A child with a history of periumbilical pain that radiates to the right lower abdomen, fever, and vomiting should have high suspicion for the diagnosis of appendicitis Typically, the child with appendicitis will have focal tenderness in the right lower quadrant; however, diffuse tenderness with involuntary guarding may be seen later in the course The diagnosis of ovarian torsion should be considered in females with acute onset of lower abdominal pain and vomiting; less severe, but focal tenderness, can also be seen with a ruptured ovarian cyst Epigastric tenderness may be observed in children with gastritis or pancreatitis Right upper quadrant tenderness may be appreciated among children with hepatitis or cholecystitis Jaundice or scleral icterus may be present Pain or limitation of inspiration during palpation of the right upper quadrant (Murphy sign) may be elicited in patients with acute cholecystitis Focal tenderness in the flank region suggests pyelonephritis or urolithiasis Colicky Pain Intussusception should be considered in a child with colicky abdominal pain, particularly among children younger than years of age Among older children, a “lead” point for an intussusception should be considered (e.g., mesenteric adenitis, lymphoma, polyp, cystic fibrosis, anaphylactoid purpura) Abdominal radiographs may be useful in confirming obstruction or the presence of a mass; an air-contrast enema is indicated urgently if there is a high suspicion for intussusception In low or moderate probability settings, an ultrasound is the standard imaging for diagnosis of intussusception Flank tenderness and/or gross or microscopic hematuria may suggest urolithiasis Gastroenteritis and constipation can be associated with colicky abdominal pain, but these diagnoses should be made after more serious conditions have been excluded Fever Although most children with appendicitis will have peritoneal signs or focal tenderness, this diagnosis must be considered in any child with fever and abdominal pain Children with gastroenteritis may have crampy abdominal pain and diarrhea Although viral pathogens commonly cause gastroenteritis, the presence of fever, bloody stool, or severe abdominal pain may point to a bacterial etiology A thorough physical examination should be performed to assess for extra-abdominal conditions such as pharyngitis, UTI, and pneumonia Other conditions associated with abdominal pain and fever are shown in Figure 53.1 Chronic or Recurrent Pattern