What is the best approach to manage lower abdomen pain in an adolescent patient?

Management of Lower Abdominal Pain in Adolescents

A complete pelvic examination is always indicated for lower abdominal pain in adolescents to identify serious causes including pelvic inflammatory disease, ovarian torsion, ectopic pregnancy, and appendicitis. 1

Initial Clinical Assessment

Key Historical Features to Elicit

• Fever, bilious vomiting, bloody diarrhea, and pain migration to the right lower quadrant strongly suggest appendicitis 2
• Vomiting before pain onset makes appendicitis less likely 2
• In post-menarchal females, always obtain menstrual history, sexual activity history, and pregnancy status 1
• Assess for alarm features: fever, tachycardia, weight loss, nocturnal symptoms, and family history of inflammatory bowel disease 2, 3

Physical Examination Priorities

• Positive psoas sign, fever, or migratory pain to the right lower quadrant indicates appendicitis 2
• Voluntary guarding, rigidity, rebound tenderness, and absent bowel sounds indicate surgical abdomen 2, 3
• Always perform external genital and testicular examination in males to rule out testicular torsion presenting as abdominal pain 3
• In females with lower abdominal pain, pelvic examination identifies ovarian torsion, ectopic pregnancy, and pelvic inflammatory disease 1

Diagnostic Imaging Algorithm

First-Line Imaging

• Ultrasound is the initial imaging modality for suspected appendicitis in adolescents, with 93% accuracy, 86% sensitivity, and 97% specificity 1
• Ultrasound also evaluates ovarian pathology (cysts, torsion), ectopic pregnancy, and pelvic inflammatory disease in females 1

Second-Line Imaging

• If ultrasound is equivocal or nondiagnostic AND clinical suspicion remains high, proceed to CT abdomen/pelvis with IV contrast 1
• CT has 90% sensitivity and 95% specificity for appendicitis and identifies alternative diagnoses 1
• MRI is an alternative to CT with similar accuracy while avoiding radiation, though availability may be limited 1

When to Skip Further Imaging

• If ultrasound shows a normal appendix with no inflammatory findings in the right lower quadrant, further imaging is unnecessary unless clinical picture is discordant 1
• Repeat clinical assessment after equivocal ultrasound can correctly rule out appendicitis in 59% of cases without additional imaging 1

Management Based on Etiology

Appendicitis

• Laparoscopic appendectomy with 2-4 days of post-operative antibiotics is the standard treatment 4
• Admit all patients with confirmed appendicitis 5
• For periappendicular abscess, percutaneous drainage serves as bridge to interval appendectomy 4

Gynecologic Causes

• Ovarian torsion requires emergent surgical consultation for detorsion to prevent ovarian loss 1, 2
• Pelvic inflammatory disease: Obtain cervical or vaginal swabs for Chlamydia trachomatis and Neisseria gonorrhoeae via nucleic acid amplification testing 1
• Ectopic pregnancy: Obtain quantitative β-hCG and transvaginal ultrasound; requires gynecology consultation 2

Diverticulitis (Rare in Adolescents)

• Uncomplicated diverticulitis in immunocompetent patients can be managed conservatively without antibiotics 4
• Small abscesses respond to antibiotics alone; larger abscesses require percutaneous drainage 4

Inflammatory Bowel Disease

• Consider in adolescents with chronic or recurrent lower abdominal pain, bloody diarrhea, weight loss, and elevated inflammatory markers 5
• May require admission for severe flares, but many cases can be managed outpatient with gastroenterology follow-up 5

Functional Abdominal Pain (After Excluding Organic Disease)

First-Line Treatment

• Start soluble fiber (ispaghula/psyllium) 3-4 g/day, titrating gradually to avoid bloating 6, 7
• Prescribe regular physical exercise as foundational therapy 6, 7
• For meal-related pain, use peppermint oil or anticholinergic antispasmodics (dicyclomine, hyoscyamine) 6, 7
• Provide structured dietary advice: regular meals, adequate hydration (6-8 glasses water daily), avoid excessive caffeine and fatty foods 6

Second-Line Treatment

• If pain persists after 3 months of first-line therapy, start amitriptyline 10 mg at bedtime, titrating by 10 mg weekly to 30-50 mg daily 6, 7
• Critical counseling: Explain amitriptyline is used for gut-brain pain modulation, NOT depression treatment 6, 7
• Tricyclic antidepressants are superior to SSRIs for abdominal pain based on meta-analysis 7

Psychological Interventions

• Consider cognitive behavioral therapy or gut-directed hypnotherapy when symptoms persist despite 12 months of pharmacological treatment 6, 7
• Early identification of anxiety, depression, or trauma history predicts progression to chronic pain and warrants early psychological intervention 6

Critical Pitfalls to Avoid

• Never prescribe opioids for chronic abdominal pain in adolescents—they cause narcotic bowel syndrome, dependence, worsened constipation, and increased mortality risk 6, 4, 7
• Do not perform repetitive diagnostic testing once functional pain is established, as this reinforces illness behavior without improving outcomes 6, 7
• Do not delay pelvic examination in post-menarchal females with lower abdominal pain—ovarian torsion and ectopic pregnancy require emergent intervention to prevent organ loss 1, 2
• Avoid anticholinergic antispasmodics if constipation predominates, as they worsen gut motility 6
• Plain abdominal radiographs are neither sensitive nor specific for appendicitis and should not be used for this diagnosis 1

When to Refer or Admit

• Admit all patients with confirmed appendicitis, ovarian torsion, ectopic pregnancy, or signs of peritonitis 5
• Refer to gastroenterology when symptoms are refractory to first-line treatments or for colonoscopy if alarm features present 7
• Severe or refractory functional pain requires integrated multidisciplinary care with gastroenterology, pain management, and mental health services 7