What is the appropriate management for a 13-year-old male presenting to the emergency room (ER) with abdominal pain around the navel, vomiting, and constipation?

Management of 13-Year-Old Male with Periumbilical Pain, Vomiting, and Constipation

Immediate Priority: Rule Out Appendicitis and Surgical Emergencies

This presentation is appendicitis until proven otherwise—immediate surgical consultation and imaging are mandatory. The classic triad of periumbilical pain migrating to the right lower quadrant, vomiting, and constipation in a 13-year-old male has high specificity for acute appendicitis, which requires urgent surgical intervention to prevent perforation and sepsis 1.

Initial Assessment and Stabilization

Vital Signs and Physical Examination

• Check for tachycardia, fever, and signs of hemodynamic instability immediately—these predict serious complications including perforation or sepsis 1
• Perform focused abdominal examination specifically looking for:
  • Rebound tenderness, guarding, or rigidity (peritoneal signs indicating possible perforation) 1
  • Right lower quadrant tenderness (McBurney's point)
  • Abdominal distension with diminished bowel sounds (suggests obstruction) 1
  • Empty rectum on digital examination (supports complete obstruction if present) 1

Critical Caveat

Absence of peritoneal signs does NOT exclude serious pathology—bowel ischemia can present without peritonitis, making laboratory tests and imaging essential 1.

Laboratory Workup

Obtain immediately 1:

• Complete blood count (elevated WBC supports appendicitis)
• Electrolytes and renal function (assess dehydration from vomiting)
• Blood gas and lactate levels (essential for detecting bowel ischemia even without peritonitis)
• C-reactive protein (predicts complications)

Imaging Strategy

First-Line Imaging

CT abdomen/pelvis with IV contrast is the definitive diagnostic test and should be obtained urgently 2, 1. This will:

• Confirm or exclude appendicitis
• Identify bowel obstruction and transition points
• Detect bowel ischemia
• Rule out other surgical causes (intussusception, volvulus, abscess)

Alternative if CT Unavailable

• Point-of-care ultrasound can detect free fluid, appendiceal inflammation, or intestinal distention if CT is not immediately available 2, 1
• Plain abdominal radiograph has limited sensitivity and negative films do NOT exclude serious pathology 1

Immediate Management While Awaiting Imaging

Resuscitation

• NPO status immediately 1
• Aggressive IV crystalloid resuscitation for dehydration from vomiting 1
• Nasogastric tube decompression if bilious vomiting or suspected obstruction 1

Antibiotics

Do NOT delay antibiotics if appendicitis is suspected—start broad-spectrum coverage once diagnosis is considered likely 2. Use:

• Third-generation cephalosporin PLUS metronidazole, OR
• Fluoroquinolone PLUS metronidazole 2

This covers Gram-negative bacteria and anaerobes typical of intra-abdominal infection 2.

Differential Diagnosis Considerations in This Age Group

While appendicitis is most likely, consider 1, 3:

• Small bowel obstruction (from adhesions if prior surgery, though less common in adolescents)
• Sigmoid volvulus (rare but reported in adolescents presenting with this exact triad) 3
• Mesenteric ischemia (if pain is out of proportion to examination findings) 1
• Intussusception (can occur in adolescents with lead points)

Surgical Consultation Timing

Obtain immediate surgical consultation—do not wait for imaging if patient has 1:

• Signs of shock (tachycardia, hypotension, altered mental status)
• Diffuse peritonitis
• Clinical deterioration

For stable patients, surgical consultation should occur as soon as imaging confirms surgical pathology 2, 1.

Serial Reassessment

Perform abdominal examinations every 4-6 hours to detect development of peritonitis if initial management is conservative 1. Any clinical deterioration mandates immediate surgical re-evaluation 2.

Common Pitfall to Avoid

Do not attribute symptoms to "simple constipation" without imaging in this presentation—the combination of periumbilical pain, vomiting, and constipation in an adolescent male is a surgical emergency until proven otherwise 1, 4. Even if constipation is present, it may be secondary to an obstructive process rather than the primary problem 5.