Recurrent Abdominal Pain In Children
Dr. Arati Deka*
Prof. & HOD, Paediatrics Silchar Medical College, Silchar *
Introduction
Recurrent abdominal pain (RAP) is relatively common paediatric problem occurring mainly in older children and adolescents. It is worrisome to the parents, as regards acceptance in the diagnosis as well as for doctor for management. Paediatricians may have a dismissive attitude towards functional pain and parents find it difficult to understand whether to deal with the pain being real or not.

Definition
RAP is defined as episodes of pain occurring at least monthly for three consecutive months with severity that interrupts routine functioning.

Incidence
RAP affects about 15% of middle and high school students. Approximately 10% of students who experience abdominal pain seek medical advice. The peak age group is 8-10 years, unusual before 5 years and rapidly decline above 15 years.
Clinicopathological entities of RAP
RAP can be classified as either organic or non-organic depending on whether a specific cause of pain is identified or not. Accordingly three distinct patterns have been identified.

Considering the stormy onset, monophasic course, angiographically demonstrable diffuse vasculitis with subsequent complete resolution and overall good prognosis clinches the final diagnosis as BACNS.

  • Organic
    -
    5-10%
  • Non-organic
    -
    90-95%
    • Dysfunctional 80-85%
    • Psychogenic 10%
  • Organic pain: More than 80% of abdominal pain from organic cause present as acute abdominal pain, or as recurrent pain which do not fit in to the pattern of RAP.

Pointers to Organic Pain (Red flag)

History Physical examination and Lab findings
  • Age younger than 5 years
  • Significant weight loss
  • Pain disturbs night sleep
  • Pain associated with change in bowel habits, diarrhoea, constipation, nocturnal bowel movements
  • Localized pain particularly away from umbilicus
  • Constitutional symptoms such as recurrent fever, loss of appetite or energy
  • Dysuria / altered frequency
  • Faecal incontinence
  • Haematemesis
  • Bilious vomiting
  • Haematochezia
  • Haematuria
  • Arthritis
  • Organomegaly
  • Rashes
  • Localized abdominal
  • tenderness
  • Occult blood in stool
  • Anaemia
  • Jaundice

Causes of organic pain
A. G.I. System

  • Alimentary system: Malrotation, strangulated hernia, Intussusception, abdominal migraine, bowel ischemia, helminthiasis (ascariasis), lactose intolerance, post-operative adhesions, chronic constipation, recurrent appendicitis, Meckel's diverticulitis
  • Hepatobiliary causes: Liver abscess, cholecystitis, choledochal cyst, sclerosing cholangitis, gall stone, hepatitis
  • Pancreatic causes: Chronic pancreatitis, pancreatic divisum

B. Non G.I. System
  • Genitourinary: Urinary tract infection, Pelvic inflammatory disease, dysmenorrhoea, ovarian cyst and tumors, urolithiasis
  • Splenic: Portal hypertension
  • Lymphatic:Inflammation, infection
  • Peritoneal: Primary peritonitis
  • Metabolic: Diabetic ketoacidosis, lead poisoning, porphyria
  • CVS: Rheumatic fever,pericarditis
  • Nervous system: Abdominal epilepsy
  • Lungs: Basal pneumonia, diaphragmatic pleurisy
  • Skeletal: Vertebral osteomyelitis, osteomyelitis of hip, spinal tumors
  • Sickle cell disease
Non-organic pain
Dysfunctional and psychogenic pain can be considered as two sides of the same coin, with one group (dysfunctional) having a definite pattern e.g., IBS and non-ulcer dyspepsia and the other (psychogenic) having no recognizable pattern to their symptoms.
Characteristic features
  • Onset > 6 years of age
  • Pain is often midline periumbilical, may be localized to the epigastric /suprapubic region
  • Non-radiating or have bizarre radiations
  • Usually no relationship with meals
  • Generally does not disturb sleep but can interfere with diurnal variation
  • Pain episodes are short, lasting for 15 minutes to 1 hour with fairly asymptomatic pain-free interval in between
  • Improvement of symptoms during school holidays and vacations
  • Examination and lab investigation do not disclose any abnormality

Psychogenic pain

Here, purely psychogenic factors with no somatic predisposition are involved in the causation of pain. Besides abdominal pain, these children also have the behavioral disorders and a close connection to some precipitating events which make the clinical diagnosis easy. Factors involved are:
  • Complaint modeling - parents with abdominal pain
  • School phobia - learning problems, anxious overachievers, teacher incompatibility, fear of ridicule by peers, dislike of schools
  • Attention seeking - busy parents, sibling jealousy, single child, attention withdrawal after an illness
  • Forced feeding and toilet training
  • Sexual abuse
  • Family psychopathology - illness / death in family, parental conflicts and separation, step parents

Dysfunctional pain

Unlike psychogenic pain, children with dysfunctional pain have normal behavior pattern and are quite often intelligent.

Clinical features: John Apley has aptly summarized the features of FRAP as follows -
Physique - slightly underweight
Intelligence - normal
Psyche - emotionally disturbed
Personality - timid and anxious
Family history - parents usually have vague aches and pains and psychological problem.
Age - it is seen in children between 4-14 years, mean age of onset being 5-10 years
Sex - seen more in females
Major paediatric disorders associated with FRAP - IBS, functional abdominal pain syndrome, functional dyspepsia.


Diagnosis of RAP: A good clinical history and thorough examination are mandatory and sufficient to arrive at a diagnosis in some patients. But in some cases, laboratory and imaging studies are required for diagnosis of RAP.
Diagnosis of RAP
A good clinical history and thorough examination are mandatory and sufficient to arrive at a diagnosis in some patients. But in some cases, laboratory and imaging studies are required for diagnosis of RAP.

A. History: Salient points in history are
  • Location, intensity, character and duration of pain, time of day or night that pains
  • Appetite, diet, satiety, nausea, reflux, emesis
  • Stool pattern, consistency, completeness of evacuation
  • Review of systems: weight loss, growth or puberty delay, fever, rash
  • Nutritional interventions
  • Family history, travel: night pain or pain on awakening suggests a peptic origin, pain that occurs at evening or during dinner is a feature of constipation, pain with weight loss, fever, joint complaints or rash suggests an inflammatory or infectious disease.

B. Site of pain
  • Above the umbilicus: upper GI pain
  • Right lower quadrant: distal ileal and appendicular pain
  • Lower abdomen: colonic pain
  • Right upper quadrant: gall bladder
  • Suprapubic UTI

C. Drug History: A careful review of recent medication to be taken.

D. Family History: Peptic disease / IBS / pancreatitis / migraine.

E. Social History: The child itself - personality, habits, response to pain, relationship with family and friends, sociability, school performances and nearby examination.

Child's family - interpersonal relationship between parents, marital disharmony similar pain related problems in same family.

Loss in the family / tragedy / death / divorce / separation.

Physical Examination

The examination must be thorough and comprehensive to rule out organic problems. It also reassures the child as well as their parents that their problem being evaluated well and their concerns are taken seriously. Physical examination includes.
  • Weight, height, growth, velocity, pubertal stage, blood pressure
  • Completed physical examination
  • Objective abdominal findings - location, rebound, mass, psoas and hepatomegaly, hepatosplenomegaly
  • Costovertebral angle tenderness
  • Right lower quadrant mass or fullness
  • Perianal fistula, fissure or ulceration, perianal faecal staining
  • Arthritis
Investigations
Accepting that only 10-15% of cases of RAP are due to organic aetiology, the laboratory, radiological or endoscopic evaluation of children with RAP should be individualized and carefully targeted depending on the findings suggested by detailed history and physical examination.

Laboratory studies may be unnecessary if the history and physical examination clearly suggest functional pain. However, a complete blood count, ESR, stool test for parasite, urinalysis are routine screening test, to avoid missing organic problems.

This will help us to decide next line of investigation. For example, if urine shows hematuria or albuminuria, USG KUB is mandatory.

Other investigations are to be done according to clinical suspicion.

Biochemical test: Enzyme assay are rarely of diagnostic benefit and are done only in suspicion of hepatobiliary, renal and pancreatic dysfunction - liver enzyme, amylase and lipase.

USG Abdomen: Helpful only in patients suspected of hepatobiliary, pancreatic or renal disease.

USG Pelvis: is indicated to detect - retroperitoneal disease and visualization of ileum of Crohn's disease, adenopathy, pelvic abscess.

X-ray abdomen: X-ray abdomen may be valuable in diagnosing intestinal obstruction, fecal loading, and ureteric calculus. Barium studies are helpful to establish Malrotation, Intussusception etc.

Radio nucleotide scan: is particularly helpful to detect Meckel's diverticulum.

Upper GI Endoscopy: Upper GI endoscopy is helpful to diagnose peptic ulcer disease. Endoscopic biopsy may be helpful in identifying the aetiology of inflammation. Particularly H Pylori infection rapid urease test.

Sigmoidoscopy / colonoscopy: indicated IBD are suspected.

Breath hydrogen test: suspected lactose intolerance test.

Urine for porphyrins: for porphyria.

Association of H. Pylori with RAP in children is still controversial.
Management
The first step of the management is to rule out organic pain. Although many cases of RAP may reveal a probable diagnosis on first encounter, diagnostic certainly in others may be achieved only after several office encounters and completion of salient investigation.

The aim of therapy is to treat the whole child and family and not just the symptoms. Psychological problems may coexist with organic problems. Therefore, management of RAP in children demands a much more broad based approach.

Management of Psychogenic and Dysfunctional RAP
This group is managed by - counseling, plenty of reassurance, involved doctoring and minimal drugs.

Management of some specific organic conditions
Constipation - managed by regular toilet training, increased dietary fibers, bulking agents and lactulose. Irritable bowel syndrome - managed by explanation, avoiding / managing psychosocial trigger and fiber supplementation.

Lactose intolerance - a trail of lactose-free diet for 1-2 weeks may be both diagnostic and therapeutic.
Prognosis
FRAP could be a difficult problem for the child, the parents and the physician, 30-50% of children with RAP settle within 6 weeks with the rest somewhat taking longer. However, if properly evaluated and treated, most of the children outgrow the pain by the end of the school-going age. In patients with severe pain, not responding to the usual measures there may be evidence of major stress and depression in the child and family and psychological opinion needed. Small number of children with functional abdominal pain are likely to become adult with functional disorder although the nature of the symptoms may change.
Conclusion
RAP in childhood is a common condition. The vast number of children does not have serious underlying GI disease and those that do can be readily distinguished by clinical assessment and a few basic screening investigations.
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