Recurrent Abdominal Pain In Children
Dr. Subhash Agrawal*
Senior Consultant, Pediatrician & Neonatologist Moolchand Hospital & Tirathram Hospital , Delhi*
Recurrent Abdominal Pain (RAP)
  • Common Pediatric Problem, Age : 4-16 yrs.
  • Apple's Definition: Paroxysmal Abdominal pain, Persists > 3 mths., Affects normal activity
  • Chronic pain abdomen: If persists> 6 mths
  • Incidence: Equal till 9 yrs., Then > in males
  • Adolescents: 75% Suffer, 21% severe pain
  • Approx. 10% Abdominal pain - Seek medical help
  • Mostly in RAP: No identifiable cause
  • Exclude organic cause: Before labeling functional etiology
Common Clinical Presentations
  • solated paroxysms of abdominal pain
  • Abdominal pain associated With dyspepsia
  • Abdominal pain associated With altered bowel habits
Common Organic Causes
  • G.I. Tract: Chronic constipation, Esophagitis, Lactose intolerance, Parasitic infestation, Excess Fructose/Sorbitol Ingestion, Crohn's disease, Peptic Ulcer, Appendicitis, Cholelithiasis, Choledochal Cyst & Pancreatitis, etc

  • G.U.Tract: UTI, Hydronephrosis, Urolithiasis etc.

  • Miscellaneous : Abdominal Epilepsy, Lead Poisoning Porphyria, Henoch-Schonlein Purpura, Angioneurotic Edema, Gilbert's Syndrome, Sickle Cell Crisis etc
Clues to an Organic Cause
  • Age : <6 yrs, Pain away from umbilicus
  • Severe pain - Sudden onset, Sleep disturbed
  • Fever, Vomiting, Diarrhea, Blood in stool
  • Age : <6 yrs, Pain away from Umbilicus.
  • Abdominal distention, Dysuria, jaundice
  • Reduced activity, Short stature - Abnormal growth.
  • No emotional stress or positive family history
Functional RAP
Also known as
  • Psychogenic abdominal pain
  • Functional abdominal pain
  • Periodic syndrome

Functional RAP
  • Indicator of psychological disturbances
  • High frequency of behavioral disorders
  • Evidence of maladjustment, Anxiety reactions
  • High strung perfectionists and apprehensive personalities, have no evidence of disease
  • Past H/o Colic & feeding problems in infancy
  • Family H/o Abdominal pain present
  • Stress within the family and/or at school

Functional RAP
Associated with 5 major paediatric disorders:
  • Inflammatory bowel syndrome
  • Functional dyspepsia
  • Abdominal migraine
  • Aerophagia
  • Functional abdominal pain syndrome

Rome II Guidelines - Functional RAP
Features of Inflammatory bowel syndrome:
  • Abnormal stool frequency (>3/d or <3/week
  • Abnormal stool form : Lumpy, hard or loose
  • Abnormal stool passage : Straining, Urgency, feeling of incomplete defecation.
  • Passage of mucus, Bloating, Feeling of abdominal distention.
Rome II Guidelines for IBS
  • Child old enough to provide accurate H/o pain
  • Pain present for at least 12 wks in previous 12 months - Not necessarily consecutive
  • Pain is relieved with defecation or change in stool form or frequency
  • No structural/metabolic abnormalities present to explain the symptoms

Rome II Guidelines - Functional dyspepsia
  • Pain centered in the upper abdomen (Above Umbilicus) for 12 wks in previous 12 months
  • No evidence of organic disease
  • Dyspepsia neither relieved by defecation nor by change in stool frequency or form

Rome II Guidelines - Abdominal migraine
  • 3 or more paroxysmal episodes
  • Intense, Acute, Midline abdominal pain
  • Lasting for 2 hrs to several days
  • Intervening symptom free interval : wks to months
  • No evidence of metabolic, GI or CNS disease
  • Any 2 of the following features presents:
  • Headache, confined to one side only
  • Photophobia - family history of migraine
  • An aura of visual, sensory or motor symptoms
Rome II Guidelines - Aerophagia
Presence of 2 or more of the following:
  • Air swallowing, abdominal distention
  • Due to intra-luminal air
  • Repetitive belching or increased flatus
Rome II Guidelines
Functional abdominal pain syndrome
  • Continuous pain in elderly child or adolescent
  • No relation with eating, defecation, menses
  • Some loss of daily functioning
  • Pain is not feigned
  • No other associated organic GI disorder
Clues to a Functional Causes
  • Age of onset: > 6 years
  • Para-umbilical, midline paroxysmal pain
  • No consistent duration, frequency periodicity of pain
  • Brief pain with intervals from days to weeks
  • Child unable to pin-point the exact site of pain
  • No radiation, no relation with meals
  • Sleep or pleasure activities - not interfered
  • Normal growth, no weight loss, O/E - Normal
  • Emotional stress present or positive family history
  • RAP children have autonomic nervous system and abnormal intestinal motility
Investigations
  • Complete blood count, Hb, ESR (Raised in IBS)
  • Urinalysis and culture, stool-parasites and occult blood
  • Upper GI X-rays, Abdominal ultrasound
  • If Peptic Ulcer: H. Pylori antibody test or endoscopy
  • If pancreatitis: Serum amylase during active pain
  • LFT in suspected hepato-biliary disorders
  • Others: EEG, GI Barium studies, IVP, CT Scan, Cholecystography, Endoscopy & proctoscopy
Treatment - Dietary
  • In IBS: No food rich in fat, alcohol and caffeine
  • Avoid high sorbitol high fructose foods as they cause increased gas production and intestinal distention
Cochrane review
  • Lack of evidence on effectiveness of diet
  • Fiber supplements are not effective
  • Lactose restricting diets are inconclusive
  • Need for well designed trials for dietary interventions in functional RAP
Treatment - Pharmacological
Cochrane Review
  • Recommended drugs: Not very effective
  • Lactose intolerance: Lactose free diet
  • Gastro-esophageal reflux: Acid blockers
  • IBS & loose stools: Fiber supplementation
  • Anticholinergics and Antidepressants: In some patients
  • Abdominal migraine: Anti-migraine drugs e.g., Pizotifen Prophylaxis - useful
  • Chronic constipation: Standard treatment
  • Close follow up of the patients: Must
Treatment - Psychological
Cochrane Review
  • Good evidence: Relaxation and cognitive behavioral therapy are effective in reducing the severity and frequency of pain.
Prognosis
  • Many children with RAP: Continue to suffer in adult life from symptoms of IBS
  • Poor Prognosis:
    1. Early development of symptoms
    2. Delayed treatment
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Agrawal S D.. Available From : http://www.pediatriconcall.com/fordoctor/ Conference_abstracts/report.aspx?reportid=411
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