Pediatric GI Complaints

Don’t forget to do a thorough GU exam!

Step 1: Write Out Your Differential Diagnosis

  • Remember 2-4-2-4
  • (2) In the upper abdomen
    • Pyloric stenosis
    • Pneumonia
  • (4) In the lower abdomen
    • Hirschsprung’s disease
    • Intussusception
    • Appendicitis
    • Hernia
  • (2) Genitourinary
    • UTI
    • Testicular/Ovarian torsion
  • (4) Generalized
    • Volvulus
    • Necrotizing enterocolitis
    • Henoch Schonlein Purpura
    • Diabetic ketoacidosis

Step 2: Do Pediatric History and Exam

  • Pediatric assessment triangle
    • Appearance
    • Breathing
    • Color
  • Birth history
    • Gestational age
    • Complications
  • Eating/drinking/peeing/pooping
  • Immunizations
  • Physical exam
    • Don’t forget GU exam!

Step 3: Five Important Tests

  • Finger stick blood glucose
  • Urinalysis
  • Chest x-ray
  • Abdominal x-ray
  • Abdominal ultrasound

Step 4: Common Treatments

  • Fever/Pain
    • Acetaminophen
  • Vomiting
    • Zofran
  • Diarrhea
  • Dehydration
    • Pedialyte

Additional Reading


  1. Sophie

    Hi Zach,

    I LOVE your podcast. Just wanted to quickly ask how you’d fit in Meckel’s, ulcer perforation, and bacterial peritonitis into your framework. It popped up on one of my review sources. Thanks so much for all your hard work!

    -Current MS3

    • Zack

      Great question. Meckels is actually very common in pediatric patients but is almost always asymptomatic. It can present as intussusception, GI bleeding, or as an appendicitis mimic. Perforations absolutely go in the differential as well but are pretty uncommon on this list. The thing to remember with those (as well as with peritonitis) is that they have peritoneal signs on abdominal exam and are pretty sick appearing. Also, with peritonitis, there typically has to be a decent amount of peritoneal fluid. Most commonly we see it in adults with cirrhosis, but it can occasionally happen in kids as well when they have CHF/nephrotic syndromes causing a bunch of peritoneal fluid that can get infected. Great job keeping your differential broad! I think the reason it’s not as high up in my framework is because I haven’t seen to many of those cases yet in my training, so my differential is skewed towards things I’ve seen and thus have read lots about!

  2. Otari Beldishevski-Shotadze

    Hi Zack,

    I was wondering if you could differentiate between mesenteric adenitis and appendicitis based on the clinical history/exam and testing? Thank you for your podcasts.

    • Zack

      I don’t think it’s smart to try to do that. Appendicitis is too high risk of a diagnosis to miss and the symptoms overlap too much. I imagine that even if there was an objective clinical scenario where your pre-test probability for mesenteric adenitis was greater than your pretest suspicion for appendicitis, there is so much overlap of symptoms that you would still meet testing threshold for appendicitis and still require imaging which will help tell the difference.

      • Otari Beldishevski-Shotadze

        Thank you : )

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