Paeds · gastroenterology-hepatology-and-nutrition
Acute abdominal pain in children
Also known as Acute abdomen · Acute tummy pain · The surgical abdomen · Belly pain in children · Appendicitis assessment · Acute abdominal pain in children
Fellowship guide to acute abdominal pain in children: the disciplined emergency-department approach that separates the surgical abdomen (appendicitis, intussusception, malrotation with volvulus, and the adolescent torsions) from common medical mimics, the migration pattern and pain pathway, the age-based differential, the Pediatric Appendicitis Score and ultrasound-first imaging, resuscitation with early analgesia and antibiotics, enema reduction of intussusception, and the safety-netting that catches the deteriorating child.
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Target exams
Red flags
- Bilious (green) vomiting with abdominal pain is malrotation with midgut volvulus until proven otherwise and is a time-critical surgical emergency
- Severe constant pain, guarding, rigidity, rebound tenderness or a silent abdomen signalling peritonitis or a surgical abdomen
- Pain that progressively localises from the periumbilical region to the right lower quadrant and is worse on walking or hopping, the classic migration of appendicitis
- Episodic drawing up of the legs, pallor, vomiting and a redcurrant-jelly stool in an infant suggesting intussusception
- Pain with shock, pallor, mottling or a torsed testis on examination, pointing to ovarian or testicular torsion
- Altered conscious state, deep sighing breathing or dehydration out of proportion to the history suggesting diabetic ketoacidosis, sepsis or a metabolic crisis
- A shocked, lethargic or inconsolable infant in whom necrotising enterocolitis, an incarcerated hernia or sepsis must be excluded
Life stages
Care settings
Clinical exam formats
Board mappings
- Distinguishes a surgical abdomen from common medical causes of acute abdominal pain
- Recognises appendicitis from the migration pattern and right lower quadrant signs
- Treats bilious vomiting with abdominal pain as malrotation until proven otherwise
- Builds the age-based differential from intussusception and volvulus to ovarian and testicular torsion
- Justifies ultrasound-first imaging and selective computed tomography in children
- Coordinates resuscitation, analgesia and antibiotics with timely surgical referral
- Applies the Pediatric Appendicitis Score and red flags to stratify risk
- Explains why opioid analgesia does not mask the surgical abdomen
- Outlines the imaging and reduction pathway for intussusception
- Takes a focused history and examines the abdomen and groin in a child with acute pain
- Communicates the differential and plan to a worried family
- Safety-nets a child discharged with a non-surgical diagnosis
- Stage 1: Recognition of the surgical abdomen and its red flags
- Stage 2: Age-based differential and targeted investigations
- Level 3: Leadership of resuscitation and the surgical referral
- Pathophysiology of visceral, somatic and referred abdominal pain
- Pediatric Appendicitis Score components and interpretation
- Diagnosis and management of intussusception and malrotation
- History-taking that captures migration, vomiting quality and systemic features
- Abdominal examination including hernial orifices and testes in boys
- Structured assessment of a child with severe acute abdominal pain
- AAP and WSES approach to suspected appendicitis in children
- Ultrasound-first imaging strategy and radiation stewardship
- Recognition of intussusception and the infant surgical abdomen
- Resuscitation and timely analgesia in the acute abdomen
- Antibiotics and source control for complicated appendicitis
- Identification of ovarian and testicular torsion in adolescents
- Canadian approach to the acute abdomen in children
- Diagnostic scoring and imaging stewardship in suspected appendicitis
- Enema reduction of intussusception and surgical decision-making
Overview & Definition
A child who develops abdominal pain over hours rather than weeks demands a different mindset from the clinician than the child with chronic, recurrent pain. The single task is to find the few who have a surgical emergency before ischaemia, perforation or torsion causes irreversible harm, while sparing the majority with self-limiting medical causes the risks of unnecessary imaging and operation. Acute abdominal pain is therefore a problem of disciplined triage rather than exhaustive diagnosis. [2]
Acute abdominal pain in children is most usefully defined as pain of recent onset, evolving over hours to a few days, that is severe enough to bring the child to medical attention and that requires active exclusion of a surgical cause. The boundary with chronic pain matters because it changes the priorities: chronic pain asks the clinician to avoid over-investigation and to make a positive functional diagnosis, whereas acute pain asks the clinician to assume a surgical cause until it is ruled out. The two presentations share a differential, but the order of threat is reversed. [4]
The common surgical emergencies in children are appendicitis, intussusception and malrotation with midgut volvulus, joined in adolescence by ovarian and testicular torsion. Against these stand the frequent medical mimics: gastroenteritis, mesenteric adenitis, constipation, urinary tract infection, lower-lobe pneumonia and functional pain. A confident clinician moves through this list by age, by the character and site of the pain, and by the bedside examination rather than by reflexively ordering panels of tests. [2]
References10ShowHide
- [1]Samuel M Pediatric appendicitis score. J Pediatr Surg, 2002.PMID 12037754
- [2]Podda M, Ceresoli M, De Simone B, et al. Diagnosis and Treatment of Acute Appendicitis: 2025 Edition of the World Society of Emergency Surgery Jerusalem Guidelines. JAMA Surg, 2026.PMID 41604201
- [3]Sharwood LN, Babl FE The efficacy and effect of opioid analgesia in undifferentiated abdominal pain in children: a review of four studies. Paediatr Anaesth, 2009.PMID 19453578
- [4]Michelson KA, Reeves SD, Grubenhoff JA, et al. Clinical Features and Preventability of Delayed Diagnosis of Pediatric Appendicitis. JAMA Netw Open, 2021.PMID 34463745
- [5]Kim PH, Hwang J, Yoon HM, Lee JY, Kim JR, Jung AY, Kim KM Predictors of failed enema reduction in children with intussusception: a systematic review and meta-analysis. Eur Radiol, 2021.PMID 33974147
- [6]Qafesha RM, Sharabati I, Kashbour M, et al. Pneumatic versus liquid enema reduction in the management of pediatric intussusception: an updated systematic review and meta-analysis. Ann Med Surg (Lond), 2025.PMID 41180717
- [7]Lang Y, Chen Q, Wu M, et al. Laparoscopic Vs Open Ladd's Procedure for Intestinal Malrotation in Infants and Children: A Systematic Review and Meta-Analysis. Surg Innov, 2026.PMID 42264504
- [8]Oh SK Diagnostic Accuracy of Non-Radiologist-Performed Ultrasound for Diagnosing Acute Appendicitis in Pediatric Patients: A Systematic Review and Meta-Analysis. Medicina (Kaunas), 2025.PMID 40731937
- [9]Doleman B, Fonnes S, Lund JN, et al. Appendectomy versus antibiotic treatment for acute appendicitis. Cochrane Database Syst Rev, 2024.PMID 38682788
- [10]Newman M, Smith T, Hammond P Paediatric and adolescent ovarian torsion: a eight-year retrospective cohort study and literature review. Acta Chir Belg, 2025.PMID 41217937