What Causes Tummy Pain in Children

Appendicitis

Appendicitis is a common cause of tummy pain in children. The pain usually starts as a dull aching pain all over the tummy or at the belly button area; it then becomes more localized to the right lower part of the tummy after 6-18 hours. Your child may have associated lack of appetite, with nausea and sometimes they may vomit. With this they can become dehydrated and with a fast heart rate. 

Appendicitis often goes along with a low-grade fever initially (under 38 degrees celcius), but if perforation (burst appendix) has occurred, then a high fever will develop. The tummy is usually very tender to touch in the lower, right corner and hopping on the right leg worsens the pain. Perforation of the appendix is more common and occurs sooner in children under 5. 

Most times, the diagnosis is evident with examination by a child surgeon; however in girls, especially those heading towards puberty, an ultrasound scan to rule out her tummy pain due to an ovarian or uterine cause is advisable.

Ultrasound and blood tests may be necessary to help with making the diagnosis and very rarely a CT scan might be performed. A period of observation in hospital can be useful in the earlier stages of the symptoms. With intravenous fluids and pain relieving medication, the symptom associated with viral illnesses usually subsides.

Treatment

Antibiotics are given intravenously and an appendicectomy should be performed as soon as possible after a child surgeon makes the diagnosis. Laparoscopic (keyhole surgery) is best, to minimize pain after the operation with faster recovery and shorter stay in hospital. If the appendix is burst and there is pus spillage in the tummy, a further 5 days of intravenous antibiotics may be necessary.

It is rare for hospitalization to extend beyond 6 days and if recovery has not occurred by this time, then it is likely that there is a complication such as further infection within the abdomen.

Depending upon the severity and length of the illness, convalescence at home may take up to a month. If appendicitis is caught early enough, then after appendicectomy, the child may be discharged from hospital after 24 hours and may be back at school within the week.

For a detailed article on Appendicitis please click here.

Acute Gastroenteritis

In most cases this is due to a viral infection in the intestine. The symptoms typically are diarrhoea, with or without vomiting. This condition can also cause swelling to the lymph nodes especially abundant on the right lower abdomen close to the appendix. This is also known as mesenteric adenitis (swelling of abdominal lymph nodes). The tummy pain may be due to gastroenteritis or mesenteric adenitis at the same time. 

You should seek medical help if your child with diarrhoea has: 

1. Severe abdominal pain
2. Passed six or more loose stools in a day
3. Not been able to hold down fluids for more than 6 hours  
4. Been floppy or irritable or if he/she had a headache and stiff neck. 

Urinary Tract Infection 

Urinary tract infections are uncommon in children especially in boys. Symptoms include pain when passing urine, fever, blood stained or cloudy urine, which can be strong smelling. Your child will need to be seen by a doctor and a urine sample taken. If there is definite infection for the very first time, an ultrasound scan of the kidneys up to the bladder is advised to look for structural abnormalities.

Mesenteric Adenitis

Lymph nodes are small gland like structures that help develop the white blood cells to combat infection or inflammation. These are found everywhere in the body. They are especially plentiful along the length of the intestine. When these are inflamed and enlarged, they are referred to as mesenteric adenitis. The enlargement can cause tummy pain that comes and goes but occasionally constant and can mimic the pain experienced with appendicitis.  When the diagnosis for the cause of tummy pain is not clear, a period of watchful wait or active observation in hospital of 8-12 hours is useful. Often with rehydration with intravenous fluids and with simple analgesia, pain from mesenteric adenitis can disappear, unlike that of appendicitis. 

Respiratory Tract Infection

The diaphragm divides the chest and tummy hence if there is an infection at the lower lungs, the pain can feel like the cause is in the tummy. Part of the doctor’s examination and investigation is to look for this as a cause of tummy pain. 

Constipation

This is a very common cause of tummy pain. A child with normal bowel habit would open bowels at least once a day with soft feaces the consistency of toothpaste. He or she should not hold feaces derived from food eaten more than 24 hours prior. With a hold up of faeces in the colon, the colonic muscle can go into intermittent spasm to push the content through. This is what causes the pain from constipation. Moreover the distension of the bowel and gas build up can also be very uncomfortable. A simple laxative, such as lactulose is useful for a constipated child who is normally regular. Failing this, do take your child to your local doctor. A child with chronic constipation, more than 2-3 months duration, usually require a longer regime of medications to reverse the problem, best seen to by a Paediatrician or Paediatric surgeon.  

Choledochal Cyst

These are extremely rare cysts of the bile ducts that drain bile from the liver to the intestine. Symptoms with this condition are jaundice, upper right tummy pain that can be intermittent, fever or pale stools. This condition can be diagnosed with blood tests and ultrasound scan. 

For a detailed article on Choledochal Cysts please click here.

Intussusception

This happens when the small intestine goes into (telescopes) the large intestine and becomes stuck there. The problem occurs in children from about 4 months of age to about 2 years of age.  There may be a preceding viral infection, causing the lymph patches on the intestine to enlarge and not move normally. 

In a small number of cases, a polyp, Meckel’s diverticulum or an abnormality on the wall of the bowel, causes it. Intussusception occurs in about 1 in 350 young children. 

Symptoms of intussusception often occur after 2-3 days of a viral illness with a fever. The tummy pain is often in spasms and your child may draw up his or her legs in response to this. Shortly, your child might become pale, stop feeding properly and may even vomit. As time goes by, your child may develop signs of a bowel obstruction with swelling of the abdomen, bile stained (green) vomiting and a reduction in the number of normal bowel motion. Your child may also pass thick with mucous and blood with the stools (red currant jelly stools). 

Sometimes, a child surgeon may be able to feel a sausage shaped lump in the right side of the tummy. A child surgeon should be able to diagnose a child who is suspected of having an intussusception urgently. 

Investigations include, an ultrasound of the abdomen and sometimes a contrast enema.

The child may need to be resuscitated with intravenous fluids and will be given medications to relieve the pain. In the majority of cases, the intussusception can be pushed back into place by performing an enema, in which air or fluid is pumped into the bowel from the bottom end. If the bowel does not pop back into place with the assistance of this pressure, the child will need an operation. In some cases when the intussusception has been present for some days, a portion of the bowel may need to be removed if it has become too badly damaged to survive.

Once the intussusception has been reduced, the prognosis is excellent. In those children whose intussusceptions were reduced using pressure, the chance of intussusception occurring again is about 10%. 

If an intussusception is left too long without being treated, the child may become desperately unwell. The bowel may puncture, causing peritonitis and septicemia and very rarely, death.

Meckels Diverticulitis

The Meckels diverticulum is a finger like projection on the small intestine not too far from the appendix. It is present in almost 2% of people. Though it is reasonably common, only about 5-10% of people with this, gets symptoms. One of the complications is inflammation/infection (diverticulitis) similar to appendicitis and the symptoms are also almost similar to appendicitis too. The process of investigations follows the same path as for appendicitis. 

With laparoscopic surgery the appendix is examined and if it seemed normal on outward appearance, Meckels diverticulitis could be the alternative diagnosis to look for.   

Ovarian Cysts

Pubertal or almost pubertal girls have “normal” or follicular cysts, which may cause pain in the lower tummy. Larger ovarian cysts are rare though its important to exclude this as a cause of lower tummy pains in your girl with an ultrasound scan. The third possible cause of pain from the ovary is if it is twisted or otherwise called ovarian torsion. Again this is rare and needs to be looked for with an ultrasound scan too.

Testicular conditions

The testis originates from the tummy and comes down into the scrotum before birth, with this; the nerve supply to the testis is derived from the tummy. With discomfort or issues with his testis, your boy may point to the tummy as the area of pain though it’s the testis, which has an issue. This is called referred pain. It is useful to check your boy’s testis if he claims to have lower tummy pain. There may be swelling or redness to his scrotum and is tender to touch. With any such findings, you should take your boy to the nearest hospital immediately. 

Gallstones

Gallstones are usually formed in the gall bladder. It is rare for children to have this though they can occur in children born at extreme prematurity and had spent a long time in the neonatal intensive care unit. Gallstones can also occur in children with blood abnormalities such as thalassemia, spherocytosis or sickle cell diseases. 

The commonest presentation of gallstones is infections of the gall bladder (cholecystitis) with symptoms being tummy pain, jaundice and fever.

If the stones “fall” through the tract of the bile ducts towards the intestine it can cause pain, colicky in nature in the right upper part of the tummy.  Your child might even experience jaundice and the stools becoming pale due to the blockage of bile flow. If the stone blocks the drainage of the pancreas (which joins the bile duct before they open together into the intestine) this can cause pancreatitis, an extremely painful condition and your child may become very sick or even be in a life-threatening state.

With symptoms of jaundice with fever and tummy pain, it is best to present your child to a unit with a good paediatric gastroenterologist or paediatric surgeon.

The diagnosis is made by clinical examination, blood investigations and an ultrasound scan. In most cases the initial treatment for cholangitis is with antibiotics to treat the infection. Once settled, its best to discuss with your surgeon to see if an operation to remove your child’s gall bladder (cholecystectomy) is warranted. With the keyhole surgery the recovery is swift and the stay in hospital short. 

Kidney or Urinary Tract Stones

Urinary tract stones or infections often presents with pain in the lower tummy and can get worse with passing urine. Stones can give crampy intermittent pain, which can be from one or other side on the back going down to the lower tummy. There can sometimes be visible blood in the urine. Urinary tract infection causes dull pain with burning sensation with the passage of urine. The urine can be cloudy or strong smelling or there may be blood. Fever may be an accompanying symptom with a urinary tract infection. Urine test must be done to confirm if there is infection and appropriate antibiotics given. With a possible stone in the urinary tract or with a first episode of urinary tract infection an ultrasound scan of the renal system is strongly recommended.