Clinical Practice Guidelines : Abdominal pain (2024)

Key Points

In most children, no organic cause is found
Non-specific or functional abdominal pain is a distinct diagnosis and does not require exclusion of all organic causes
Many children do not need investigations. Investigations are guided by red flags or likely diagnosis. Imaging is rarely required
Significant functional impairment should prompt consideration of referral to a specialist

Background

Chronic abdominal pain is intermittent or constant abdominal pain that has been present for at least two months
Non-specific abdominal pain that self-resolves over time without specific treatment is very common in primary school aged children
The aetiology may be organic or functional. These are not mutually exclusive; they can exist alongside each other and interact
- Organic: an underlying medical cause is found, either a primary gastrointestinal disorder or non-gastrointestinal disease
- Functional: the child has physical symptoms without any readily identifiable organic cause
Comorbid mental health issues (including anxiety and depression) are very common in children with chronic abdominal pain. These may both result from, and contribute to, the experience of chronic pain

Assessment

History

Pain characteristics (location, time course, triggers, association with meals, pain waking the child from sleep)
Associated symptoms:

unintentional weight loss/stunting of height
unexplained fever
changes in bowel habit, chronic diarrhoea, blood in stools
nocturnal stooling
appetite changes
dysphagia (the sensation of food sticking, or moving slowly down the oesophagus, after swallowing), odynophagia (pain on swallowing)
persistent vomiting (especially if bilious. See acute abdominal pain)
urinary symptoms
extraintestinal manifestations of inflammatory bowel disease (IBD) (eyes, skin, joints, perianal)

History of reflux symptoms (heartburn, waterbrash, regurgitation)
Dietary history (including foods excluded from diet)
Menstrual history, sexual history and contraception (if relevant)
Family history of IBD or coeliac disease
HEADSSS screen
Functional impact of pain on usual activities (eg school attendance, social activities, physical activity)

Examination

Signs of dehydration
Weight and height, preferably over time
Pubertal status
Abdominal examination for palpable faeces, palpable mass
Extraintestinal manifestations of IBD

Differential Diagnosis

Organic More likely if there are red flags
Condition:	Key features:
Constipation	Infrequent stools (<=2 stools/week) History of painful or hard bowel movements
Gastroesophageal Reflux Disease (GORD)	Regurgitation, dysphagia, waterbrash Pain relieved by eating
IBD	Diarrhoea, may contain blood or mucus Fever
Coeliac disease	Altered bowel habit Poor weight gain or slow growth Anaemia/iron deficiency (treatment resistant) Bloating Family history of coeliac disease
Parasitic infection (giardia)	Loose, pale, greasy stools – foul-smelling Bloating Nausea, loss of appetite
DKA/first presentation of Type 1 Diabetes	Excessive thirst, frequent urination Loss of weight
Gynaecological	Pain associated with menstrual cycle
Functional May be exacerbated by psychosocial stressors May be exacerbated by physical stressors (specific foods, missing meals, tiredness)
Condition:	Key features:
Irritable bowel syndrome	Abdominal pain at least 4 days per month, associated with change in bowel habit Pain associated with change in frequency or form of stool Pain related to defecation
Abdominal migraine	Stereotypical, paroxysmal episodes of periumbilical or diffuse abdominal pain with few or no GI complaints between attacks Migraine in child (or family)
Functional dyspepsia	Bothersome postprandial fullness Early satiety Epigastric pain and burning not associated with bowel habit
Non-specific abdominal pain/functional abdominal pain (not otherwise specified)	No obvious organic aetiology Pain may be episodic or continuous Not associated with change in stool frequency/consistency Chronic abdominal pain may develop as a response to psychosocial stressors or emotional distress
Somatic symptom disorder	Child has a significant focus on physical symptoms, resulting in major distress or difficulty functioning May describe symptoms that are incongruent with findings on examination or investigation

Management

Investigations

Many children do not need investigations
Investigations should be targeted to likely diagnoses

Investigations, depending on likely diagnoses, may include:

urinalysis (+/- culture +/- pregnancy test +/- STI screen if indicated)
stool sample: M/C/S, ova, cysts and parasites
faecal calprotectin for children over 4 years (if features of IBD). Do not test under the age of 4 years without discussion with a paediatrician or paediatric gastroenterologist
blood: UEC, LFTs, CMP, lipase, TSH, blood sugar, coeliac serology and total IgA level, inflammatory markers (ESR, CRP), FBE & ferritin
imaging:

imaging is not routinely required
abdominal ultrasound has very low yield in childhood chronic abdominal pain

it may be useful in excluding an intra-abdominal mass for children with abnormal examination or significant constitutional symptoms

do not perform abdominal X-rays for investigation of non-specific abdominal pain. Abdominal X-rays are rarely helpful in diagnosing constipation
CT, MRI and other investigations (such as endoscopy) are rarely required. Seek specialist advice

Only test for H. pylori (by stool antigen or urease breath test) if there are red flags for peptic ulcer disease (eg haematemesis, family history of H. pylori complication). Do not test H. pylori serology

Treatment

Treatment is targeted to the underlying cause

Constipation
For older children and adolescents with reflux symptoms, a 4-week trial of proton pump inhibitor (PPI) pre-referral may be helpful. Refer to a specialist if not responding appropriately or unable to wean PPI
If IBD is suspected, seek specialist advice, and refer to paediatric gastroenterology

Non-specific or functional abdominal pain is a distinct diagnosis and does not require exclusion of all organic causes. Red flags should be considered, but children may not need investigations to make this diagnosis. Often multi-disciplinary input is required

For non-specific, suspected functional abdominal pain:

Consider consultation with local paediatric team when

Child requiring admission
Red flags or abnormal investigations
Abdominal pain causing significant interruption to usual activities (schooling, social interactions, eating) – consider referral to general paediatrics, adolescent medicine or paediatric chronic pain management service

Consider transfer when

Child requires care beyond the comfort level of the local hospital

For emergency advice and paediatric or neonatal ICU transfers, see Retrieval Services

Consider discharge when

There are no concerning clinical features and red flags have been considered AND
A clear follow-up plan has been arranged, often with either general paediatrics, adolescent medicine or paediatric chronic pain management service

Parent information

Kids Health Info: Abdominal Pain
Functional abdominal (tummy) pain disorders

Last updated March 2023