Abdominal pain, at four ages

2 months

Volvulus, incarcerated hernia, intussusception at the older end, and non-abdominal causes (urinary tract infection, sepsis).

Differential

1. Infantile colic (thriving, well between episodes)
2. Malrotation with volvulus
3. Incarcerated inguinal hernia (check the groin)
4. Urinary tract infection
5. Cow's milk protein allergy

What changes

The abdomen is examined by watching the face. Undress the child and look at the groin and the scrotum. Bilious vomiting or a tender, distended abdomen is surgical.

18 months

Intussusception and the abdominal presentation of infection elsewhere.

Differential

1. Intussusception
2. Gastroenteritis
3. Constipation
4. Urinary tract infection
5. Lower lobe pneumonia presenting with abdominal pain

What changes

Ask about intermittent episodes with pallor and drawing up the legs. Red-currant jelly stool is late. Ultrasound is the test. Examine the chest.

8 years

Appendicitis, which peaks in later childhood, and constipation, which is much more common.

Differential

1. Appendicitis
2. Constipation
3. Mesenteric adenitis
4. Gastroenteritis
5. Streptococcal pharyngitis
6. Diabetic ketoacidosis
7. Henoch-Schonlein purpura (IgA vasculitis) with abdominal pain

What changes

Pain that migrates to the right lower quadrant, anorexia, and pain with movement point to appendicitis; the child who hops on the spot without pain probably does not have it. Look at the legs and the urine for IgA vasculitis.

15 years

Appendicitis still, plus gynecological and testicular emergencies.

Differential

1. Appendicitis
2. Ovarian torsion, ectopic pregnancy, pelvic inflammatory disease
3. Testicular torsion (the abdomen can be the only complaint)
4. Inflammatory bowel disease
5. Pancreatitis
6. Functional abdominal pain

What changes

A pregnancy test in anyone who could be pregnant. Examine the testes in every boy with abdominal pain. Ask privately about sexual activity.