Persistent stomach pain in children may signal appendicitis: Doctors

Appendicitis in children can be difficult to recognise in its early stages as its symptoms may resemble those of common stomach infections, but delays in diagnosis can significantly increase the risk of appendix perforation and other complications, doctors said.

They said abdominal pain accompanied by vomiting, fever, loss of appetite or increasing tenderness should not be dismissed as a routine stomach infection, particularly when the pain persists or becomes progressively severe.

“Appendicitis in children usually presents with typical symptoms and signs which are apparent to a discerning doctor,” Dr Sandeep Agarwala, Head of Department of Paediatric Surgery at AIIMS, Delhi, said.

“However, it does not always present in the textbook manner. A child usually has a vague central abdominal pain which, in a few hours, localises to the right lower abdomen. When this is associated with or preceded by loss of appetite, nausea and vomiting or fever, one should have a high index of suspicion of appendicitis,” Dr Agarwala said.

Appendicitis can frequently be mistaken for gastroenteritis, which typically has diarrhoea as a main symptom, Agarwala said. “The important point is to watch how the symptoms evolve and seek medical evaluation when the pain persists or worsens,” he said.

Younger children pose a particular diagnostic challenge as they may not be able to clearly describe or localise their pain, he said. “In them, the diagnosis can be delayed, and therefore complications like perforation may be higher,” Agarwala said.

According to Dr Shandip Kumar Sinha, Director of Paediatric Surgery and Paediatric Urology at Medanta – The Medicity in Gurugram, parents may initially assume that the child has a stomach infection and wait for the symptoms to settle, but appendicitis can progress, and in young children the progression may be faster.

“Persistent abdominal pain, particularly when associated with fever, vomiting or refusal to eat, warrants medical assessment,” he said, adding that the consequences of delayed diagnosis have also been highlighted in larger studies.

He said appendicitis may begin with pain around the navel before shifting towards the lower right side, although this pattern is not seen in every child. Nausea, vomiting,



fever and loss of appetite are also common symptoms.

“Diagnosis should be based on the child’s symptoms and physical examination, supported by investigations when required. Ultrasound can be particularly useful in children because it does not involve radiation, but an inconclusive scan should not provide false reassurance if clinical suspicion remains high,” Dr Sinha said.

Imaging decisions need to be individualised, with ultrasound commonly used in children and further imaging considered when the clinical picture and initial findings do not match, he said. Agarwala said that once appendicitis is confirmed, surgical removal of the appendix remains a standard treatment in cases of acute appendicitis even when associated with perforation and peritonitis.

The presence of a localised abscess in the right lower abdomen may mandate initial drainage of the abscess followed by delayed or interval appendicitis.

“Development of such complications does require more intensive management and may be associated with higher complications and prolonged hospitalisation,” Agarwala said.

Occasionally, early appendicitis may be managed non-surgically, with surgery performed later on an elective basis, he stated. Doctors advised parents to seek urgent medical attention from a paediatrician or paediatric surgeon if abdominal pain is persistent or worsening, particularly when accompanied by repeated vomiting, fever, increasing abdominal tenderness, refusal to eat or drink, unusual lethargy or pain aggravated by movement.

“The intensity of pain alone should not determine whether a child needs evaluation. A child can have appendicitis even when the initial symptoms are relatively mild. Persistence and progression of symptoms are important warning signs,” Agarwala said.

Dr Prabudh Goel, professor of Paediatric Surgery at AIIMS, Delhi, stressed that not every episode of abdominal pain is appendicitis, but persistent or progressively worsening symptoms should be assessed by a medical professional.

“The objective is not to alarm parents but to ensure that a potentially serious surgical condition is not missed because its early symptoms resemble a common childhood illness. Timely diagnosis and treatment can prevent avoidable complications,” he said.