Urgent considerations
See Differentials for more details
Red-flag symptoms that may require urgent management include lethargy, fever, volume depletion, weight loss, bilious vomiting, hematemesis, papilledema, abdominal tenderness, and/or the presence of a mass.
Children are at increased risk of volume depletion, and they should be specifically assessed for this feature when there is a history of vomiting, diarrhea, or poor oral intake. Signs of volume depletion include depressed anterior fontanel (in infants), sunken eyes, dry mucosal membranes, sticky saliva, loss of skin turgor, and slow capillary refill. Oral or nasogastric fluids should be started in order to avoid shock. If this is not possible, or if the child does not respond, intravenous hydration is needed.
Antiemetics are generally not recommended in infants and children with a suspected obstruction or increased intracranial pressure, especially if the cause of the vomiting is unknown. They may be useful in patients with gastroenteritis to help decrease fluid loss.
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Adverse effects of antiemetics include sedation and neurological symptoms.
Neonates
Intestinal malrotation:
Should be suspected in newborns with bilious vomiting.
Patient may require urgent upper gastrointestinal series and surgery.
Ladd procedure may be indicated to prevent midgut volvulus and intestinal necrosis.
Hirschsprung disease:
Should be suspected in a newborn baby who has failed to pass meconium within 48 hours of birth and has bilious vomiting, explosive diarrhea, or abdominal distension.
Initial treatment is bowel irrigation, followed by definitive surgical treatment.
Metabolic disorders:
Should be suspected in infants with lethargy, hepatomegaly, and absence of fever.
Electrolytes, venous pH, blood glucose level, ammonia level, and liver function tests (LFTs) should be obtained.
Patient may require hospital admission for metabolic decompensation.
Infants or toddlers
Intussusception:
Should be suspected in infants or toddlers with cramps, intermittent abdominal pain, lethargy, and bloody stools.
Patient should be sent to the emergency department for evaluation.
Abdominal ultrasound and possible hydraulic or pneumatic reduction should be performed.
Failure to thrive:
Enteropathy, milk protein allergy, and pancreatic insufficiency should be suspected in infants with poor weight gain and diarrhea.
Appropriate referral for pancreatic function studies and possible endoscopy may be indicated.
Toxic ingestions:
Should be suspected in infants or toddlers with lethargy, seizures, and ataxia. Access to a medication or toxin should be queried.
Patient should be sent to the emergency department for evaluation.
Electrolytes, blood gases, urine, and blood for toxic substances should be obtained.
Hemolytic uremic syndrome:
Should be considered in children with abdominal pain, bloody diarrhea, and absence of fever. Characterized by microangiopathic hemolytic anemia, thrombocytopenia, and nephropathy.
If suspected, patient should be hospitalized. A complete blood count (CBC), peripheral blood smear, and renal function test should be ordered initially.
Treatment is mainly supportive.
Older children or adolescents
Nephrolithiasis:
Should be suspected in children with abdominal/back pain and hematuria.
Appropriate imaging includes abdominal ultrasound and possibly a computed tomographic (CT) urogram.
Jaundice:
Hepatitis should be suspected in children or adolescents with jaundice and abdominal pain.
Abdominal ultrasound, LFTs, and hepatitis viral panel (including Epstein-Barr virus) are the most appropriate initial tests.
Constipation/fecal impaction:
Should be suspected in older children (and toddlers) with abdominal distension, soiling, and the presence of a mass in the abdomen.
Rectal exam may be considered in difficult or atypical cases, but there is limited evidence to support its use in the diagnosis of functional constipation.[72][73] Rectal exam should only be undertaken by healthcare professionals competent to interpret features of anatomic abnormalities or Hirschsprung disease.[74]
Abdominal x-ray may serve as an adjunct to the diagnosis , or as an alternative to rectal exam when it is not feasible.[73][75]
Peptic ulcer disease:
Should be suspected in children and adolescents with epigastric abdominal pain, melena, or hematemesis.
May require referral for upper gastrointestinal endoscopy and initiation of acid suppression therapy.
Gonadal torsion:
Should be considered in males with acute onset of testicular/scrotal pain (testicular torsion) and in females with severe sharp lower abdominal pain and a palpable adnexal mass (ovarian torsion).
Considered a surgical emergency. A high index of suspicion is important to ensure timely diagnosis and management.
All ages
Bacterial meningitis:
Should be suspected in infants with lethargy, fever, and tense fontanel, or children and adolescents with headache, fever, or nuchal rigidity.
Patient requires urgent admission and workup with blood, urine, and cerebrospinal fluid cultures.
Antibiotics should be given immediately to prevent neurologic sequelae.[76][77]
Pneumonia:
Should be considered in patients with fever, cough, dyspnea, chest pain, crackles/rales on auscultation, or signs of respiratory distress.
Chest x-ray and blood/sputum cultures should be ordered.
Empiric antibiotic therapy should be started as soon as possible.[78] Whether the patient is treated as an inpatient or outpatient will depend on specific patient factors (e.g., severity of symptoms, presence of comorbidities, likelihood of drug resistance).
Increased intracranial pressure:
Should be suspected in patients with headache and vomiting early in the morning with or without papilledema and ataxia.
Immediate brain CT or magnetic resonance imaging (MRI) is indicated to help determine etiology (e.g., brain tumor, pseudotumor cerebri [benign intracranial hypertension], hydrocephalus, infection, concussion, or ventriculoperitoneal shunt malfunction).
Acute abdomen:
Differential diagnosis includes appendicitis, intussusception, intestinal volvulus, pancreatitis, and renal calculi.
If suspected, abdominal/pelvic CT imaging with contrast should be ordered. If renal calculi are strongly suspected, obtain CT without contrast first.
Small bowel lymphoma:
Should be suspected in patients with abdominal pain, diarrhea, weight loss, fever, presence of mass, or organomegaly.
CT or MRI of the abdomen should be ordered to confirm the presence of a mass or obstruction.
Considered a surgical emergency if obstruction is present.
Eosinophilic disease:
Should be suspected in patients with dysphagia, choking, food impaction, rhinitis, or asthma (eosinophilic esophagitis), or in patients with diarrhea, hematochezia, or failure to thrive (eosinophilic gastroenteritis).
Peripheral eosinophilia is seen on a CBC.
Diabetic ketoacidosis (DKA):
Should be considered in patients with type 1 diabetes or in patients with polyuria, polydipsia, polyphagia, weight loss, drowsiness, lethargy, anorexia, and abdominal pain for whom DKA may be the first manifestation of diabetes.
Urinalysis (for glucose and ketones) and ABG should be performed, and blood samples taken for glucose, ketones, and electrolytes.
Can cause severe complications or even death if untreated.
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