PM Pediatrics
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Dr. Christina Johns
Senior Medical Advisor, PM Pediatrics

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5 Abdominal Pain Situations You Shouldn’t Ignore

Abdominal Pain. When I see these 2 words written as the reason for a medical visit I never really feel like it points me towards a straightforward diagnostic direction, since the actual cause is anywhere from gas pain to strep throat to appendicitis. And more. As such, I’ve successfully avoided the minefield of writing a discussion about abdominal pain for over 2 years now, and I think that’s pretty good if the metric is “run away from difficult stuff.” But my time has run out today, friends, and I’m going to try to hit some useful highlights that might come in handy should you encounter abdominal pain in your child that gets you concerned.

This is a topic that is challenging for many reasons:

  1. The broad range of causes does not lend itself to the creation of a digestible document that one might label with the words “concise and helpful;”
  2. Each child experiences pain so differently that there seems to be a lot of exceptions to the usual “rules” of abdominal pain;
  3. Abdominal pain in children, even seemingly severe pain, often just goes away without ever revealing its cause. Unsatisfying for everyone involved.

In order to try to achieve the label in #1 above, I think the best approach is to identify a few situations that are associated with abdominal pain that should trigger your “we need to get a medical evaluation” reflex. Let’s try it.

Situation #1: The child is really young.

I’m talking like less than 2 years old. While babies can seem uncomfortable and many parents attribute that discomfort to abdominal pain due to colic or gas, there are a few serious gastrointestinal (GI) disorders that need to be considered and ruled OUT before we just call it gas pain from lack of a good burp or constipation. If the baby is very young and having forceful vomiting of formula or breastmilk that tracks across the room, then projectile vomiting makes me concerned about pyloric stenosis, where the circumferential muscle called the pylorus that marks the entrance of the small intestine from the stomach is too tight and so fluids can’t get through very well. This situation needs to be corrected surgically and since it usually happens to small babies in the first few months of life, there is an increased chance of electrolyte disturbance, so time is of the essence.

image of crying baby

Situation #2: The child has had previous abdominal surgeries.

Abdominal pain in the setting of previous procedures in the area always get my attention. After any history of abdominal surgery, during the healing process fibrous bands called adhesions can form that can cause tension on parts of the intestines, causing the segments to twist and compromise blood flow, which can cause obstruction and bilious emesis, which takes us back to #2 above. Any age is at risk.

 

Situation #3: The vomiting won’t stop, and it has turned green.

This green vomit (sometimes can be kind of yellow/green) is called bilious emesis, and it usually means that there has been so much vomiting in a system where there’s an obstruction or very slow moving intestines that the only direction for the bile fluids/stomach secretions to go is back up and out of the mouth. Common causes include malrotation and midgut volvulus, most often congenital disorders where, during the embryology of the GI tract development, the usual twists and turns of the gut tube happen incorrectly and the end result is an obstruction with disordered intestinal anatomy that compromises bloodflow to that important organ. Again a surgical emergency, this also usually happens in younger babies less than a year, and must be evaluated immediately in order to preserve viability of the intestinal tract. Most of my surgeon colleagues say that “bilious emesis is a surgical emergency until proven otherwise,” and I think this is reasonable: investigate right away to make sure no serious condition is missed.

Occasionally a (usually older) child will have bilious emesis and abdominal pain from a non-surgical and what can be a less serious cause, like a stomach bug (called gastroenteritis). A simple examination and assessment by a pediatric clinician can determine this, but in general, if there’s bile in the vomit it needs to be addressed. At the very least I’m concerned about dehydration; but even more so I’m wondering if the child needs to be seen by a pediatric surgeon. Don’t delay.

emoji with green vomit

Situation #4: The child’s abdomen is distended, protuberant, tense or has a palpable mass.

This also applies to any age. If I feel a child’s abdomen and it feels tense and hard and painful, or fuller on one side or another, then further study is often warranted. Sometimes the abdomen can be this way due to fluid from inflammation (like with appendicitis), a mass or tumor, or even an ovarian cyst. All of these situations require different diagnostic plans and imaging, but all also do best with a medical assessment sooner rather than later. Getting an ultrasound or abdominal CT scan along with some bloodwork are typical pathways to diagnosis.

Additionally, especially in this particular setting getting some medicine for pain control is in order. Some of these conditions can be quite painful, and making a child more comfortable as soon as possible is part of our mission as the pediatric healthcare team.

 

Situation #5: There are bloody stools.

Sorry that we have to get into some graphic details on this one. Bright red blood streaks around the edge of the stool or on the diaper are actually usually less concerning to most clinicians than dark red blood admixed within the stool or a large amount coming out on its own. Grossly but accurately described as “currant jelly stools,” this can be associated with abdominal pain and a serious situation called “intussusception” (25 cents). This situation occurs most typically in the latter part of the small intestine and is a telescoping of one segment of the intestine into another. Compromise of necessary bloodflow occurs and if not resolved the segment of bowel can lose its oxygen supply and need to be removed altogether. Intussusception can be corrected in the radiology suite by a barium enema whereby, under the supervision of pediatric radiologists and the surgery team, contrast and/or air is introduced into the rectum in a retrograde direction to try to “un-telescope” the interlocked intestinal segments. This often works just fine, but in some cases this condition needs to be corrected in the operating room. Regardless, time is of the essence and immediate medical attention is crucial.

Bright red blood in the diaper or around the edge of the stool along with a history of abdominal pain with straining during stooling indicating constipation is less emergently concerning. Does it still need to be addressed? Absolutely, but it is usually corrected over a longer period of time and poses less of an immediate threat to the child. Increased hydration, change in diet, and sometimes stool softeners are indicated to help alleviate the problem.

image of jelly

So how did we get through the belly pain minefield?

Will these clinical scenarios stick in your mind? By no means is this an exhaustive list, but abdominal pain in the setting of any of the 5 situations above directs my clinical efforts in very specific ways and is important to address in an urgent fashion. Your pediatrician can help guide you if you’re unsure if your child fits into any of these situations, and please keep them in mind the next time your child tells you:

“My tummy hurts.”

 

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