Pediatric Annals

Chronic Abdominal Pain in Adolescents

Mervin Silverberg, MD

Abstract

Abdominal pain is one of the most troublesome enigmas facing most practitioners who care for children and adolescents. Although those patients in preteen years with abdominal pain have been reviewed and closely scrutinized in the literature,1'2 there is still little scientific explanation for the various presentations of abdominal pain in adolescents. The health care provider faced with an adolescent with nonacute abdominal pain is likely to think in terms of adult presentations, and this often causes some discomfort to the pediatrician. More often than not, an organic etiology of such pain is pursued without adequate indications, and diagnoses are made by exclusion.

CLASSIFICATION

For all practical purposes, chronic abdominal pain (CAP) refers to recurrent or persistent bouts of pain that occur over a minimum period of 3 months, with or without compromising the daily activities of the patient.

Three major categories can he recognized:

* Dysfunctional abdominal pain. More than 90% of adolescents with CAP fell into this subdivision, and two subtypes of it can be defined: ( 1 ) The larger group involves alteration of bowel motility and is referred to as the irritable bowel syndrome (IBS), sometimes called irritable colon, spastic colon, mucous colitis, or nervous stomach; and (2) the smaller group involves upper abdominal complaints and is known as nonulcer dyspepsia. This latter group has emerged during the past decade and has been variously called pseudoulcer syndrome, functional dyspepsia, and pyloroduodenal irritability.

* Psychogenic chronic abdominal pain. Patients with CAP who do not have any disorder of bowel habits fell into this category. There is an apparent or subtle association with psychosocial events.

Table

* a strong family history of psychiatric illness, and

* an obvious unresolved emotional or stressful situation.

Organic Chronic Abdominal Pain

With the exception of appendicitis, almost all organic intra-abdominal disease may initially present with an acute severe episode, a low-grade chronic pattern, or a combination of the two. Organic disease is also more likely to have chronic continuous pain as opposed to the nonorganic group, which usually has a chronic recurrent pain cycle. The list of organic conditions presenting with CAP is long and impressive, and it is possible to highlight here only the more common specific entities that may be confused with the most common dysfunctional syndromes. It should be kept in mind that these organic disorders and dysfunctional syndromes may coexist in selected cases.

Chronic Inflammatory Bowel Disease. Crohn's disease and ulcerative colitis present in the adolescent age group in over 20% of patients.12 Chronic abdominal pain occurs in more than half of these patients, and it is the predominant complaint in 75% of Crohn's disease. Typically, the pain in Crohn's disease is postprandial and maximal in the right lower quadrant. Perianal disease such as fissure, fistula, and abscess occurs in more than 75% of patients. Other common features associated with Crohn's disease are fever, weight loss, sexual immaturity, and a variety of extra- intestinal manifestations involving the skin, joints, and eyes. There is a higher incidence in patients of Jewish descent, and a family history may be elicited in 30%.

Ulcerative colitis is less common in adolescents and is usually associated with bloody diarrhea and signs and symptoms of rectosigmoid disease. Table 2 lists characteristics of organic CAP.

Acid Peptic (Ulcer) Disease. Peptic ulcer in adolescents is usually primary in nature and duodenal in location; recurrences are noted in over half of patients.13 Pain and tenderness are localized to the epigastric region, often occurring more than 1 hour postprandially, particularly during the night; in older adolescents, it tends to be characterized by the pain-food-relief cycle. A positive family history…

Abdominal pain is one of the most troublesome enigmas facing most practitioners who care for children and adolescents. Although those patients in preteen years with abdominal pain have been reviewed and closely scrutinized in the literature,1'2 there is still little scientific explanation for the various presentations of abdominal pain in adolescents. The health care provider faced with an adolescent with nonacute abdominal pain is likely to think in terms of adult presentations, and this often causes some discomfort to the pediatrician. More often than not, an organic etiology of such pain is pursued without adequate indications, and diagnoses are made by exclusion.

CLASSIFICATION

For all practical purposes, chronic abdominal pain (CAP) refers to recurrent or persistent bouts of pain that occur over a minimum period of 3 months, with or without compromising the daily activities of the patient.

Three major categories can he recognized:

* Dysfunctional abdominal pain. More than 90% of adolescents with CAP fell into this subdivision, and two subtypes of it can be defined: ( 1 ) The larger group involves alteration of bowel motility and is referred to as the irritable bowel syndrome (IBS), sometimes called irritable colon, spastic colon, mucous colitis, or nervous stomach; and (2) the smaller group involves upper abdominal complaints and is known as nonulcer dyspepsia. This latter group has emerged during the past decade and has been variously called pseudoulcer syndrome, functional dyspepsia, and pyloroduodenal irritability.

* Psychogenic chronic abdominal pain. Patients with CAP who do not have any disorder of bowel habits fell into this category. There is an apparent or subtle association with psychosocial events.

Table

TABLE 1Characteristics of Nonorganic Chronic Abdominal Pain

TABLE 1

Characteristics of Nonorganic Chronic Abdominal Pain

* Organic chronic abdominal pain. This subdivision includes CAP due to a variety of disorders, which may number up to 100, and for which there are a diversity of presentations.

PATHOPHYSIOLOGY

Dysfunctional Chronic Abdominal Pain

Irritable Bowel Syndrome. Irritable bowel syndrome (IBS) is characterized by alterations in bowel habits, ie, constipation or diarrhea with abdominal pain. Irritable bowel syndrome is well-defined clinically in children and adults, and an impressive number of adult studies allude to a variety of abnormalities involving motor function of the small and, especially, the large bowel.5'5

The young adolescent, up to 14 years of age, may have the typical features of IBS of childhood2 or recurrent abdominal pain (RAP) syndrome.6 This group of patients may have mild changes in bowel habits or alternating diarrhea and constipation, with CAP.

The adolescent over 14 years of age presents more like adult IBS with either constipation-predominant or diarrhea -predominant pain. Hereditary and familial factors appear to have some causal relationship; however, the link to altered bowel motility is poorly understood. Abnormal motility patterns have been noted by many investigators, although very few of the subjects studied have been in the adolescent age group. Studies of patients with adult IBS suggest that the colon is hyperreactive to a variety of stimuli,7 including mechanical distention of the bowel with a balloon, food stimulation, and emotional arousal. To date, there is no evidence to link stress to any specific patterns of intestinal motility. Most studies of common neurotransmitters, eg, serotonin and catecholamines, have been unrevealing. Additionally, attempts to relate the motility disorders to autonomie nervous system dysfunction have provided equivocal results. This is an attractive hypothesis, since so many of the associated clinical manifestations of CAP, eg, headache, limb pains, and dizziness, may be easily explained by autonomie dysfunction. In general, all these motility studies are vulnerable to close scrutiny, eg, no change in patterns of diarrhea or constipation have been noted and most have lacked adequate age -matched controls.

Nonu/cer Dyspepsia. This category of CAP is characterized by "peptic ulcer" symptoms with chronic or recurrent upper abdominal pain.8 Attempts to differentiate these patients from those with IBS on the basis of psychopathology reveal that the distribution of abnormal personality traits is very similar in both conditions. A variety of etiological factors have been studied, but most of those investigations have been negative, unclear, or inconclusive. The etiological factors studied include gastroduodenal dysmotility; food, substance, or medication abuse; and heredity. Chronic gastritis, particularly that due to Helicobacter pylori and chronic duodenitis are often coexistent, but the cause-effect relationship is unproven.

Psychogenic Chronic Abdominal Pain

This form of CAP does not originate from intraabdominal primary processes. The causal relationship to psychophys io logical factors is usually present, but not always evident, eg, stress or the presence of an obvious psychiatric disorder.

Organic Chronic Abdominal Pain

Organic CAP is usually associated with specific structural, inflammatory, and biochemical abnormalities that can be demonstrated directly, eg, by biopsy, or indirectly by H2 breath analysis. The complaints of pain arise from changes in a specific abdominal organ system. The majority of cases in adolescents are due to disorders in the gastrointestinal tract, with genitourinary diseases not too far behind. This group of diseases is frequently accompanied by constitutional abnormalities, such as weight loss, impaired growth rate, and delayed sexual development. Laboratory studies, although often not specific, point to active inflammatory processes by demonstration of anemia, leucocytosis, an elevated sedimentation rate, and a high serum gamma globulin level.

CLINICAL PRESENTATION

Dysfunctional Chronic Abdominal Pain

Recurrent Abdominal Pain. The RAP syndrome is said to affect 10% to 15% of unselected school children between the ages of 5 and 1 5. The median age is 9 to 10 years for girls and 10 to 1 1 years for boys. The syndrome is usually more prevalent in females than in males, ranging up to a ratio of 2:1.

The pain is described as episodic with no signs or symptoms during pain-free intervals. Usually, there are at least three episodes of pain during any 3-month period, each lasting about half a Jay1; the pain is usually located in the periumbilical area. There is no relationship of the occurrence of pain to time of day, meals, or activities, and it rarely wakes the patient from sleep. More than half of the patients describe the pain as crampy. Associated complaints of fatigue, headache, limb pains, dizziness and nausea are reported in two thirds of the patients; weight gain and growth are rarely affected, except when overzealous dietary restrictions are implemented. A history of other functional gastrointestinal disorders may be found in the patient (50%) or in the immediate family (75%), as shown in Figure 1.

Figure. The ciinical spectrum of chronic abdominal pain. The child may demonstrate each of the clinical features in an orderly progression or experience only part of the spectrum, most commonly recurrent abdominal pain. The older adolescent usually presents with stress- related pain and altered bowel habits.

Figure. The ciinical spectrum of chronic abdominal pain. The child may demonstrate each of the clinical features in an orderly progression or experience only part of the spectrum, most commonly recurrent abdominal pain. The older adolescent usually presents with stress- related pain and altered bowel habits.

The physical examination in these patients is usually not revealing. The patient looks well, but is nervous and often claims to be in pain without showing commensurate pain reactions. Abdominal tenderness without guarding is often diffuse, but maximal in the periumbilical region. Tenderness over the entire colon can frequently be demonstrated. Diagnostic studies are usually within normal limits; however, excess stool retention can usually be seen in abdominal roentgenograms. Table 1 lists characteristics of nonorganic CAP.

Adult IBS is seen in the adolescent over 14 years of age and is the most common reason for visits to a gastroenterologist's office by adolescents. Its frequency in adolescents is not documented, but it is said to affect close to 5 million adults in the United States.9 The abdominal pain is usually low in the abdomen and associated with at least three of the following10:

* abdominal pain relieved by defecation,

* increased frequency of stools with the onset of pain,

* looser stools with the onset of pain,

* abdominal distention,

Table

TABLE 2Characteristics of Organic Chronic Abdominal Pain

TABLE 2

Characteristics of Organic Chronic Abdominal Pain

* mucus in the stool, and

* a feeling of incomplete evacuation after defecation.

Constipation is present more commonly than is diarrhea. Females predominate in a ratio of 2:1, and the disorder is less frequent among blacks than among other races. The patients tend to be high achievers, to be obsessive compulsive, to not be very affectionate, and to do well in school, often working hard to achieve good grades. They tend not to be confrontational and are often upset by separation phenomena of all varieties. Many have undue fears, particularly fears about the safety of their parents.

Nonu/cer Dyspepsia. Nonulcer dyspepsia, a frequently abused and misunderstood term, in the present context is defined as chronic or recurrent upper abdominal pain or nausea of at least 3 months duration that may or may not be related to meals. The full-blown syndrome includes bloating, early satiety, eructation, and anorexia. No discernible pathology or laboratory abnormalities have been consistently associated with this disorder. The prevalence in the adult population is said to be more than twice that of peptic ulcer disease. The differential diagnoses includes gastroesophageal reflux, gastric motility disorders, biliary dyskinesia, and gall bladder disease. Biliary dyskinesia is a motor disorder of the biliary tract that should be considered in patients with typical biliary pain in whom all traditional evaluations are negative.11 Chronic pancreatitis is a rare condition that also may be confused with nonulcet dyspepsia.

Psychogenic Chronic Abdominal Pain

Chronic psychogenic pain is easier to diagnose when it accompanies a psychiatric syndrome such as a conversion reaction or depression. It may provide an important secondary gain whereby it diverts attention or provides relief from a more serious affective disorder. It is seen relatively infrequently in clinical practice, and patients who suffer from it may have psychological profiles and abnormal family constellations that are difficult to differentiate from those observed in many of the dysfunctional syndromes. Helpful diagnostic features include the presence of: * a personality disorder such as hysteria,

Table

TABLE 3Management Principles in Adolescents With Chronic Abdominal Pain

TABLE 3

Management Principles in Adolescents With Chronic Abdominal Pain

* a strong family history of psychiatric illness, and

* an obvious unresolved emotional or stressful situation.

Organic Chronic Abdominal Pain

With the exception of appendicitis, almost all organic intra-abdominal disease may initially present with an acute severe episode, a low-grade chronic pattern, or a combination of the two. Organic disease is also more likely to have chronic continuous pain as opposed to the nonorganic group, which usually has a chronic recurrent pain cycle. The list of organic conditions presenting with CAP is long and impressive, and it is possible to highlight here only the more common specific entities that may be confused with the most common dysfunctional syndromes. It should be kept in mind that these organic disorders and dysfunctional syndromes may coexist in selected cases.

Chronic Inflammatory Bowel Disease. Crohn's disease and ulcerative colitis present in the adolescent age group in over 20% of patients.12 Chronic abdominal pain occurs in more than half of these patients, and it is the predominant complaint in 75% of Crohn's disease. Typically, the pain in Crohn's disease is postprandial and maximal in the right lower quadrant. Perianal disease such as fissure, fistula, and abscess occurs in more than 75% of patients. Other common features associated with Crohn's disease are fever, weight loss, sexual immaturity, and a variety of extra- intestinal manifestations involving the skin, joints, and eyes. There is a higher incidence in patients of Jewish descent, and a family history may be elicited in 30%.

Ulcerative colitis is less common in adolescents and is usually associated with bloody diarrhea and signs and symptoms of rectosigmoid disease. Table 2 lists characteristics of organic CAP.

Acid Peptic (Ulcer) Disease. Peptic ulcer in adolescents is usually primary in nature and duodenal in location; recurrences are noted in over half of patients.13 Pain and tenderness are localized to the epigastric region, often occurring more than 1 hour postprandially, particularly during the night; in older adolescents, it tends to be characterized by the pain-food-relief cycle. A positive family history and occult blood loss are noted in 20% to 25% of patients. Although the exact sensitivity and specificity are unknown, gastroduodenoscopy is the diagnostic gold standard because it allows for direct visualization and biopsy of the ulcer; radiographie studies are less revealing.

Carbohydrate Intolerance. Lactose intolerance is the most common of the carbohydrate intolerances.14 Chronic abdominal pain due to lactose intolerance is commonly associated with bloating, flatulence, and diarrhea. The syndrome is more prevalent in adolescents who are black, peri-Mediterranean, American Indian, or Asian in origin. Sorbito!, a nonabsorbable, common sugar substitute in diets is also a frequent offender.

Dysmenorrhea and Pelvic inflammatory Disease Syndromes. In the adolescent female, dysmenorrhea and pelvic inflammatory disease (PID) syndromes are two common causes of CAP that must be considered.*5 With dysmenorrhea, the pain typically begins before or close to the onset of menses, lasts up to 3 or 4 days, and is suprapubic and bilateral in location. Most cases are due to primary dysmenorrhea; however, secondary dysmenorrhea should be suspected when there is associated fever, weight loss, and the presence of an intrauterine device. This periodic pain may also be part of endometriosts and pelvic inflammatory disease. It should be recognized that menses may exacerbate the signs and symptoms of IBS. Patients with IBS might show an exaggerated bowel motility response due to pros tagland ins or other substances released during menstruation.

Pelvic inflammatory disease syndrome is the most serious complication of sexually transmitted diseases, which are increasing in frequency because of adolescent sexual behaviors. The risk is greater when the patient is promiscuous and when intrauterine contraceptive devices are used. TKe PID syndrome may cause recurrent lower abdominal pain, dyspareunia, dysmenorrhea, and occasionally perihepatitis (Rtz-HughCurtis syndrome).

TREATMENT

A number of generalizations can be made when one approaches the problem of chronic abdominal pain (Table 3). The physician should try to make the diagnosis of dysfunctional and psychogenic causes in a positive, logical manner rather than by exclusion of organic causes. It is essential to clearly explain the symptoms and signs to the patient from a physiopathological point of view and to convey that the pain and other complaints are really in the abdomen and not in the head. Terms such as emotional, psychogenic, and stress-related are frequently misinterpreted as "imaginary and manipulative" and may alienate the patient or the family. The patient's perception and expectations should be factored into the treatment goals, and this should be discussed openly.

Irritable Bowel Syndrome

In mild cases, reassurance is the cornerstone of treatment, and the patient is encouraged to eat regularly, including only foods that are well-tolerated. Dietary manipulation16 is still controversial, except with suspected or actual nutrient intolerances, eg, lactose. Despite the widespread "bran wagon," the efficacy of dietary fiber supplements has been studied in IBS patients in controlled crossover studies, with beneficial effects reported in only 4 out of 10 reports; a placebo effect is most common.17 When patients insist on a dietary fiber supplement or diet, it should be prescribed with the caveat that excessive fiber may actually increase pain and also cause excess gas and abdominal distention.

A mild laxative should be used when there is evidence of constipation. A stool softener, such as dioctyl sulfosuccinate, 300 mg two or three times daily, or a Senna preparation given twice a day, may be very effective in about half of cases. Chronic laxative use of any kind should be avoided.

Severe cases are usually functioning poorly and require more aggressive therapy. The recommendations for reassurance, dietary therapy, and laxatives are similar to those used for milder cases. A clear plan for effecting a postprandial bowel movement is indicated with diarrhea-prone and constipation-prone patients. It is important to present the goal of learning to live with "some discomfort" and to develop a plan to normalize lifestyle as soon as possible. This requires the cooperation of the family and school officials, and general agreement to decrease attention to the patient's somatic complaints. Other behavioral strategies include increasing physical activities, rewarding healthy behaviors, and encouraging patient coping and participation in the treatment. Specific techniques such as biofeedback, relaxation, and stress management require special professional intervention (see the March 1991 issue of Pedíame Annals).

Multitreatment pain control centers have recently emerged as a rational and efficient modality to treat difficult cases. Some of these centers have used acupuncture and hypnosis as part of the regimen. Unfortunately, to date, there are few studies to evaluate the work of these centers.

Psychiatric or psychosocial referrals are frequently necessary and should be made early in the course of management. Several approaches have been used with success, such as individual psychotherapy, behavior modification, and family and group therapy.

Although many patients appear to improve dramatically following hospitalization, this is only transitory and is frequently rejected for reimbursement by thirdparty payers. Medications as a general rule should be used minimally. These include analgesics, antidepressants and benzodiazepines. Anticholinergic and antispasmodic drugs are widely used by primary care physicians, but there is no evidence that they have any consistently good results.

Nonulcer Dyspepsia

These patients also require an individualized treatment plan with emphasis on reassurance, primary care physician availability, and defusion of psychosocial issues. Although there is little evidence that these factors make a difference, patients should be advised to avoid smoking, using analgesics, and drinking alcohol and coffee. While no relationship of symptoms to eating specific foods has been established, limited dietary elimination should be tried, based on the patient's recorded experience. The use of prokinetic drugs, H2-receptor blockers, and antibiotics directed to H pylori are anecdotally successful, but require further substantiation before they can be generally recommended.

Finally, psychogenic CAP patients almost always require appropriate input from mental health professionals, and psychoactive drugs may be indicated. The various psychotherapies as noted above should be recommended early in the management of these patients to enable the development of coping strategies.

SUMMARY

Although there are very few prospective studies of CAP, organic causes of the problem are misdiagnosed probably in less than 5% of adolescents. Response to treatment seems to be better in males who have had signs and symptoms for less than 6 months, and is rather poor for patients with complaints exceeding 2 years. An organized nomenclature is necessary for classifying dysfunctional disorders, and physicians must recognize that these patients represent a heterogeneous population. In general, adequate data for the number of the adolescent population affected by these diseases is not available, so that physicians are still required to depend to a large extent on speculation and anecdotal information in assessing and managing these patients.

REFERENCES

1. Apley J. The CMd With Abdominal Pomi. 2nd ed. Oxford: Blackwell 1975.

2. Davidson M, Wissetman R. The irritable tolun of childhood (chiunic nonspecific diarrhea syndrome). J Pediatr. i966;69:I027-1038.

3. Sullivan MA, Cohn S, Snapc WJ. Chronic myoeleclrical activity in the irritable bowel syndrome: effect of eating and antic holinerg ics. N Engl ) MoJ. 1978;298:878883.

4. Kelkiw JE, Gill RC, Wingate DL. Prolonged ambulem recordings of small bowel motility demonstrate abnormalities in the irritable bowel syndrome. Gosrroenieroiogv. 1990;98:120T-1218.

5. Kopel FB, Kim IC, Barberu GJ. Comparison of recEosigmoid motility in normal children, children with recurrent abdominal pain and children with ulcerative colitis. Pediatrici. 1967:39:539.

6. Barbero CJ. Recurrent abdominal pain in childhood. Pediorr Rev. 1982;4i29-34.

7. Whitehead WE, Hultkotier B, Enck P, et al. Tolerance foi reciosigmoid distenlion in irritable bowel syndrome. Grclroeruerniogj. 1990;98:l 187-1 192.

8. Talley NJ, Phillips SE Non-ulcer dyspepsia: potential causes and pathophysiology. Ann i™ Me¿. 1988:108:865-879.

9. Current Estimates From àie National Health Interview Surveys of United Stales, i987. Dala fVum Af National HÍOÍI/I Survey, Series 10, No 166. Hyatville, Md: National Center for Health Statistics; 1988. US Depl of Healrh and Human Services publication PSH 88-1594.

10. Manning AP, Thompson WG, Heaton KW, et al. Towards a positive diagnosis of the irritable bowel syndrome. BrMeJJ. 1978:2:653-654.

11. Kingham JGC, Dawson AM. Origin cf chronic tight upper quadrant pain. Gui. 1985;26:7S3-78S.

12. Daum E Pediatrie inflammatory bowel disease. In: Silverbeig M, Daum F, eds. Textbook of Pediatrie Gastroenterology. Chicago, ill: Yearbook Medical Publishers; 1988:392-412.

13. Drumm B, Rhoads JM, Stringer D"\, et al. Peptic ulcer disease in children: etiology, clinical findings, and clinical course. Pediamcs. 1988. 82:410-414.

14. Lebenthal E, Rossi TM, Nord KS, et al. Recurrent abdominal pain and lactose absorption in children. Pediatrics. 1981;67:828-832.

15. Barr RG. Abdominal pain in the female adolescent. Pediutr Rev. 1983;4:2?1-289.

16. Nanda R, James R, Smith JR, et al. Fond intolerance and the irritable brave! syndrome. Gut. 1989;ÌO:1099-1104.

17. Cook JJ. living EJ, Campbell D. et al. Effect of dietaty fibei on symptoms and rectosigmoid motility in patients with irritable bowel syndrome: a controlled crossover study. Gastroenterologe 1990:98:66-72.

TABLE 1

Characteristics of Nonorganic Chronic Abdominal Pain

TABLE 2

Characteristics of Organic Chronic Abdominal Pain

TABLE 3

Management Principles in Adolescents With Chronic Abdominal Pain

10.3928/0090-4481-19910401-06

Sign up to receive

Journal E-contents