OfficialreprintfromUpToDate

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Causesofacuteabdominalpaininchildrenandadolescents
Author
MarkINeuman,MD,MPH

SectionEditors
GaryRFleisher,MD
JanEDrutz,MD

DeputyEditor
JamesFWiley,II,MD,
MPH

Alltopicsareupdatedasnewevidencebecomesavailableandourpeerreviewprocessiscomplete.
Literaturereviewcurrentthrough:Jul2015.|Thistopiclastupdated:Jun25,2015.
INTRODUCTIONThecausesofacuteabdominalpaininchildrenwillbediscussedinthisreview.The
emergentevaluationofchildrenwithacuteabdominalpainandtheevaluationandmanagementofchildrenwith
chronicabdominalpainarediscussedseparately.(See"Emergentevaluationofthechildwithacuteabdominal
pain"and"Chronicabdominalpaininchildrenandadolescents:Approachtotheevaluation".)
BACKGROUNDAbdominalpainisoneofthemostcommoncomplaintsinchildhoodandonethatfrequently
requiresurgentevaluationintheofficeoremergencydepartment.Thecauseistypicallyaselflimitedminor
condition,suchasconstipation,gastroenteritis,orviralsyndrome[1].Thechallengefortheclinicianistoidentify
thosefewpatientswithabdominalpainwhohavepotentiallylifethreateningconditions(table1).Thediagnosisis
oftensuggestedbythechild'sageandclinicalfeatures(ie,associatedsymptomsandphysicalexamination
findings).(See'Lifethreateningcauses'below.)
NEUROLOGICBASISOFABDOMINALPAINPainreceptorsintheabdomenincludevisceralreceptors
(locatedonserosalsurfaces,withinthemesentery,andwithinthewallsofhollowviscera)andmucosalreceptors.
Visceralreceptorsrespondtomechanicalandchemicalstimuliwhereasmucosalreceptorsrespondprimarilyto
chemicalstimuli.
Visceralpainisusuallypoorlylocalized.Mostvisceraldigestivetractpainisperceivedinthemidlinebecauseof
bilaterallysymmetricinnervation.Insomeconditions,suchasappendicitis,preciselocalizationofthepainmay
developoncetheoverlyingparietalperitoneum(whichissomaticallyinnervated)becomesinflamed.
Painoriginatinginthevisceramaysometimesbeperceivedasoriginatingfromasitedistantfromtheaffected
organ.Referredpainusuallyislocatedinthecutaneousdermatomessharingthesamespinalcordlevelasthe
visceralinputs.
Theneurologicbasisofabdominalpainisreviewedindetailseparately.(See"Differentialdiagnosisofabdominal
paininadults",sectionon'Neurologicbasisofabdominalpain'.)
LIFETHREATENINGCAUSES
TraumaChildrenwithabdominalpainwhohavesustainedtraumamustbecarefullyevaluatedfor
intraabdominalinjuries.Mechanismstypicallyassociatedwithsignificantinjury(ie,solidorganlacerationor
perforatedviscus)includemotorvehiclecollisions,motorvehiclepedestriancollisions,falls,sportsrelatedinjuries,
andchildabuse.(See"Overviewofbluntabdominaltraumainchildren".)
AppendicitisThethreemostpredictiveclinicalfeaturesofappendicitisarepainintherightlowerquadrant,
guarding,andmigrationofperiumbilicalpaintotherightlowerquadrant.However,atleastoneofthese
manifestationsisfrequentlyabsent,particularlyinyoungerchildren.Cliniciansshouldthereforeconsiderthe
diagnosisofappendicitisinchildrenwhohaveahistoryofabdominalpainandvomiting,withorwithoutfeveror
focalabdominaltenderness.(See"Acuteappendicitisinchildren:Clinicalmanifestationsanddiagnosis",section
on'Clinicalmanifestations'.)
IntussusceptionChildrenwithintussusception(invaginationofapartoftheintestineintoitself,causing
obstruction)aretypicallytwomonthstotwoyearsofageandpresentwithcharacteristicpainthatdevelops

suddenly,isintermittent,severe,andclassicallyaccompaniedbyinconsolablecryingwithdrawingupofthelegs
towardtheabdomen.Biliousemesismaydevelopastheobstructionprogresses.
Betweenthepainfulepisodes,thechildmaybehavenormally.Initialsymptomscanbeconfusedwith
gastroenteritis.Lethargyoralteredconsciousnesscanbetheprimarysymptomofintussusception,especiallyin
infants.Althoughfewchildrenwillhavegrossbloodorcurrantjellystool,mostwillhavefecaloccultblood.
Presentationsmaybevariable,however,withsomechildrenhavingnoapparentpainorbloodinthestool.(See
"Intussusceptioninchildren",sectionon'Clinicalmanifestations'.)
MalrotationwithmidgutvolvulusNeonatesmayhaveemesis(biliousornonbilious)withapparentabdominal
discomfortastheresultofmidgutvolvulus(figure1).Over50percentofchildrenwithmalrotationpresentbefore
onemonthofagewiththislifethreateningcondition.Amongolderchildrenwithvolvulusfrommalrotation,the
onsetofsymptomsisusuallyacute,butsomechildrenpresentwithmorechronicpatternsofepisodicvomiting
andabdominalpain.(See"Intestinalmalrotation",sectionon'Volvulus'.)
IncarceratedinguinalherniaInfantswithincarceratedinguinalherniasareusuallyirritableandcrying.
Vomitingandabdominaldistentionmaydevelop,dependingonthedurationofincarcerationandwhetherornot
intestinalobstructionhasoccurred.Onphysicalexamination,afirm,discreteinguinalmass,whichmayextendto
thescrotumorlabiamajora,canbepalpatedinthegroin.(See"Overviewofinguinalherniainchildren",sectionon
'Incarceratedmass'.)
AdhesionswithintestinalobstructionChildrenwithabdominalpainand/orvomitingwhohavehadprevious
abdominalsurgerymayhavesmallbowelobstruction(SBO)astheresultofadhesions.Shock(fromhypovolemia
and/orsepsis)candevelopastheresultofischemicbowelinjury.
Inretrospectiveseriesdescribingchildrenwhohadabdominalsurgery,1to5percentdevelopedadhesionswithin
fiveyearsofsurgery[2,3].Factorsassociatedwiththedevelopmentofadhesionsintheseseriesincludedmultiple
procedures,peritonitis,andsurgeryontheileum.
NecrotizingenterocolitisNewbornswhodevelopnecrotizingenterocolitis(NEC),asyndromeofintestinal
necrosis,typicallyhavevomiting,abdominaldistention,andtenderness.Systemicsignsincludeapnea,respiratory
failure,lethargy,poorfeeding,temperatureinstability,orhypotensionresultingfromsepticshockinthemost
severecases.Althoughthemajorityofaffectedinfantsarebornprematurely,rarelynormalterminfantsmay
developNEC.(See"Clinicalfeaturesanddiagnosisofnecrotizingenterocolitisinnewborns",sectionon'Clinical
presentation'.)
PepticulcerdiseasePepticulcerdisease(PUD)occurslesscommonlyinchildrenthaninadults,andmaybe
complicatedbyseverehemorrhageorperforation.TheclinicalmanifestationsofPUDvarybyage.Vomiting,
hemorrhage,andperforationaremorecommonlyseeninyoungchildren,whileolderchildrenandteenshavea
presentationsimilartoadultsconsistingofepigastricpain,oftenoccurringseveralhoursaftereating.Somecases
ofPUDarerelatedtoHelicobacterpyloriinfection,althoughthisisalsolesscommoninchildrencomparedwith
adults[4].Pepticulcersamongchildrenlessthan10yearsofageareoftenduetomedications(corticosteroidsor
nonsteroidalantiinflammatorydrugs[NSAIDs])ormajorstresses.ApproximatelyhalfofPUDcasesareidiopathic
innature[5,6].
Theclinicalmanifestationsandmanagementofpepticulcerdiseaseinadultsisdiscussedseparately.(See
"Pepticulcerdisease:Clinicalmanifestationsanddiagnosis"and"Pepticulcerdisease:Management".)
EctopicpregnancyEctopicpregnancymustbeconsideredinthediagnosisofabdominalpainfor
postmenarchalgirls,asitmaybeassociatedwithlifethreateninghemorrhage.Abdominalpain,amenorrhea,and
vaginalbleedingaretheclassicsymptoms,withorwithoutrupture.Symptomstypicallyappearsixtoeightweeks
afteramissedmenstrualperiod.Riskfactorsincludepreviousgenitalinfectionandpreviousectopicpregnancy
(table2).(See"Ectopicpregnancy:Clinicalmanifestationsanddiagnosis".)
UncommonlifethreateningcausesThefollowingunusuallifethreateningcausesofabdominalpaingenerally

haveotherdistinguishingclinicalfeatures:
DiabeticketoacidosisDiabeticketoacidosis(DKA)isalifethreateningconditionthatusuallypresents
withpolyuria,polydipsia,andglycosuria,butmayalsopresentwithabdominalpainandvomiting,especially
inyoungchildren.(See"Clinicalfeaturesanddiagnosisofdiabeticketoacidosisinchildren",sectionon
'Signsandsymptoms'.)
HirschsprungdiseaseHirschsprungassociatedenterocolitis(HAEC)isanuncommon,fulminant
complicationofHirschsprungdisease.Childrentypicallyhaveexplosivediarrhea,fever,andabdominalpain.
HAECcanoccurpriortosurgicalintervention,intheimmediatepostoperativeperiod,ormorethantwoyears
afterdefinitiverepair.(See"EmergencycomplicationsofHirschsprungdisease",sectionon'Enterocolitis'.)
HemolyticuremicsyndromeHemolyticuremicsyndrome(HUS)typicallydevelopsafteraninfectionwith
ShigatoxinproducingenterohemorrhagicE.coli(EHEC)orShigella(figure2).HUShasalsobeen
associatedwithpneumococcalinfection,HIV,andgeneticfactors.ClinicalandlaboratoryfeaturesofHUS
includebloodydiarrhea,hemolyticanemia,thrombocytopenia,andacuterenalinjurymanifestedbyelevated
bloodureanitrogen.(See"ClinicalmanifestationsanddiagnosisofShigatoxinproducingEscherichiacoli
(STEC)hemolyticuremicsyndrome(HUS)inchildren"and"Complementmediatedhemolyticuremic
syndrome".)
PrimarybacterialperitonitisPrimarybacterialperitonitis,usuallycausedbyStreptococcuspneumoniae
orE.coli,isalifethreateninginfectiouscomplicationofnephroticsyndromeandoccasionallyother
conditionsthatcauseascites(eg,cirrhosisoftheliver).(See"Complicationsofnephroticsyndromein
children",sectionon'Bacterialinfection'.)
MyocarditisMyocarditismaycauseabdominalpainastheresultofpassivehepaticcongestionfromheart
failureorreferredpaincausedbypericarditis.(See"Clinicalmanifestationsanddiagnosisofmyocarditisin
children".)
MagnetingestionCasereportshavedescribedchildrenwhohavedevelopedvolvulusandbowel
perforationfollowingingestionofsmallrareearthmagnets.Injuryoccurswhenobjectsbecomemagnetically
attachedtoeachotheracrossbowelwall.Symptomsarenonspecificandtypicallyincludeabdominalpain.
(See"Foreignbodiesoftheesophagusandgastrointestinaltractinchildren",sectionon'Magnets'.)
COMMONCAUSES
ConstipationChildrenwithconstipationcanpresentwithcolickyabdominalpain,whichattimes,maybe
severe.Inaseriesof83childrenpresentingtoprimarycareprovidersoranemergencydepartmentwithacute
abdominalpain,acuteorchronicconstipationwasthemostcommonunderlyingcause,occurringin48percentof
subjects[7].Inmanycases,rectalexaminationwasakeystepinestablishingthediagnosis.
Constipationislikelyinchildrenwithatleasttwoofthefollowingcharacteristics:fewerthanthreestoolsweekly,
fecalincontinence(usuallyrelatedtoencopresis),largestoolspalpableintherectumoronabdominalexamination,
retentiveposturing,orpainfuldefecation[7].Parentsmaynotrecognizetherelationshipofconstipationtothe
child'sabdominalpain.(See"Constipationininfantsandchildren:Evaluation"and"Functionalfecalincontinence
ininfantsandchildren:Definition,clinicalmanifestationsandevaluation".)
GastrointestinalinfectionChildrenwithacutegastroenteritismaydevelopfever,severecrampingabdominal
pain,anddiffuseabdominaltendernessbeforediarrheabegins[8].Intheabsenceofdiarrhea,thediagnosisof
gastroenteritisshouldbeconsideredadiagnosisofexclusion.(See"Evaluationofdiarrheainchildren"and"Viral
gastroenteritisinchildren:Epidemiology,clinicalpresentation,anddiagnosis".)
Yersiniaenterocoliticagastroenteritiscancausefocalrightlowerquadrantpainandperitonealsignsthatmaybe
clinicallyindistinguishablefromappendicitis.(See"ClinicalmanifestationsanddiagnosisofYersiniainfections",
sectionon'Pseudoappendicitis'.)

Otherinfections
UrinarytractinfectionsAbdominalpainandfeverarethemostcommonpresentingsymptomsofurinary
tractinfectionforchildrentwotofiveyearsofage[9].Infantsmayalsohavevomitingoranorexia,whilechildren
>5yearsofagearemorelikelytohaveclassicsymptoms,suchasdysuria,frequency,and/orflankdiscomfort.
(See"Urinarytractinfectionsininfantsandchildrenolderthanonemonth:Clinicalfeaturesanddiagnosis",section
on'Clinicalpresentation'.)
StreptococcalpharyngitisChildrenwithgroupAbetahemolyticstreptococcal(GABHS)pharyngitismay
haveabdominalpaininadditiontofeverandexudativepharyngitis.(See"Approachtodiagnosisofacuteinfectious
pharyngitisinchildrenandadolescents",sectionon'Clinicalpredictors'.)
PatientswithpharyngitisfromcausesotherthanGABHScanalsohaveabdominalpain.Thiswasdemonstratedin
oneobservationalseriesdescribingchildrenpresentingtoanemergencydepartmentwithsuspectedGABHS
pharyngitisinwhich25percentofthosewiththroatculturespositiveforGABHSand34percentofthosewith
negativethroatcultureshadabdominalpain[10].
PneumoniaChildrenwithpneumonia,particularlyinthelowerlobes,maycomplainofabdominalpain[11].
Associatedsymptomsusuallyincludefever,tachypnea,and/orcough.Auscultationofthelungsmaydemonstrate
focalabnormalities(ie,decreasedbreathsoundsorcrackles),althoughsomechildrenwithpneumoniamayhave
normalbreathsoundsonexamination.(See"Communityacquiredpneumoniainchildren:Clinicalfeaturesand
diagnosis",sectionon'Clinicalpresentation'.)
ViralillnessesViralillnessesotherthangastroenteritis(ie,viralpharyngitisandupperrespiratorytract
infection)mayalsobeassociatedwithabdominalpain[12,13].Historyoffever,cough,sorethroat,and/or
rhinorrheamayalsobereported.
PelvicinflammatorydiseasePelvicinflammatorydisease(PID),anacuteinfectionoftheupperfemale
genitaltract,maybethecauseoflowerabdominalpaininsexuallyactivegirls.Painoftenbeginsduringorshortly
aftermenses.Theremaybevaginaldischarge.Rarely,sepsisandtuboovarianabscessarelifethreatening
complicationsofPID.(See"Clinicalfeaturesanddiagnosisofpelvicinflammatorydisease"and"Epidemiology,
clinicalmanifestations,anddiagnosisoftuboovarianabscess".)
MesentericlymphadenitisMesentericlymphadenitisisaninflammatoryconditionofthemesentericlymph
nodesthatcanpresentwithacuteorchronicabdominalpain.Becausethenodesareusuallyintherightlower
quadrant,mesentericlymphadenitissometimesmimicsappendicitis.Inoneseriesof70childrenwithclinically
suspectedacuteappendicitis,16percenthadafinaldiagnosisofmesentericlymphadenitisestablishedby
ultrasound,clinicalcourse,orsurgery[14].
Mesentericlymphadenitisisdiagnosedbyanultrasoundthatshowsabdominallymphnodesgreaterthan10mm.
Thepresenceofenlargedlymphnodesondiagnosticimagingdoesnot,byitself,excludeadiagnosisof
appendicitisitisnecessarytodemonstrateanormalappendixaswell[15].Etiologiesofmesentericlymphadenitis
includeviralandbacterialgastroenteritis(eg,Yersiniaenterocolitica),GroupAStreptococcalpharyngitis,
inflammatoryboweldisease,andlymphomaviralinfectionismostcommon.(See"Clinicalmanifestationsand
diagnosisofYersiniainfections"and"Acuteappendicitisinchildren:Clinicalmanifestationsanddiagnosis",
sectionon'Othernonsurgicaldiagnoses'.)
RupturedovariancystAcuteseverepainsimulatingappendicitisorperitonitismayresultfromruptureofan
ovariancyst.Rarely,lifethreateninghemorrhagedevelops.(See"Ovariancystsandneoplasmsininfants,
children,andadolescents".)
ForeignbodyingestionYoungchildrencommonlyingestsmall,smooth,nonfoodobjectsthatareusually
eliminatedwithoutdifficultyoncetheyhavepassedthroughthepylorus.Abdominalpaininchildrenwhohave
ingestedforeignbodies,particularlyobjectsthataresharp(whichmayperforatethebowel)or>5cminlength
(whichmaycauseobstruction),multiplemagnets(whichmayleadtoentrapmentofapieceofbowelwallbetween

twomagnetsthatareattractedtoeachother),orbuttonbatteries(whichmayreleasecausticmaterial)warrant
emergentevaluationforobstructionorperforation.(See"Buttonandcylindricalbatteryingestion"and"Foreign
bodiesoftheesophagusandgastrointestinaltractinchildren".)
ColicInfantswithcolic,maypresentwithirritability,crying,orappeartohaveabdominalpain(table3).(See
"Infantilecolic:Clinicalfeaturesanddiagnosis",sectionon'Colic'.)
Otherclinicalfeaturesthatsuggestthediagnosisofcolicinclude:

Atypicalpatternofparoxysmalcrying
Cryingusuallyintheevening
Cryingrelievedwiththepassageofflatusorstool
Normalfeeding
Noassociatedsymptoms
Normalphysicalexamination

OTHERCAUSES
Gastrointestinal
InflammatoryboweldiseaseInflammatoryboweldisease(moreoftenCrohndiseasethanulcerative
colitis)canpresentwithintermittentabdominalpain.Associatedfeaturesmayincludediarrheaandweight
loss.Althoughtheonsetofsymptomsforchildrenwithulcerativecolitisisusuallysubacute,afulminant
presentationwithsevereabdominalpain,bloodydiarrhea,tenesmus,andfevercanoccur.(See"Clinical
manifestationsofCrohndiseaseinchildrenandadolescents",sectionon'Presentingsymptoms'and
"Managementofmildtomoderateulcerativecolitisinchildrenandadolescents",sectionon'Clinical
manifestations'.)
PancreatitisPancreatitisgenerallycausesacuteupperabdominalpain(usuallyinthemidepigastriumor
rightupperquadrant)attheonset,whichmayradiatetotheback.Vomiting(thatmaybebilious)andfever
alsooccurcommonly.Causesofpancreatitisamongchildrenincludetrauma,infection,structuralanomalies,
andsomemedications(ie,tetracycline,Lasparaginase,valproicacid,andsteroids)[16,17].(See"Clinical
manifestationsanddiagnosisofacutepancreatitis".)
AcutecholecystitisAcutecholecystitistypicallycausespainintherightupperquadrantorepigastrium.
Painmayradiatetotherightshoulderorback.Associatedcomplaintsincludenausea,vomiting,and
anorexia.Cholecystitisisuncommonamongchildren,andmosthavepredisposingconditions,suchas
hemoglobinopathiesorcysticfibrosis.(See"Acutecholecystitis:Pathogenesis,clinicalfeatures,and
diagnosis".)
IntraabdominalabscessIntraabdominalabscesscancauseabdominalpain.Childrenaretypicallyfebrile
andmayhavehistoriesofpriorintraabdominaldiseaseorabdominalsurgery.(See"Feverofunknownorigin
inchildren:Etiology",sectionon'Intraabdominalabscess'.)
FoodallergyDietaryproteinallergycanbeassociatedwithirritabilitythatparentsmayinterpretas
abdominalpain.Infantstypicallypassbloodtingedstoolsandmucus,butdonothavediarrhea.(See"Food
proteininducedproctitis/colitisandenteropathyofinfancy",sectionon'Foodproteininduced
proctitis/proctocolitis'.)
MalabsorptionMalabsorption(suchasoccurswithceliacdiseaseandcarbohydratemalabsorption)may
causerecurrentabdominalpain.Childrenwithceliacdiseasetypicallyhavechronicdiarrhea,anorexia,and
weightloss.Somemayalsohavevomiting.(See"Epidemiology,pathogenesis,andclinicalmanifestationsof
celiacdiseaseinchildren",sectionon''Classical'gastrointestinalsymptoms'and"Chronicabdominalpainin
childrenandadolescents:Approachtotheevaluation",sectionon'Organicdisorders'.)

 Meckel'sdiverticulumMeckel'sdiverticulumusuallypresentswithpainlessrectalbleeding.Abdominal
painmaydevelopastheresultofmucosalulceration(fromectopicgastrictissue)withperforationorfrom
bowelobstruction[18].(See"Lowergastrointestinalbleedinginchildren:Causesanddiagnosticapproach",
sectionon'Meckel'sdiverticulum'.)
AbdominalmigraineAbdominalmigraine(includedinchildhoodperiodicsyndromes)oftenpresentswith
acuteonsetofabdominalpainthatisperiumbilical(78percent),oroccasionallymorediffuse(16percent).It
ismorecommonafteragesevenyears.Thepainisoftenincapacitating,withorwithoutvomitingand
headache.Afamilyhistoryofmigraineiscommon.Sincethisconditionisarecurrentproblem,theremaybe
ahistoryofsimilarpresentations.Thefirstepisodemustbedifferentiatedfromgastrointestinalandothernon
gastrointestinalcausesofacuteonsetabdominalpain.Physicalexaminationmaybenormalorrevealmild
abdominaldiscomfort.Bloodworkandimagingstudiesareusuallynormal.(See"Classificationofmigrainein
children",sectionon'Abdominalmigraine'.)
WanderingspleenWanderingspleenreferstoacquiredlaxityorcongenitalunderdevelopmentorabsence
oftheprimaryligamentousattachmentsofthespleenintheleftupperquadrant[19].Asaresult,patientsare
atincreasedriskofsplenictorsionandinfarction.Wanderingspleenismostcommonlyseeninchildrenand
isassociatedwithcongenitaldiaphragmatichernia,prunebellysyndrome,renalagenesis,andgastric
volvulus.Ittypicallypresentswithacute,diffuse,severeabdominalpain.Patientsmayalsohavean
abdominalmasswhichismobiletotheleftupperquadrantandmayhaveacrenatedborder.Ultrasoundis
mosthelpfulinestablishingapreoperativediagnosisandcanassessadequacyofsplenicperfusion.
Accordingtocaseseries,approximatelytwothirdsofpatientsrequiresplenectomy.Earlydiagnosispermits
splenopexyandpreservationofsplenicfunction.
Nongastrointestinal
HenochSchnleinpurpura(HSP[IgAvasculitis(IgAV)])HenochSchnleinpurpura(HSP[IgA
vasculitis(IgAV)])isasystemicvasculitisaffectingsmallvesselsinskin,gut,andglomerulithatmay
presentwithcolickyabdominalpain(presumablyduetolocalvasculitis).Paintypicallydevelopsafterthe
appearanceofacharacteristicpurpuricrashinvolvingpredominantlythelowerextremitiesandbuttocks
(picture1AB).Stooloftencontainsgrossoroccultblood.RarecomplicationsofHSP(IgAV)thatcancause
abdominalpainincludeintussusception(typicallyintheileum),pancreatitis,andcholecystitis.(See"Henoch
Schnleinpurpura(immunoglobulinAvasculitis):Clinicalmanifestationsanddiagnosis".)
HepatitisHepatitistypicallycausesjaundice,mildabdominalpain,andfever,butyoungchildrenin
particularmaybeafebrileand/oranicteric.TheincidenceofhepatitisAandBinfectionsamongchildrenhas
declinedsincetheintroductionofeffectivevaccines.(See"OverviewofhepatitisAvirusinfectioninchildren"
and"OverviewofhepatitisBvirusinfectioninchildrenandadolescents"and"Approachtothepatientwith
abnormalliverbiochemicalandfunctiontests".)
SicklecellvasoocclusivecrisisSicklecellsyndromesaretypicallyassociatedwithacutepainful
episodesthatmaymanifestasabdominalpain.Patientsmustalwaysbecarefullyevaluatedforothercauses
ofabdominalpain.(See"Overviewoftheclinicalmanifestationsofsicklecelldisease",sectionon'Acute
painfulepisodes'and"Variantsicklecellsyndromes".)
NeoplasmsMalignantsolidtumorsmaypresentwithabdominalpainandabdominalmass.Wilms'tumor
andneuroblastomaoccurmorecommonlyininfants,whereasleukemicorlymphomatousinvolvementofthe
liver,spleen,orretroperitoneallymphnodesoccursmoreofteninolderchildren.Othercausesincludehepatic
tumors,ovariantumors,Burkittlymphoma,andsofttissuesarcomas.(See"Clinicalassessmentofthechild
withsuspectedcancer",sectionon'Abdominalmasses'.)
UrolithiasisNonspecificabdominalpainistypicalasapresentingfeatureofurolithiasisamongyoung
children.Incomparison,adolescentsaremorelikelytoexperiencecolickyflankpain[20,21].Hematuriaand
urinarytractinfectionareotherfrequentmanifestationsofurolithiasisamongchildren.

 TesticulartorsionTesticulartorsioncausesscrotalpainthatmayradiatetotheabdomen.Patientsmay
haveassociatednausea,vomiting,andfever.Theaffectedtestisusuallyistender,swollen,andslightly
elevatedbecauseofshorteningofthecordfromtwisting.Itmaybelyinghorizontally,displacingthe
epididymisfromitsnormalposterolateralposition.Acarefulgenitourinaryexaminationshouldbeperformedin
allmaleswithabdominalpain,asthepainisoftenreferred,andahistoryofscrotalpainmaynotalwaysbe
disclosedbythepatient.(See"Causesofscrotalpaininchildrenandadolescents",sectionon'Testicular
torsion'.)
OvariantorsionOvariantorsiontypicallydevelopsastheresultofanovarianmassorcystbutmayoccur
inisolation.Althoughmorecommoninpostmenarchalgirls,itmaybeseeninpremenarchalgirlswithan
ovarianmass.Nauseaandvomitingfrequentlyoccur.Partialorintermittentovariantorsiontypicallypresents
asintermittentsevere,adnexalabdominalpainassociatedwithanadnexalmass.(See"Ovarianandfallopian
tubetorsion",sectionon'Epidemiologyandriskfactors'and"Ovarianandfallopiantubetorsion",sectionon
'Clinicalpresentation'.)
PoisoningToxinsthatareassociatedwithabdominalpainincludeleadandiron.Leadpoisoningisusually
theresultofchronicingestionandcausesintermittentabdominalpain.Bycontrast,ironpoisoningistypically
anacuteingestionwithothergastrointestinalsymptoms,suchasvomitinganddiarrhea.(See"Childhood
leadpoisoning:Clinicalmanifestationsanddiagnosis"and"Acuteironpoisoning".)
AcuteporphyriasAcuteporphyriaspresentwithavarietyofnonspecificneurovisceralsymptoms(eg,
abdominalpain,psychiatricdisorders,neurologicsymptoms),themostcommonofwhichisabdominalpain.
Thesecanincludepotentiallylifethreateningneurologicaleffects(eg,seizures,coma,bulbarparalysis)and
areassociatedwithelevationsintheporphyrinprecursorsdeltaaminolevulinicacid(ALA)and
porphobilinogen(PBG).Symptomsusuallyoccurasacuteattacks,butaresometimeschronic.(See
"Pathogenesis,clinicalmanifestations,anddiagnosisofacuteintermittentporphyria",sectionon'Clinical
manifestations'.)
FamilialMediterraneanfeverFamilialMediterraneanfeverischaracterizedbyepisodicattacksoffever
lastingonetothreedaysandaccompaniedinmostcasesbyabdominalpain,pleurisy,andarthralgiasor
arthritis,theresultofaccompanyingserositisandsynovitis.Attacksareaccompaniedbyanelevationin
peripheralwhitebloodcellcountandacutephasemarkers,whilefluidfrominflamedjointsexhibitsa
neutrophilpredominantleukocytosis.Persistentinflammationcanleadtosecondary(AA)amyloidosis.(See
"Periodicfeversyndromesandotherautoinflammatorydiseases:Anoverview".)
INFORMATIONFORPATIENTSUpToDateofferstwotypesofpatienteducationmaterials,TheBasicsand
BeyondtheBasics.TheBasicspatienteducationpiecesarewritteninplainlanguage,atthe5thto6thgrade
readinglevel,andtheyanswerthefourorfivekeyquestionsapatientmighthaveaboutagivencondition.These
articlesarebestforpatientswhowantageneraloverviewandwhoprefershort,easytoreadmaterials.Beyond
theBasicspatienteducationpiecesarelonger,moresophisticated,andmoredetailed.Thesearticlesarewritten
atthe10thto12thgradereadinglevelandarebestforpatientswhowantindepthinformationandarecomfortable
withsomemedicaljargon.
Herearethepatienteducationarticlesthatarerelevanttothistopic.Weencourageyoutoprintoremailthese
topicstoyourpatients.(Youcanalsolocatepatienteducationarticlesonavarietyofsubjectsbysearchingon
patientinfoandthekeyword(s)ofinterest.)
Basicstopics(see"Patientinformation:Acuteabdomen(bellypain)(TheBasics)"and"Patientinformation:
Intussusception(TheBasics)")
SUMMARYAbdominalpainisoneofthemostcommoncomplaintsinchildhoodandonethatfrequently
requiresurgentevaluationintheofficeoremergencydepartment.Althoughthecauseistypicallyaselflimited,
minorcondition,suchasconstipation,gastroenteritis,orviralsyndrome,potentiallylifethreateningcausesthat
requireurgenttreatment,suchasappendicitisorbowelobstruction,mustbepromptlyidentified(table1).

 Visceralabdominalpainisgenerallypoorlylocalized.Oncetheparietalperitoneumbecomesirritated(as
occursinappendicitiswhentheserosalsurfacebecomesinflamed),painmaybecomemorelocalized.
Referredpainusuallyislocatedinthecutaneousdermatomessharingthesamespinalcordlevelasthe
visceralinputs.(See"Differentialdiagnosisofabdominalpaininadults",sectionon'Neurologicbasisof
abdominalpain'.)
Lifethreateningcausesofabdominalpainoftenresultinhemorrhage,obstruction,and/orperforation(suchas
occurswithtrauma,intussusception,volvulus,orappendicitis).Extraabdominalcauses(ie,hemolyticuremic
syndromeandmyocarditis)usuallyhaveotherdistinguishingclinicalfeatures.(See'Lifethreateningcauses'
above.)
Commoncausesofabdominalpainincludeconstipation,gastrointestinal(GI)infections,infectionsoutsideof
theGItract,andcolic.(See'Commoncauses'above.)
LesscommonGIconditions(ie,inflammatoryboweldisease,pancreatitis,cholecystitis,intraabdominal
abscess,dietarymilkproteinallergy,malabsorption,andMeckel'sdiverticulum)andconditionsoutsideofthe
GItract(ie,diabeticketoacidosis,painfulcrisiswithsicklesyndromes,HenochSchnleinpurpura(IgA
vasculitis),tumors,urolithiasis,ovariantorsion,testiculartorsion,andsometoxicingestions)canpresent
withabdominalpain.(See'Othercauses'above.)
ACKNOWLEDGMENTTheeditorialstaffatUpToDatewouldliketoacknowledgeGeorgeFerry,MD,who
contributedtoanearlierversionofthistopicreview.
UseofUpToDateissubjecttotheSubscriptionandLicenseAgreement.
Topic6454Version9.0

GRAPHICS
Causesofacuteabdominalpaininchildrenbyage
Neonate

2monthsto2
years

2to5years

>5years

Adhesions*

Adhesions*

Adhesions*

Adhesions*

Necrotizing
enterocolitis*

Foreignbody
ingestion*

Appendicitis*

Appendicitis*
Diabeticketoacidosis*

Volvulus*

Hemolyticuremic

Foreignbody
ingestion*

syndrome*

Colic

syndrome*

Dietaryproteinallergy

Hirschsprungdisease*

Hemolyticuremic
syndrome*

Testiculartorsion

Incarceratedhernia*

Intussusception*

Intussusception*

Primarybacterial
peritonitis*

Trauma(including
inflictedinjury)*
Gastroenteritis
Viralillness

Dietaryproteinallergy
Hepatitis
Meckel'sdiverticulum

Myocarditis,
pericarditis*
Perforatedulcer*

Trauma(including

Primarybacterial
peritonitis*

inflictedinjury)*

Trauma*

Gastroenteritis
Viralillness

Pharyngitis
Constipation

Sicklecellsyndrome
vasoocclusivecrisis

HenochSchnlein
purpura

Toxin

Hepatitis

Tumor

Intraabdominal
abscess

Urinarytractinfection

Hemolyticuremic

Meckel'sdiverticulum
Urinarytractinfection

Constipation

Gastroenteritis
Pharyngitis
Viralillness
Abdominalmigraine
Cholecystitis
FamilialMediterranean
fever
HenochSchnlein
purpura
Hepatitis

Ovariantorsion

Inflammatorybowel

Pneumonia

disease

Sicklecellsyndrome
vasoocclusivecrisis

Intraabdominal
abscess

Toxin

Meckel'sdiverticulum

Tumor

Ovariantorsion
Pancreatitis
Pneumonia
Rupturedovariancyst
Sicklecellsyndrome
vasoocclusivecrisis
Testiculartorsion
Urinarytractinfection

Urolithiasis
*Lifethreateningcondition.
Commoncondition.
Graphic65488Version8.0

Midgutvolvulus

Volvulusoccursbecausethenarrowmesentericbase,whichdevelops
asaresultofmalrotation,allowsthesmallboweltotwistaroundthe
superiormesentericartery.Thisleadstovascularcompromiseoflarge
portionsofthemidgut.
Graphic78111Version2.0

Riskfactorsforectopicpregnancy
Degreeofrisk
High

Moderate

Riskfactors

Oddsratio

Previousectopicpregnancy

9.347

Previoustubalsurgery

6.011.5

Tuballigation

3.0139

Tubalpathology

3.525

InuteroDESexposure

2.413

CurrentIUDuse

1.145

Infertility

1.128

Previouscervicitis(gonorrhea,
chlamydia)

2.83.7

Historyofpelvicinflammatory

2.13.0

disease

Low

Multiplesexualpartners

1.44.8

Smoking

2.33.9

Previouspelvic/abdominal
surgery

0.933.8

Vaginaldouching

1.13.1

Earlyageofintercourse(<18
years)

1.12.5

Forwomenundergoingassistedreproductivetechnology(ART)procedures,theriskofectopic
pregnancyvariesaccordingtothetypeofARTprocedure,thewoman'sreproductivehealth
characteristics,andestimatedembryoimplantationpotential. 1
WomenwhoundergoARTareatmuchhigherriskofheterotopicpregnancythanwomenwho
conceivenaturally(152/100,000versus3.3to6.4/100,000). 2
References:
1. ClaytonHB,SchieveLA,PetersonHB,etal.Ectopicpregnancyriskwithassistedreproductive
technologyprocedures.ObstetGynecol2006107:595.
2. ClaytonHB,SchieveLA,PetersonHB,etal.Acomparisonofheterotopicandintrauterineonly
pregnancyoutcomesafterassistedreproductivetechnologiesintheUnitedStatesfrom1999to
2002.FertilSteril200787:303.
Adaptedfrom:
1. AnkumWM,MolBWJ,VanDerVeenF,BossuytPMM.Riskfactorsforectopicpregnancy:ameta
analysis.FertilSteril199665:1093.
2. MurrayH,BaakdahH,BardellT,TulandiT.Diagnosisandtreatmentofectopicpregnancy.CMAJ
2005173:905.
3. BouyerJ,CosteJ,ShojaeiT,etal.Riskfactorsforectopicpregnancy:acomprehensiveanalysis
basedonalargecasecontrol,populationbasedstudyinFrance.AmJEpidemiol2003157:185.
Graphic82282Version5.0

ProgressionofEcoliO157:H7infectionsinchildren

Aboutthreedaysafteringestionoftheorganism,thepatientdevelops
diarrhea,abdominalpain,fever,andvomiting.Thediarrheabecomes
bloodyonetothreedayslater,rarelyonthefirstday.In80to90percentof
infectedchildrenwithpositivecultures,visiblebloodispresentinthestools.
Whenbloodydiarrheafirstdevelops,thepatienthasanormalplateletcount,
creatinineconcentration,andpackedcellvolume,withnoredcell
fragmentation.However,ifstudiesofthecoagulationandfibrinolyticsystems
aredoneearlyintheillness,thereisevidencethatthrombingenerationis
increased,fibrindepositionisoccurring,andplasminogenactivationis
suppressed.
HUS:hemolyticuremicsyndrome.
Reproducedwithpermissionfrom:TarrPI,GordonCA,ChandlerWL.Shigatoxin
producingEscherichiacoliandhaemolyticuraemicsyndrome.Lancet2005365:1073.
Copyright2005Elsevier.
Graphic75352Version3.0

Featuresofhypertoniaininfantswithcolic
Thefaceofthebabyisflushed,withoccasionalcircumoralpallor
Theabdomenisdistendedandtense
Thelegsaredrawnupontheabdomenandthefeetareoftencold(thelegsmayextend
periodicallyduringforcefulcries)
Thefingersareclenched
Thearmsarestiff,tight,andextended(theelbowsmayalsobeflexed)
Thebackisarched
AdaptedfromLesterBM.ColicandExcessiveCrying.Reportofthe105thRossConferenceonPediatric
Research,LesterBM,BarrRG(Eds),RossProductsDivision,Columbus1997.p.18.
Graphic78133Version3.0

SkinmanifestationsofHenochSchnleinpurpura(IgA
vasculitis)

ThispictureshowstheclassicskinmanifestationsofHenochSchnlein
purpura(IgAvasculitis),withclustersoftypicalecchymoses,petechiae,and
palpablelesionsonthelegsinatypicaldistribution(gravity/pressure
dependentareas).
IgA:immunoglobulinA.
CourtesyofSusanKim,MD.
Graphic63367Version5.0

SkinmanifestationsofHenochSchnleinpurpura(IgA
vasculitis)

CourtesyofSusanKim,MD.
Graphic72094Version4.0