What is the appropriate management for a 9-year-old girl presenting with severe abdominal pain?

Management of Severe Abdominal Pain in a 9-Year-Old Girl

A 9-year-old girl with severe abdominal pain requires immediate clinical assessment to differentiate surgical emergencies (particularly appendicitis) from benign causes, with ultrasound as the first-line imaging modality when clinical suspicion warrants investigation. 1

Initial Assessment and Risk Stratification

Critical First Steps

• Assess hemodynamic stability immediately: Check for tachycardia, tachypnea, hypotension, or signs of shock that indicate life-threatening conditions requiring urgent intervention 2, 3
• Establish IV access and give normal saline 20 mL/kg if shock or hypovolemia is present 2
• Obtain surgical consultation early if any concerning features are identified 2

Key History Elements to Elicit

• Pain characteristics: Location (periumbilical migrating to right lower quadrant suggests appendicitis), onset, duration, severity, and quality 1
• Associated symptoms: Anorexia, nausea, vomiting (especially bilious vomiting), fever, last bowel movement/gas passage 1
• Previous abdominal surgery: 85% sensitivity for adhesive small bowel obstruction 1
• Menstrual history: Consider gynecologic causes in post-menarchal girls 1

Physical Examination Priorities

• Right lower quadrant guarding or peritoneal signs: Highly suggestive of appendicitis 1
• Abdominal distension with absent bowel sounds: Consider bowel obstruction 1, 2
• Blood-tinged stools or abdominal bruising: Indicate potential surgical emergency 3
• Testicular examination in all cases: Testicular torsion can present as abdominal pain 3

Diagnostic Approach Based on Clinical Suspicion

High Suspicion for Appendicitis (Most Common Surgical Emergency)

Ultrasound is the first-line imaging modality to avoid radiation exposure in children 1

• If ultrasound is equivocal or nondiagnostic, proceed to MRI (preferred) or CT with contrast 1
• Clinical scoring systems (Alvarado Score, Pediatric Appendicitis Score) help stratify risk but should not replace clinical judgment 1

Low Suspicion for Surgical Pathology

• Most cases are benign and self-limiting (gastroenteritis, viral illness, constipation) 4, 2
• Broad-spectrum antibiotics are NOT routinely indicated for children with fever and abdominal pain when there is low suspicion for complicated appendicitis or intra-abdominal infection 1
• Observation with serial examinations is appropriate 2

Moderate-Severe Pain with Localizing Findings

Ultrasound abdomen is the first investigation in almost all cases 2

• Consider CT with contrast if significant trauma or pancreatitis suspected 2
• Nothing by mouth, IV fluids, nasogastric tube decompression if indicated 2

Pain Management

Provide adequate analgesia early - this does not mask surgical findings and improves diagnostic accuracy 2

• Ibuprofen 400 mg every 4-6 hours for mild-moderate pain (weight-based dosing: 10 mg/kg/dose, max 400 mg) 5
• Stronger analgesia (opioids) may be needed for severe pain while awaiting definitive diagnosis 2

Surgical Conditions Requiring Urgent Intervention

Appendicitis (Most Common)

• Appendectomy is standard treatment 1
• For perforated appendicitis with abscess: percutaneous drainage followed by broad-spectrum antibiotics, then interval appendectomy 1

If Complicated Intra-Abdominal Infection Confirmed

Acceptable broad-spectrum regimens for pediatric patients include 1:

• Piperacillin-tazobactam: 200-300 mg/kg/day (of piperacillin component) divided every 6-8 hours
• Carbapenem (meropenem 60 mg/kg/day every 8 hours, or ertapenem 15 mg/kg twice daily for ages 3 months-12 years)
• Advanced cephalosporin + metronidazole: Ceftriaxone 50-75 mg/kg/day every 12-24 hours PLUS metronidazole 30-40 mg/kg/day every 8 hours
• For β-lactam allergy: ciprofloxacin 20-30 mg/kg/day every 12 hours plus metronidazole 1

Other Surgical Emergencies to Consider

• Bowel obstruction: Complete obstruction requires emergency surgical assessment 1
• Intussusception: More common in younger children, presents with intermittent severe pain and "currant jelly" stools 2
• Ovarian torsion: Consider in post-menarchal girls with acute severe pain 1

Common Pitfalls to Avoid

• Do not withhold pain medication while awaiting diagnosis - this is outdated practice 2
• Do not assume extra-abdominal causes are ruled out: Lower lobe pneumonia, diabetic ketoacidosis can present as abdominal pain 2, 3
• Do not rely solely on laboratory values in elderly or immunocompromised patients: Signs may be masked despite serious infection 1
• Do not skip testicular examination: Testicular torsion commonly presents as abdominal pain in adolescent boys 3
• Serial examinations are mandatory in all cases where diagnosis is uncertain 2