Acute Abdominal Pain In Children

Acute abdominal pain is a symptom rather than a single disease. Most episodes are benign, but the primary clinical task is rapid recognition of conditions requiring surgery or urgent resuscitation.

Important causes vary with age and include gastroenteritis, constipation, urinary infection, appendicitis, intussusception, intestinal obstruction, volvulus, incarcerated hernia, testicular torsion and diabetic ketoacidosis.

Red flags include:

• Bilious vomiting
• Guarding or rigidity
• Peritonism
• Significant abdominal distension
• Gastrointestinal bleeding
• Persistent focal pain
• Haemodynamic instability
• Absent bowel sounds with distension
• Palpable abdominal mass
• Severe testicular or groin pain

Young children often localize pain poorly. Extra abdominal disease such as pneumonia can present primarily as abdominal pain.

• Perform a complete abdominal examination including hernial orifices and, where appropriate, genital examination.

• Urinalysis is useful because UTI commonly mimics abdominal pathology.

• Pregnancy testing is essential in postmenarchal adolescents where pregnancy is possible.

• Ultrasound is preferred first line imaging for appendicitis, intussusception, gallbladder disease and many pelvic conditions.

• Plain abdominal radiography is reserved mainly for suspected obstruction, perforation or foreign body rather than nonspecific pain.

• CT should be reserved for situations where ultrasound and clinical assessment remain inconclusive and the result will change management.

• Stabilize first if shock, sepsis or major dehydration is present.

• Give appropriate analgesia. Analgesia does not need to be withheld while awaiting surgical assessment.

• Keep the child fasting when a surgical abdomen is suspected and establish IV fluids as required.

• Bilious vomiting, peritonism, suspected volvulus, testicular torsion, perforation or strangulated obstruction requires immediate surgical involvement.

• Reassessment is essential when the diagnosis remains uncertain because evolving appendicitis or obstruction may initially have subtle findings.

Clinical toolsCalculators

BMI GCS EDD Parkland Formula

Corrected Sodium Corrected Calcium Anion Gap Creatinine Clearance Insulin Calculations qSOFA Wells PE Wells DVT CHA₂DS₂-VASc HAS-BLED CURB-65 Centor/McIsaac

Acute Liver Failure In Children

Paediatric acute liver failure is rapid onset severe hepatic dysfunction in a child without known chronic liver disease, characterized by biochemical evidence of liver injury and significant coagulopathy that does not correct with vitamin K. Encephalopathy may occur but is not required for diagnosis in children.

Causes include paracetamol toxicity, viral hepatitis, autoimmune hepatitis, Wilson disease, metabolic disease, mitochondrial disorders, drug toxicity and indeterminate causes.

Urgently assess:

• ALT and AST
• Bilirubin
• Albumin
• PT and INR
• Glucose
• Electrolytes
• Renal function
• Ammonia
• Lactate and blood gas

Investigate the cause with paracetamol concentration, hepatitis testing, autoimmune markers, ceruloplasmin and copper studies, metabolic investigations and toxicology according to presentation.

Persistent INR at least 1.5 with encephalopathy or at least 2.0 without encephalopathy, not corrected by vitamin K, strongly supports paediatric acute liver failure.

• Transfer early to a centre capable of paediatric intensive care and liver transplantation. Do not wait for severe encephalopathy before discussing transfer.

• Correct hypoglycaemia continuously with glucose containing fluids and frequent glucose monitoring.

• Give vitamin K 0.3 mg/kg IV once, maximum 10 mg, to correct deficiency and clarify whether coagulopathy reflects hepatic synthetic failure.

• Give N acetylcysteine immediately for paracetamol toxicity, using the standard IV protocol. Its routine use in non paracetamol paediatric liver failure is not established and should be specialist directed.

• Do not routinely correct INR with fresh frozen plasma unless there is clinically important bleeding or an invasive procedure is required, because INR is useful for tracking disease severity.

• Manage cerebral oedema, hyperammonaemia, infection, renal failure and haemodynamic instability aggressively in PICU.

• Evaluate for transplantation early when synthetic failure progresses.

Acute Abdominal Pain In Children

Overview

Clinical Features

Diagnosis

Management

Overview

Clinical Features

Diagnosis

Management