Remembering common causes of abdominal pain helps triage students with and safely determine whether to refer (urgent or emergent), treat or teach. The most common emergency room diagnoses associated with abdominal pain in school-age children are gastroenteritis and appendicitis.  The most often missed diagnoses in one study of emergency room assessments of children were appendicitis and acute intestinal obstruction. However, many children get no definitive diagnosis.

Initial assessment begins with checking stability (airway, breathing, circulation, disability) and signs of conditions that warrant urgent or emergency referrals.  History and physical exam follow for others. Mnemonics or other consistent approach help to ensure thoroughness. Physical assessment begins with the least invasive step, i.e., inspection, followed by auscultation, percussion, and finally palpation.

Common gastroenteritis is usually due to a virus, but severe signs (toxic appearance, fever, bloody stools) suggest a bacterial infection.  Frequent vomiting (ten or more episodes in the past 24 hours) or stools (more than five a day for two or more days) warrant immediate medical evaluation. Accompanying dehydration may present as no urination for the past 12 hours, rapid pulse (>20 beats above expected) or slow capillary refill (>2 seconds) rather than low blood pressure in children.

Erosive gastritis and peptic ulcer disease (PUD) may present similarly, but evidence of bleeding warrants an urgent referral for evaluation. Distinguishing features include history (gastritis is often related to diet, certain medications, or stress); pain (PUD has more constant, severe or repetitive pain); relief (PUD is improved by eating); and duration (gastritis is usually self-limiting).

Intestinal obstruction is an emergency and classically presents with severe spasmodic pain that radiates, nausea/vomiting, and/or distention. Bowel sounds are high-pitched proximal to the obstruction and low-pitched or silent beyond the blockage.

Irritable bowel is associated with abnormal intestinal motility (i.e., crampy pain relieved by passing gas or stool, intermittent diarrhea without pain or alternating constipation and diarrhea), possibly due to visceral hypersensitivity. Management involves stress management and diet changes to increase fiber and avoid known trigger foods.

Appendicitis is common but may not be obvious. History may include loss of appetite and diffuse pain which later localizes in the right lower quadrant. In addition to checking for rebound tenderness, note if pain increases with movement such as coughing or walking (heel jar) or heel tap.

Infrequent but noteworthy causes of abdominal pain include diabetes ketoacidosis (due to elevated ketone acids in undiagnosed or poorly controlled cases) and physical or emotional abuse.

(Zimmermann P. J Sch Nurs. 2003;19(1):4-10)

Comment:  An emergency nurse perspective. School health staff often find that “tummy aches” are due to undone homework, tests, breakups with boyfriends or substituting candy for the lunch.  For significant signs, tell teachers and parents in the ‘beginning of school’ newsletter how you define  “frequent” stools or vomiting so they trust in your calls and referrals.  
–J.O.