrolithiasis because it is effective in detection of renal and ureteral stones while avoiding radiation. (See "Kidney stones in children: Clinical features and diagnosis", section on 'Ultrasonography'.)

Intussusception (image 6). (See "Intussusception in children", section on 'Ultrasonography'.)

Appendicitis – US is the recommended imaging modality for children with atypical or equivocal findings, although the utility of US for diagnosing appendicitis depends upon the experience of the ultrasonographer, and may also vary based upon a child's body mass index (table 2 and image 7). (See "Acute appendicitis in children: Diagnostic imaging", section on 'Imaging approach' and "Acute appendicitis in children: Diagnostic imaging", section on 'Test performance'.)

Blunt abdominal trauma – As part of a focused abdominal sonography for trauma (FAST examination) in a trauma patient with blunt injury, a negative FAST examination by an experienced ultrasonographer may exclude significant intra-abdominal hemorrhage as the explanation for shock. (See "Trauma management: Approach to the unstable child", section on 'e-FAST (extended focused assessment with sonography for trauma)'.)

Computed tomography (CT) – CT is generally not used as the primary imaging modality for abdominal pain in children because of the risks of radiation exposure and the availability of alternative modalities that provide accurate imaging. The radiation exposure of an abdominal CT in children can be significant, although lower-dose imaging protocols can mitigate this risk.

Alternative imaging modalities such as ultrasound or magnetic resonance imaging (MRI) can frequently provide equivalent or higher diagnostic certainty without radiation exposure. Sequential use of ultrasound prior to (or rather than) CT may reduce radiation exposure (eg, children with suspected appendicitis), especially in young children. When an abdominal CT is performed, the clinician should consider a focused examination as well as ensure that CT scanning energy parameters are appropriate for children in their institution. (See "Acute appendicitis in children: Diagnostic imaging", section on 'Focused CT' and "Acute appendicitis in children: Diagnostic imaging", section on 'CT scanning parameters'.)

CT with contrast is useful for the evaluation of patients with acute abdominal pain when a wide variety of diagnoses are being considered (such as advance/complicated appendicitis , pancreatitis, intra-abdominal abscess, blunt abdominal trauma, and for the evaluation of an intra-abdominal mass). As an example, CT has high sensitivity and specificity for diagnosing appendicitis and liver or spleen laceration. (See "Acute appendicitis in children: Diagnostic imaging", section on 'Test performance' and "Pediatric blunt abdominal trauma: Initial evaluation and stabilization", section on 'Abdominal and pelvic CT'.)

CT without contrast is the most sensitive imaging test for pediatric nephrolithiasis. (See "Kidney stones in children: Clinical features and diagnosis", section on 'Imaging'.)

Ultrasound is the primary imaging modality to assess for hydronephrosis and kidney stones in children. Helical CT is the most sensitive imaging test for renal or ureteral stones in children and can detect stones <5 mm in size. When CT is necessary for diagnostic purposes, low-dose protocols may provide adequate resolution for identifying most calculi or alternative diagnoses, with significant reduction in radiation are recommended by guidelines from the National Cancer Institute. (See "Kidney stones in children: Clinical features and diagnosis", section on 'Imaging'.)

Magnetic resonance imaging – MRI is increasingly being used in the evaluation of children with abdominal pain. However, some studies suggest that MRI without contrast has similar diagnostic accuracy for appendicitis as CT and has the advantage of not exposing a child to ionizing radiation. MRI may be preferred in settings with adequate experience in the use of this modality for the detection of appendicitis, and with the resources to rapidly obtain and interpret the study. (See "Acute appendicitis in children: Diagnostic imaging", section on 'Magnetic resonance imaging'.)

ANALGESIA — We recommend that children with acute abdominal pain receive effective analgesia, as indicated by their degree of discomfort. Three clinical trials have concluded that morphine analgesia in children with acute abdominal pain provides significant pain reduction without affecting the examination or the ability to identify those with surgical conditions [13-15].

ALGORITHMIC APPROACH — Most children with acute abdominal pain who have conditions that require emergency diagnosis and treatment can be effectively identified with a systematic approach that considers age, the presence of worrisome clinical features, and selected ancillary studies (table 1 and algorithm 1 and algorithm 2).

Trauma — The first step in the evaluation of abdominal pain in children is to identify those who have sustained trauma. For this population, injury is the likely cause of abdominal pain and a specific approach to the evaluation is required. Mechanisms typically associated with significant injury (such as solid organ laceration or perforated viscus) include motor vehicle crashes, motor vehicle pedestrian collisions, falls, and physical assault (including child abuse). (See "Pediatric blunt abdominal trauma: Initial evaluation and stabilization".)

Rapid, aggressive stabilization and evaluation are indicated for children with the following:

Unstable vital signs at presentation

Obvious serious or multiple injuries

High risk mechanism of injury (penetrating injury, severe blunt trauma, fall from higher than 20 feet, ejection from a vehicle, impact velocity more than 30 miles per hour)

Identification of specific injuries, when clinically indicated, typically requires imaging:

Focused abdominal sonography for trauma (FAST examination) may detect free fluid (usually blood) in the abdomen. However, a negative FAST examination does not exclude serious intra-abdominal trauma. (See "Initial evaluation and management of blunt abdominal trauma in adults", section on 'Ultrasound'.)

Solid organ injuries are generally diagnosed with abdominal CT, whereas plain radiographs may demonstrate signs of a perforated viscus (although normal plain radiography does not exclude perforation).

Signs of obstruction or peritoneal irritation — Signs of obstruction (such as abdominal distention and/or bilious vomiting), history of prior abdominal surgery (predisposing to adhesions which may cause obstruction), and peritoneal irritation (such as guarding, percussive tenderness, and rebound) are clinical features associated with serious intra-abdominal conditions that require prompt diagnosis and treatment.

In every case where clinical findings suggest obstruction or peritonitis, either treatment must be initiated (such as laparotomy for suspected appendicitis) or diagnostic steps must be undertaken to identify a cause. Supportive care (such as monitoring, intravenous isotonic crystalloid fluids, analgesia, and often parenteral antibiotics) should be provided while results from ancillary studies are pending. Hospital admission for observation and serial examinations should occur for any patient with signs of obstruction and/or peritoneal irritation for whom a cause cannot be identified.

Obstruction – Life-threatening causes of abdominal pain as the result of bowel obstruction include the following:

Volvulus (most often in neonates). An upper GI contrast series is the imaging study of choice. Ultrasonography may demonstrate findings suggestive of malrotation, but a normal study does not exclude the diagnosis. (See "Intestinal malrotation in children", section on 'Diagnosis'.)

Intussusception (usually two months to two years of age). Plain radiographs of the abdomen are sometimes normal, but may show frank intestinal obstruction, a mass effect from an intussusceptum, or distended loops of bowel with absence of colonic gas. The diagnosis may be confirmed with ultrasound performed by an experienced ultrasonographer. Contrast enema (air or barium) can diagnose and often reduce an intussusception. (See "Intussusception in children", section on 'Evaluation' and "Intussusception in children", section on 'Nonoperative reduction'.)

Peritoneal irritation – The following conditions should be considered in children with abdominal pain and signs of peritoneal irritation:

Necrotizing enterocolitis (NEC) most commonly occurs in premature infants but may occur in full-term infants. Such infants typically have preexisting illnesses associated with poor mesenteric perfusion (such as congenital heart disease) or have hypoperfusion such as from protracted diarrhea. Abdominal radiography may demonstrate signs of ileus or characteristic findings such as pneumatosis intestinalis (image 8). (See "Neonatal necrotizing enterocolitis: Clinical features and diagnosis".)

Appendicitis occurs more often among children over five years of age but can also be the cause of abdominal pain and peritoneal irritation in infants and younger children. (See "Acute appendicitis in children: Clinical manifestations and diagnosis", section on 'Clinical manifestations'.)

Rarely, an ingested foreign body may become lodged within the GI tract, causing tissue damage or bowel perforation. The vast majority of foreign bodies (even sharp ones) that progress beyond the gastroesophageal junction pass uneventfully through the gastrointestinal tract and out with the stool, requiring no intervention. Exceptions include button batteries that may lodge in the esophagus and require emergency removal to reduce the risk of mucosal injury or perforation and ingestion of multiple magnets that can entrap bowel loops and cause volvulus and perforation. (See "Button and cylindrical battery ingestion: Clinical features, diagnosis, and initial management", section on 'Clinical features' and "Foreign bodies of the esophagus and gastrointestinal tract in children".)

Children with ascites caused by poorly controlled idiopathic nephrotic syndrome, liver disease, or portal venous thrombosis may develop spontaneous bacterial peritonitis. (See "Complications of nephrotic syndrome in children", section on 'Bacterial infection'.)

Cholecystitis and pancreatitis are unusual causes of abdominal pain among children (see "Acute calculous cholecystitis: Clinical features and diagnosis" and "Clinical manifestations and diagnosis of acute pancreatitis"). Children with cholecystitis are usually >5 years of age and often have predisposing conditions such as hemoglobinopathies or cystic fibrosis. Causes of pancreatitis among children include trauma, infection, structural anomalies, metabolic or genetic causes, and some medications (such as tetracycline, L-asparaginase, valproic acid, and steroids) [16,17]. (See "Clinical manifestations and diagnosis of chronic and acute recurrent pancreatitis in children", section on 'Further evaluation for the cause'.)

Meckel's diverticulum may cause abdominal pain mimicking an acute abdomen but is more typically associated with painless rectal bleeding. (See "Lower gastrointestinal bleeding in children: Causes and diagnostic approach", section on 'Meckel's diverticulum'.)

Perforation of a peptic ulcer is an unusual cause of abdominal pain and peritoneal irritation among children, particularly those <10 years of age. (See "Peptic ulcer disease: Clinical manifestations and diagnosis", section on 'Ulcer complications'.)

Focal physical findings — The likelihood of serious disease is lower for patients with no apparent injury, and no evidence of obstruction or obvious peritonitis, and a more deliberate evaluation can be performed. This should include a search for extra-abdominal conditions that may cause abdominal pain and abdominal findings (such as a mass or focal tenderness) that suggest an intra-abdominal process, neither of which may be obvious, particularly in a young, frightened, or uncooperative child.

Extra-abdominal — Children with abdominal pain require a full physical examination, looking for signs of systemic illness and for disease in areas adjacent to the abdomen. Specific attention should be focused on the vital signs, the skin, pharynx, the chest, the heart, and the genital region. (See 'Physical examination' above.)

Immunoglobulin A vasculitis (IgAV; Henoch-Schönlein purpura [HSP]) often causes abdominal pain (table 3). Patients generally have a typical ecchymotic rash over the lower extremities and buttocks (picture 1). Pain may develop before the rash in some cases. Intussusception may rarely develop as a complication of IgAV (HSV). (See "IgA vasculitis (Henoch-Schönlein purpura): Clinical manifestations and diagnosis".)

Children with streptococcal pharyngitis often have abdominal pain, in addition to pharyngeal irritation and exudate, although those with viral pharyngitis may also have abdominal pain. (See "Group A streptococcal tonsillopharyngitis in children and adolescents: Clinical features and diagnosis", section on 'Clinical features'.)

Lower lobe pneumonia or pleural effusion may cause diaphragmatic irritation and abdominal pain. Usually, children will have fever and frequently abnormal findings on chest examination (such as tachypnea, nasal flaring, crackles (rales), and/or dullness to percussion).

Myocarditis and pericarditis may present with abdominal pain. It may be the result of poor cardiac output with mesenteric insufficiency or secondary to distension of the liver from heart failure. The pain usually manifests in the right upper quadrant and is accompanied by a tender liver edge on abdominal palpation.

A careful genitourinary examination should be performed in children with abdominal pain. Children with testicular or ovarian torsion or incarcerated inguinal hernias may complain of abdominal pain. (See "Causes of scrotal pain in children and adolescents", section on 'Testicular torsion' and "Inguinal hernia in children".)

Mass — Palpation of the abdomen may identify an abdominal mass, suggesting the following diagnoses:

Intussusception – A mass in the right abdomen suggests intussusception, although most children with intussusception do not have this finding. (See "Intussusception in children", section on 'Clinical manifestations'.)

Solid tumors – Solid tumors are rare causes of abdominal pain in previously healthy children. Pain typically develops with bleeding into the tumors. More often, tumors present as painless masses. Wilms' tumor and neuroblastoma occur more commonly in infants, whereas leukemic or lymphomatous involvement of the liver, spleen, or retroperitoneal lymph nodes occurs more often in older children. Other causes include hepatic tumors, ovarian tumors, and soft tissue sarcomas. (See "Overview of common presenting signs and symptoms of childhood cancer", section on 'Abdominal masses'.)

Intra-abdominal abscess – Children with intra-abdominal abscesses are typically febrile and may have had previous abdominal surgery. (See "Fever of unknown origin in children: Etiology", section on 'Intra-abdominal abscess'.)

Constipation – An abdominal mass may be appreciated on physical examination in a child with constipation. Associated clinical features include prior episodes of constipation, infrequent pattern of stooling, hard stool in the rectal vault, and absence of other concerning signs or symptoms. The diagnosis of constipation should be established based on performance of a thorough history and careful physical examination rather than reliance on diagnostic imaging. (See "Constipation in infants and children: Evaluation".)

Focal tenderness — Focal tenderness on physical examination must be ascertained whenever possible, because this finding may be the only indication of serious intra-abdominal pathology. Localized tenderness on physical examination may indicate the following causes for abdominal pain:

Right lower quadrant abdominal tenderness in otherwise healthy children suggests appendicitis, although children without focal tenderness may on occasion also have appendicitis, particularly early in the course of disease. (See "Acute appendicitis in children: Clinical manifestations and diagnosis", section on 'Clinical manifestations'.)

Ovarian torsion can cause localized lower abdominal tenderness that may be indistinguishable from appendicitis when the right ovary is involved. It may occasionally occur without producing focal tenderness. Patients are typically nauseous, as with appendicitis and have associated vomiting. Although it commonly occurs as the result of an ovarian cyst, ovarian torsion can develop in a normal ovary. (See "Ovarian and fallopian tube torsion", section on 'Clinical presentation'.)

Cholecystitis and pancreatitis can cause right upper quadrant and epigastric or periumbilical tenderness, respectively. (See "Acute calculous cholecystitis: Clinical features and diagnosis" and "Clinical manifestations and diagnosis of acute pancreatitis".)

Urolithiasis may cause severe colicky flank pain which radiates into the lower abdomen. On palpation there is tenderness in the flank and lower abdomen. Pyelonephritis may cause flank tenderness with fever and/or dysuria.

Colicky pain — Intussusception should be considered for all children two months to two years of age with diffuse, colicky, severe abdominal pain regardless of findings on physical examination (including overall appearance and the presence or absence of blood in the stool). It is also an important consideration for older children with predisposing conditions (such as immunoglobulin A vasculitis [HSP] and Peutz-Jeghers syndrome). Colicky abdominal pain is sometimes described among children with a bowel obstruction.

Imaging studies that can confirm the diagnosis of intussusception include ultrasound and contrast enema. Contrast enema, usually air, should be obtained initially for patients in whom there is a high index of suspicion for intussusception because this study may be diagnostic and therapeutic. Abdominal plain radiographs and ultrasound may be useful when the diagnosis is uncertain (as is often the case), provided that these studies do not significantly delay the definitive diagnosis and treatment of intussusception. Intussusception may be an incidental finding on abdominal CT, but it should not be used as the primary imaging modality in these patients. (See "Intussusception in children", section on 'Evaluation' and "Intussusception in children", section on 'Nonoperative reduction'.)

Nonspecific symptoms — Children with abdominal pain who have not been injured and have no signs of obstruction, peritoneal irritation, evidence of extra-abdominal diseases, focal findings, or a pattern of pain suggestive of intussusception typically have infections, systemic illnesses, or a variety of minor problems (such as constipation).

For children with severe nonspecific abdominal pain, the following diagnoses, even without other distinguishing features, are possible:

Intussusception (age two months to two years, intermittent pattern)

Ovarian torsion or ruptured ovarian cyst (usually postpubertal female)

Infections that may present with abdominal pain include:

Viral or bacterial gastroenteritis (usually with diarrhea) and systemic viral syndromes (such as influenza)

Pneumonia and pharyngitis (to a lesser extent) can occasionally cause abdominal pain with a paucity of findings in the chest or pharynx, respectively

Intra-abdominal abscess (as from a ruptured appendix) may cause fever and abdominal pain without focal tenderness, particularly in a young child

Children with hepatitis may be anicteric early in their course

Young children with urinary tract infections may not have dysuria, particularly if they have pyelonephritis

Abdominal pain can be a nonspecific feature of a number of conditions that typically have other distinguishing clinical or laboratory features:

Diabetic ketoacidosis (Kussmaul respirations, "fruity" breath, polyuria, glucosuria, ketonuria, weight loss) (see "Diabetic ketoacidosis in children: Clinical features and diagnosis")

Hemolytic uremic syndrome (bloody diarrhea, pallor, petechiae, microangiopathic anemia, thrombocytopenia, renal failure) (see "Clinical manifestations and diagnosis of Shiga toxin-producing Escherichia coli (STEC) hemolytic uremic syndrome in children")

IgA vasculitis (HSP, petechiae, palpable purpura, painful swelling of feet or dependent areas, arthralgia/arthritis (table 3)) (see "IgA vasculitis (Henoch-Schönlein purpura): Clinical manifestations and diagnosis")

Pancreatitis (elevated amylase and lipase levels) (see "Clinical manifestations and diagnosis of chronic and acute recurrent pancreatitis in children")

Urolithiasis (hematuria) (see "Kidney stones in children: Clinical features and diagnosis")

Iron intoxication (occult blood in stool, foreign body on abdominal plain radiography) (see "Acute iron poisoning")

Hepatitis (jaundice, hyperbilirubinemia)

Children with chronic or recurrent abdominal pain must always be evaluated carefully for other causes, particularly when the pattern is not typical, or symptoms do not respond to the usual treatment. As an example, a child with sickle cell disease and abdominal pain who does not improve with hydration and analgesia as expected in patients with vasoocclusive crisis may have appendicitis or gall bladder disease. An approach to children with chronic abdominal pain is reviewed elsewhere. (See "Chronic abdominal pain in children and adolescents: Approach to the evaluation", section on 'Etiology'.)

Chronic conditions with acute presentations include:

Among neonates, colic is a diagnosis of exclusion that can often be distinguished from other causes of prolonged crying with a careful history and physical examination (table 4). In young infants for whom the diagnosis is uncertain, a one-to-two-hour period of observation in which no symptoms are observed, and normal feeding occurs provides support for the diagnosis of colic. (See "Infantile colic: Clinical features and diagnosis", section on 'Evaluation for identifiable causes of crying'.)

Infants with dietary protein allergy may develop irritability that is interpreted as abdominal pain. They typically pass blood-tinged stools and mucus, but do not have diarrhea. (See "Food protein-induced allergic proctocolitis of infancy".)

Children with conditions that cause malabsorption (such as celiac disease and carbohydrate malabsorption) may have recurrent abdominal pain. (See "Epidemiology, pathogenesis, and clinical manifestations of celiac disease in children", section on '"Classical" gastrointestinal symptoms' and "Chronic abdominal pain in children and adolescents: Approach to the evaluation", section on 'Etiology'.)

Abdominal pain may be a typical manifestation of vasoocclusive crises for children with sickle cell syndromes. (See "Overview of the clinical manifestations of sickle cell disease", section on 'Acute painful episodes' and "Overview of compound sickle cell syndromes".)

Intermittent abdominal pain is a classic feature of lead poisoning in children with high exposure. (See "Childhood lead poisoning: Clinical manifestations and diagnosis", section on 'Clinical manifestations'.)

Inflammatory bowel disease (more often Crohn disease than ulcerative colitis) may present with intermittent abdominal pain. Associated features may include diarrhea, hematochezia, and weight loss. (See "Clinical manifestations and complications of inflammatory bowel disease in children and adolescents", section on 'Presenting symptoms' and "Management of mild to moderate ulcerative colitis in children and adolescents", section on 'Clinical manifestations' and "Clinical presentation and diagnosis of inflammatory bowel disease in children", section on 'Typical presenting symptoms'.)

Constipation and functional abdominal pain are diagnoses of exclusion for children with recurrent abdominal pain without other concerning features. An abdominal radiograph to confirm the presence of at least moderate amounts of stool, although often performed, does not correlate well with the diagnosis of constipation and is not a routine part of evaluation of children not previously diagnosed with constipation who present with acute pain, particularly in the emergency department [18]. (See "Chronic abdominal pain in children and adolescents: Approach to the evaluation", section on 'Etiology'.)

Abdominal pain is the earliest and most common symptom of acute intermittent porphyria (AIP), the most common of the acute porphyrias. The pain is poorly localized, severe, and steady and may be associated with constipation, nausea, vomiting, and signs of ileus such as abdominal distension and decreased bowel sounds. AIP is rare before puberty and is more likely to manifest in females. (See "Acute intermittent porphyria: Pathogenesis, clinical features, and diagnosis".)

Adolescent females — For adolescent girls, an algorithmic approach must include diagnoses related to reproductive organ development and function (algorithm 2). Urine pregnancy testing should generally be performed for postmenarchal females with abdominal pain, whether or not sexual activity is reported.

Visual inspection may detect imperforate hymen in adolescent females with abdominal pain, abdominal mass, and primary amenorrhea in association with advanced sexual maturation (Tanner stage IV or V). An imperforate hymen is the simplest defect that results in primary amenorrhea and is typically associated with cyclic pelvic pain and a perirectal mass from sequestration of blood in the vagina (hematocolpos). Similar findings can be seen with defects in perineal development, which can result in absence of the distal third of the vagina and therefore absence of an outflow tract. Both of these conditions are diagnosed by physical examination. An imperforate hymen is easily corrected with surgery. (See "Congenital anomalies of the hymen and vagina".)

In addition to the conditions discussed above, the following should also be considered:

Additional diagnoses to consider for postmenarchal sexually active girls with abdominal pain who have signs of peritoneal irritation with no history of trauma include pelvic inflammatory disease (PID) and ruptured ectopic pregnancy. A bimanual pelvic examination may identify cervical motion tenderness or an adnexal mass. Pelvic ultrasonography is the imaging modality typically used to identify tuboovarian abscess and ectopic pregnancy. (See "Pelvic inflammatory disease: Clinical manifestations and diagnosis" and "Ectopic pregnancy: Clinical manifestations and diagnosis".)

For a postmenarchal female with no history of trauma and no peritoneal signs, an abdominal mass may represent an intrauterine pregnancy or hydrometrocolpos in a patient with imperforate hymen. Ovarian torsion or a ruptured ovarian cyst typically causes focal pain. (See "Ovarian and fallopian tube torsion", section on 'Clinical presentation'.)

Pregnancy (intrauterine or ectopic) must be considered as a cause of abdominal pain in postmenarchal females, whether or not sexual activity is reported. (See "Pregnancy in adolescents", section on 'Diagnosis of pregnancy'.)

Dysmenorrhea may be the cause of recurrent abdominal pain that develops during menses. (See "Primary dysmenorrhea in adolescents".)

INFORMATION FOR PATIENTS — UpToDate offers two types of patient education materials, "The Basics" and "Beyond the Basics." The Basics patient education pieces are written in plain language, at the 5th to 6th grade reading level, and they answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials. Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are written at the 10th to 12th grade reading level and are best for patients who want in-depth information and are comfortable with some medical jargon.

Here are the patient education articles that are relevant to this topic. We encourage you to print or e-mail these topics to your patients. (You can also locate patient education articles on a variety of subjects by searching on "patient info" and the keyword(s) of interest.)

Basics topic (see "Patient education: Abdominal pain (The Basics)")

SUMMARY AND RECOMMENDATIONS

Causes – For most children, the causes of abdominal pain are self-limited, minor conditions such as gastroenteritis, constipation, and other viral illnesses. Children who have experienced trauma or who have signs of bowel obstruction (such as abdominal distention and/or bilious vomiting) or peritoneal irritation (such as guarding, percussive tenderness, and rebound) may have serious conditions that require prompt diagnosis and treatment (table 1). (See 'Causes' above and "Causes of acute abdominal pain in children and adolescents".)

Evaluation – A systematic approach to the emergency evaluation of the child with acute abdominal pain that considers the patient's age and the presence of specific signs and symptoms, as well as selected ancillary studies, generally identifies those who have conditions that require emergency diagnosis and treatment. (See 'Evaluation' above.)

We recommend that children with acute abdominal pain receive effective analgesia, as indicated by their degree of discomfort, while they are being evaluated for a cause (Grade 1B). (See 'Analgesia' above.)

Diagnosis – Suggested algorithmic approaches to the diagnosis of children (algorithm 1) and postmenarchal females (algorithm 2) with acute abdominal pain are provided. (See 'Algorithmic approach' above.)

Some patients with acute abdominal pain may not receive the definitive diagnosis on the first evaluation because they present early in the course (such as appendicitis) or have subtle and/or atypical signs. Repeat examination and reliable follow-up to identify clinical features are essential components of the evaluation and management of children with acute abdominal pain. (See 'Goals of evaluation' above.)

ACKNOWLEDGMENT — The UpToDate editorial staff acknowledges Richard Ruddy, MD, who contributed to earlier versions of this topic review.

  1. Scholer SJ, Pituch K, Orr DP, Dittus RS. Clinical outcomes of children with acute abdominal pain. Pediatrics 1996; 98:680.
  2. Leung AK, Sigalet DL. Acute abdominal pain in children. Am Fam Physician 2003; 67:2321.
  3. Reynolds SL, Jaffe DM. Diagnosing abdominal pain in a pediatric emergency department. Pediatr Emerg Care 1992; 8:126.
  4. Ravichandran D, Burge DM. Pneumonia presenting with acute abdominal pain in children. Br J Surg 1996; 83:1707.
  5. Bundy DG, Byerley JS, Liles EA, et al. Does this child have appendicitis? JAMA 2007; 298:438.
  6. Dickson AP, MacKinlay GA. Rectal examination and acute appendicitis. Arch Dis Child 1985; 60:666.
  7. Andersson RE, Hugander AP, Ghazi SH, et al. Why does the clinical diagnosis fail in suspected appendicitis? Eur J Surg 2000; 166:796.
  8. Shlamovitz GZ, Mower WR, Bergman J, et al. Poor test characteristics for the digital rectal examination in trauma patients. Ann Emerg Med 2007; 50:25.
  9. Shlamovitz GZ, Mower WR, Bergman J, et al. Lack of evidence to support routine digital rectal examination in pediatric trauma patients. Pediatr Emerg Care 2007; 23:537.
  10. Kristinsson G, Wall SP, Crain EF. The digital rectal examination in pediatric trauma: a pilot study. J Emerg Med 2007; 32:59.
  11. Bachur R, Perry H, Harper MB. Occult pneumonias: empiric chest radiographs in febrile children with leukocytosis. Ann Emerg Med 1999; 33:166.
  12. Murphy CG, van de Pol AC, Harper MB, Bachur RG. Clinical predictors of occult pneumonia in the febrile child. Acad Emerg Med 2007; 14:243.
  13. Kim MK, Strait RT, Sato TT, Hennes HM. A randomized clinical trial of analgesia in children with acute abdominal pain. Acad Emerg Med 2002; 9:281.
  14. Green R, Bulloch B, Kabani A, et al. Early analgesia for children with acute abdominal pain. Pediatrics 2005; 116:978.
  15. Bailey B, Bergeron S, Gravel J, et al. Efficacy and impact of intravenous morphine before surgical consultation in children with right lower quadrant pain suggestive of appendicitis: a randomized controlled trial. Ann Emerg Med 2007; 50:371.
  16. Kandula L, Lowe ME. Etiology and outcome of acute pancreatitis in infants and toddlers. J Pediatr 2008; 152:106.
  17. Werlin SL, Kugathasan S, Frautschy BC. Pancreatitis in children. J Pediatr Gastroenterol Nutr 2003; 37:591.
  18. Reuchlin-Vroklage LM, Bierma-Zeinstra S, Benninga MA, Berger MY. Diagnostic value of abdominal radiography in constipated children: a systematic review. Arch Pediatr Adolesc Med 2005; 159:671.
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