Pediatric Annals

Recurrent Abdominal Pain: An Approach to Diagnosis and Management

Allan Olson, MD

Abstract

Recurrent abdominal pain (RAP), defined by Apley as a minimum of three episodes of pain occurring over three months or more,1 is the most common chronic pain reported by school aged children and adolescents.1 Up to 15% of children experience RAP,2 and it accounts for 5% of pediatric office visits.3 RAP is generally characterized as either organic, psychiatric, or functional.4,5 Only a minority of children with RAP (10% to 15%) have an organic basis for their pain.5 The majority of patients with severe episodes of RAP are characterized as having functional abdominal pain and are free of organic disease or psychiatric disorder. The pediatrician is then faced with a dilemma. He must ensure that each child with RAP does not have any of the potential organic causes of abdominal pain while limiting his workup to appropriate studies. It has been proposed that functional abdominal pain is caused by stretch of the intestinal wall produced by a localized increase in intraluminal pressure.6 Although the abnormal intestinal motility found in children with RAP may account for the increase in intraluminal pressure,7 the diagnostic dilemma is compounded because no pathognomonic clinical diagnostic test exists for functional abdominal pain.

EVALUATION OF RAP

Children with RAP are evaluated by a combination of history, physical examination, and laboratory tests. The physician should evaluate the child's social and psychological adjustment and document any recent stressful events at school or in the family. Parents might be interviewed without the child so they may freely express their concerns. Careful review of family history and of the child's past medical history may identify inherited disorders or instances of mimicry of adult symptoms. Details about the pain should be obtained directly from the patient, whenever practical.

There is no single characteristic finding that reliably distinguishes functional RAP from that which is organic in origin; both can be periumbilical or generalized, dull or sharp, and intermittent or constant. Functional RAP is more usually periumbilical but may present in other locations. An organic basis for RAP is suggested by pain that awakens the child from sleep and is associated with recurrent fevers and weight loss as in inflammatory bowel or peptic ulcer disease, or which radiates to the back or flank as in pancreatitis or renal stone infection. The severity of abdominal pain, while often a major concern of the patient and family, does not correlate well with the cause of the pain, and is therefore rarely helpful in distinguishing functional from organic causes of abdominal pain.

Table

PATHOPHYSIOLOGY OF FUNCTIONAL ABDOMINAL PAIN

The term functional abdominal pain is misinterpreted by many physicians to mean that the pain is either fictitious or imagined. However, in the patients with RAP who have a functional cause (up to 90%), the symptoms are believed to stem from intestinal dysmotility. Normal intestinal motility is associated with relaxation of the distal intestine in response to material arriving in that area from more proximal contractions. In dysmotility the distal intestine fails to relax under these conditions and prevents the flow of intestinal contents toward the anus. The resultant distention of the more proximal intestine by trapped material activates stretch receptors in the wall, which is perceived as abdominal pain. Abnormal intestinal motility has been documented in adults11-13 and children7 with functional RAP.

Physical or emotional stress is often associated with episodes of abdominal pain in individuals predisposed to functional RAP and the irritable bowel syndrome. It has been suggested that stress may act by increasing distal spasm and proximal large intestinal distention.13 In addition, several studies have suggested an increased incidence of psychiatric disorders in close relatives of patients…

Recurrent abdominal pain (RAP), defined by Apley as a minimum of three episodes of pain occurring over three months or more,1 is the most common chronic pain reported by school aged children and adolescents.1 Up to 15% of children experience RAP,2 and it accounts for 5% of pediatric office visits.3 RAP is generally characterized as either organic, psychiatric, or functional.4,5 Only a minority of children with RAP (10% to 15%) have an organic basis for their pain.5 The majority of patients with severe episodes of RAP are characterized as having functional abdominal pain and are free of organic disease or psychiatric disorder. The pediatrician is then faced with a dilemma. He must ensure that each child with RAP does not have any of the potential organic causes of abdominal pain while limiting his workup to appropriate studies. It has been proposed that functional abdominal pain is caused by stretch of the intestinal wall produced by a localized increase in intraluminal pressure.6 Although the abnormal intestinal motility found in children with RAP may account for the increase in intraluminal pressure,7 the diagnostic dilemma is compounded because no pathognomonic clinical diagnostic test exists for functional abdominal pain.

EVALUATION OF RAP

Children with RAP are evaluated by a combination of history, physical examination, and laboratory tests. The physician should evaluate the child's social and psychological adjustment and document any recent stressful events at school or in the family. Parents might be interviewed without the child so they may freely express their concerns. Careful review of family history and of the child's past medical history may identify inherited disorders or instances of mimicry of adult symptoms. Details about the pain should be obtained directly from the patient, whenever practical.

There is no single characteristic finding that reliably distinguishes functional RAP from that which is organic in origin; both can be periumbilical or generalized, dull or sharp, and intermittent or constant. Functional RAP is more usually periumbilical but may present in other locations. An organic basis for RAP is suggested by pain that awakens the child from sleep and is associated with recurrent fevers and weight loss as in inflammatory bowel or peptic ulcer disease, or which radiates to the back or flank as in pancreatitis or renal stone infection. The severity of abdominal pain, while often a major concern of the patient and family, does not correlate well with the cause of the pain, and is therefore rarely helpful in distinguishing functional from organic causes of abdominal pain.

Table

TABLE 1Characteristics of Abdominal Pain

TABLE 1

Characteristics of Abdominal Pain

There is no single characteristic finding that reliably distinguishes functional RAP from that which is organic in origin; both can be periumbilical or generalized, dull or sharp, and intermittent or constant. Functional RAP is more usually periumbilical but may present in other locations. An organic basis for RAP is suggested by pain that awakens the child from sleep and is associated with recurrent fevers and weight loss as in inflammatory bowel or peptic ulcer disease, or which radiates to the back or flank as in pancreatitis or renal stone infection. The severity of abdominal pain, while often a major concern of the patient and family, does not correlate well with the cause of the pain, and is therefore rarely helpful in distinguishing functional from organic causes of abdominal pain.

Various features of abdominal pain that may be elicited from history are listed in Table 1. The common locations of pain associated with various disorders are shown in Table 2. Although no single feature readily distinguishes organic from functional RAP or favors one organic cause over another, combination of the individual features of Table 1 with locations from Table 2 may suggest recognizable patterns for specific diagnostic possibilities that would justify more pointed evaluations. For example, the presence of burning epigastric pain, occurring one hour after meals, which is exacerbated by spicy foods and relieved by antacids might suggest peptic ulcer disease and would indicate the need for endoscopy; or the presence of right upper quadrant pain associated with meals and exacerbated by fatty foods might indicate possible gallbladder disease and would justify an abdominal ultrasound (Table 3).

Factors associated with exacerbation or alleviation of pain together with frequency, duration, location and quality of the pain may indicate a pattern characteristic of a specific diagnosis. Therefore, the effect of meals in general, and specifically fatty foods, lactosecontaining foods, or highly spiced foods; of defecation; and of physical activity on RAP should be carefully reviewed. Pain may be increased by meals in pancreatitis, cholelithiasis, inflammatory bowel disease (IBD), and functional RAP. Fatty foods increase discomfort in patients with cholelithiasis and pancreatitis. Abdominal pain following milk and its products indicates possible lactase deficiency. Highly spiced foods exacerbate pain from peptic ulcer disease.

Physical examination is best performed in a quiet, private area. Young children and infants should have parents present for reassurance, but teenagers are more comfortable if offered the option of privacy. The abdomen should be observed for asymmetry or distention, auscultated for the presence and quality of bowel sounds, and palpated for masses and for rebound tenderness. Both voluntary and involuntary responses to palpation should be carefully noted. Absent or high pitched bowel sounds would suggest a partial, fixed intestinal obstruction. Occult or gross blood may be present on rectal examination, providing evidence of ulcerative disease of the intestine. Abscesses in the perirectal area, which may be the external openings of fistulae, suggest Crohn's disease. Tenderness on percussion over the costovertebral angle suggests the possibility of pyelonephritis or a renal stone. Also, the child's fingers should be examined for clubbing, which has been associated with IBD as well as with chronic pulmonary or liver disease.

Initial laboratory evaluation of children with RAP should be limited and focused by the findings on history and physical examination. Possible laboratory evaluations (Table 3) include an erythrocyte sedimentation rate (ESR), a complete blood count with differential and platelet count, albumin and transaminase levels, a urinalysis, and three stool guaiac cards for occult blood. IBD, a frequent organic cause of RAP, is suggested by the presence of anemia, hypoalbuminemia, elevations in ESR and/or platelet count, and presence of occult blood in the stool. Anemia or blood in the stool may also be present in peptic ulcer disease. Stool culture for enteric pathogens should be performed if a history of diarrhea or fever exists. Stool should also be evaluated for ova and parasites to identify Giardia.

PROGNOSIS OF PATIENTS WITH RAP

Symptoms of functional RAP persist for many years. Apley in 1957 reported that 12 of 30 patients followed for 8 to 20 years continued to have abdominal pain.8 Dahl-Haahr followed 116 children for 1 to 10 years; 30% had persistent abdominal pain, and 16% developed headaches or dizziness.9 Christiansen reported in 1975 that of 34 children with RAP, 11 had symptoms as adults consistent with irritable bowel syndrome, while 5 had developed peptic ulcer disease. I0 These reports suggest that a substantial proportion of patients with RAP have an underlying constitutional predisposition to the problem that does not change throughout their lives.

Table

TABLE 2Characteristic Location of Abdominal Pain

TABLE 2

Characteristic Location of Abdominal Pain

Table

TABLE 3Laboratory Work-up for Children with Abdominal Pain

TABLE 3

Laboratory Work-up for Children with Abdominal Pain

PATHOPHYSIOLOGY OF FUNCTIONAL ABDOMINAL PAIN

The term functional abdominal pain is misinterpreted by many physicians to mean that the pain is either fictitious or imagined. However, in the patients with RAP who have a functional cause (up to 90%), the symptoms are believed to stem from intestinal dysmotility. Normal intestinal motility is associated with relaxation of the distal intestine in response to material arriving in that area from more proximal contractions. In dysmotility the distal intestine fails to relax under these conditions and prevents the flow of intestinal contents toward the anus. The resultant distention of the more proximal intestine by trapped material activates stretch receptors in the wall, which is perceived as abdominal pain. Abnormal intestinal motility has been documented in adults11-13 and children7 with functional RAP.

Physical or emotional stress is often associated with episodes of abdominal pain in individuals predisposed to functional RAP and the irritable bowel syndrome. It has been suggested that stress may act by increasing distal spasm and proximal large intestinal distention.13 In addition, several studies have suggested an increased incidence of psychiatric disorders in close relatives of patients with RAP,15,16 but others disagree.17

Levine suggests that a critical interaction among environmental factors, intrinsic temperamental factors, somatic disposition toward pain, and learned behavioral responses is required for the production of abdominal pain. The multifactorial causation of abdominal pain suggested by this model is supported by the variable response of different patients to similar stimuli and suggests the need for a multifaceted approach to the management of RAP.5

ORGANIC AND PSYCHIATRIC CAUSES OF ABDOMINAL PAIN

The common organic diseases and psychiatric disorders that account for a small minority of patients with RAP are briefly detailed here before proceeding to a discussion of management of its functional causes.

Inflammatory bowel disease (IBD) may present with abdominal pain as the sole symptom and all patients with RAP should be considered for the diagnosis. Additional suspicious historical features include weight loss, fever, anemia, short stature, diarrhea, arthritis, erythema nodosum, and pyoderma gangrenosum. Screening for IBD should include stool examination for occult blood loss, hypoproteinemia, and inflammation (Table 3). The diagnosis of IBD can be verified by colonoscopy or contrast studies of the large or small intestine.

Peptic ulcer disease (PUD) is a cause of RAP which characteristically presents in adults as sharp or burning epigastric pain occurring one to three hours after meals, which is rapidly relieved by antacids.18 Pediatric patients do not commonly have this classic presentation. 19 Therefore, if children with RAP also have a family history of PUD, this diagnosis should be considered carefully and ruled out, even if the characteristic adult pain pattern is not present. PUD is best confirmed by upper gastrointestinal endoscopy, with or without a supplementary upper GI series.20 Esophagitis presents with substernal or epigastric pain which is intensified on lying down and may be resistant to relief by antacids.

Lactose intolerance has been reported in up to 40% of children with abdominal pain. I4 We suggest a brief two week trial of a milk and milk product-free diet to ensure that lactose intolerance is not overlooked. A breath hydrogen test for lactose intolerance may be necessary if the dietary trial is inconclusive.

Pelvic inflammatory disease presents with suprapubic or pelvic pain in association with a vaginal discharge. Diagnosis can be made by pelvic examination and cervical culture. Association of pelvic pain with right upper quadrant tenderness should suggest Fitz-Hugh-Curtis syndrome, a perihepatitis associated with pelvic inflammatory disease.

Urinary bladder infection may cause suprapubic pain. Flank pain should suggest pyelonephritis or renal stones. Renal stones will often produce colicky pain that may radiate into the pelvis during passage of a stone.

Pancreatitis can result from trauma, infection, congenital malformation of the pancreatic duct, or a drug reaction. Abdominal pain due to pancreatitis is localized to the left upper quadrant, and will often radiate to the back or left shoulder. Diagnosis is generally made by an elevated serum amylase or through identification of an enlarged or edematous pancreas on ultrasound or CT scan.

Depression in adolescents and older children may present as RAP. Signs of depression include social withdrawal, decreased activity, difficulty with sleep, irritability, and difficulty with concentration and attention span.

School avoidance is characterized by a severe anxiety reaction often associated with vague abdominal pain that is characteristically most severe on weekday mornings. It improves as the day progresses and the weekend approaches. School avoidance may result from multiple causes including poor peer relations, teacher-pupil tensions, or difficulties with school assignments.21

MANAGEMENT OF PATIENTS WITH FUNCTIONAL ABDOMINAL PAIN

Most patients and their families appreciate an explanation on the first visit that despite the fact that 90% of patients with RAP do not have a severe organic disorder, the physician must complete a careful history and perform a thorough physical examination and a limited laboratory evaluation. Explanation of reasons for any individual screening tests that may later be conducted builds additional confidence.

The patient's family should be reassured that the pain is indeed "real," with an explanation of the pathophysiology related to stretching of the intestinal wall. The relationship and interaction between the spasm of the distal colon with the stretch of the wall and increased contractile force in the proximal intestine should be discussed. The role of stress in decreasing the pain threshold and increasing lack of coordination of intestinal motility and intestinal spasm should be emphasized. In addition, the complicating role of excess gas in the intestine and the associated role of constipation should be discussed. Discrete recommendations should be made to decrease those complicating factors prominent in the patient's history. We recommend a trial of psyllium bulk agents and lubricants such as mineral oil to enhance colonic emptying. A trial high fiber diet has been recommended by some authors and has proven useful in some patients. Adults with the irritable bowel syndrome have been reported to have decreased abdominal pain when receiving a 20 g high fiber diet,22 but a contrasting study reported no improvement on a 30 g high fiber diet.23 If the high fiber diet and bulk agents are not effective in our patients, they are discontinued. We recommend bowel training and encourage the patient to establish a pattern of sitting on the toilet immediately after breakfast for 10 minutes to take advantage of the natural increase in urge to defecate and increase in colonic activity following meals. If pain continues, stimulatory suppositories such as bisacodyl can be used to induce early morning defecation.

Due to the chronic nature of this condition, we counsel families and children that the pain may periodically recur. We emphasize the child's need for support through these episodes of pain, with reemphasis on the medical management that was originally helpful. Although RAP is a challenging problem requiring a comprehensive approach to diagnosis and management, its greatest challenge and reward comes from the successful long-term support required for its control.

REFERENCES

1. Apley J: The Child With Abdominal Pains. Oxford, Blackwell Scientific Publications, 1975.

2. Apley J, Naish N: Recurrent abdominal pains: A field survey of 1,000 school children. Arch Dis Child 1958; 33:165.

3. Amhold RG, Callos ER: Composition of a suburban pediatric office practice: An analysis of patient visits during one year. Clin Pediatr 1966; 5:722.

4. Barr RG: Recurrent abdominal pain, in Levine MD, et al: Developmental Behavioral Pediatrics. Philadelphia. WB Saunders Co, 1983.

5. Levine M: Recurrent abdominal pain in school children: The loneliness of the longdistance physician. ftdiatr Clin North Am 1976; 31:969-991.

6. Davidson M: Recurrent abdominal pain: Look to dyskinesia as the culprit. Contemporary ftdiatrics 1986; 3:16-42.

7. Davidson M: Functional problems associated with colonic dysfunction: The irritable bowel syndrome, ftdiatr Annals 1987; 16:776-795.

8. Apley J, Hale B: Children with recurrent abdominal pain: How do they grow up.' Br Med J 1973; 3:7.

9. Dahl L, Haaht J: Recidiverenxk raavesmecter bamealderen. Ugeslcrift for Laefer 1969, 191:1509.

10. Christensen MF, Mortensen O: Long-term prognosis in children with recurrent abdominal pain. Arch Dis Child 1975; 50:110.

11. Snape WJ Jr, Carlson GM, Matarazzo SA1 et al: Evidence that abnormal myoelectrical activity produces colonic motor dysfunction in the irritable bowel syndrome. Gastroenterology 1977; 72:383-387.

12. Taylor I, Darby C, Hammond P, et al: Is there a myoelectrical abnormality in the irritable colon syndrome? Gut 1978; 19:391-395.

13. Almy T: Wrestling with the irritable colon. Med Chn North Am 1978; 62:203-210.

14. Lebenthal E1 Rossi TM, Nord KS, et al: Recurrent abdominal pain and lactose absorption in children, ftdiamcs 1981; 67:828.

15. Green M: Diagnosis and treatment: Psychogenic recurrent abdominal pain, Pediatrics 1967; 40:84.

16. McGrath PJ, Goodman JT, Firestone P: Recurrent abdominal pain: A psychogenic disorder? Arch Dis Child 1983: 58:888.

17. Raymer P. Weininger O, Hamilton JR: Psychological problems in children with abdominal pain. Lancet 1984; 1:439.

18. Sol AH, lsenberg Jl: Duodenal ulcer diseases, in Schlesinger MH. Fortrand JS (eds): Gastmnuestmal Disease, Philadelphia. WB Saunders Co. 1983. ? 646.

19. Deckelbaum RJ. Roy OC. Lusster-LazarofTJ, et al: ftptic ulcer discase: A clinic study in 73 children. Con Med Assoc J 1974: 111:225-228.

20. Hassall E: Colonoscopy in childhood ftdiatrics 1984; 73:594-599.

21. Osmill R Diagnostic criterion fot separation anxiety disorder, in Diagnosti, and Statistical Manual- J M -R. Washington. DC. American Psychiatric Association. 1987. ? 61.

22. Manning AP. Heaton KW. Harvey RF, et al: Wheat fibre and imtable bowel syndrome: A controlled trial. Lancer 1977; 2:417-418.

23. Soltof J. Gudmand-Hoyer E, Krag B. et al: A double-blind trial of the effect of wheat bran on symptoms of irritable bowel syndrome. Lancet 1976; 1:270-272.

TABLE 1

Characteristics of Abdominal Pain

TABLE 2

Characteristic Location of Abdominal Pain

TABLE 3

Laboratory Work-up for Children with Abdominal Pain

10.3928/0090-4481-19871001-11

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