Recurrent abdominal pain is one of the chief complaints in pediatric gastroenterology.1 However, it is reassuring to know that after a methodic clinical history, physical examination, minimal diagnostic testing, and thoughtful reassurance, the majority of the patients improve, especially when functional disorders are the cause. Abdominal pain can be secondary to celiac, Crohn's, gallbladder, or pancreatic disease. The presence of red flags helps clinicians determine a diagnosis. In patients with no red flags, the need for extensive testing is rarely necessary; a “million-dollar evaluation” frequently does not yield any useful information. In contrast, it can induce more parental anxiety.2
Functional Abdominal Pain
Functional abdominal pain is a frequent symptom in the pediatric patient; it accounts for approximately 3% to 4% of visits to primary care pediatricians, and 25% of visits to pediatric gastroenterologists.1 According to the Rome III criteria, functional gastrointestinal disorders are defined as the presence of abdominal pain at least once a week for at least 2 months.3 Complex factors, including the presence of comorbidities such as anxiety, school pressure, lack of coping skills, parental reinforcing factors, history of infectious processes, and dietary factors, can induce and perpetuate abdominal pain in children.4–7 Together, these factors constitute the “biopsychosocial model” for pain. The primary care visit should include (1) a complete history and physical examination to rule out red flags, (2) an in-depth discussion of parental concerns, coupled with education about reinforcing factors and coping skills, and (3) substantial reassurance; this is all essential to managing children with functional abdominal pain.
The pathophysiology of functional abdominal pain involves a distortion of the perception of visceral sensation that alters the brain-gut communication. In a healthy person, the interoceptive signaling from the viscera to the brain is usually not perceived; however, in patients with functional abdominal pain, the afferent signals traveling through the spinothalamic afferents to the somatosensory cortex are distorted and therefore perceived as pain in the abdomen. Because afferent signals travel in conjunction with autonomic pathways and project on different somatosensory areas, including the amygdala, it explains why these patients have multiple abnormal autonomic and behavioral responses associated with the perception of the pain. Central and peripheral sensitization also contribute to pain, and previous traumatic experiences or infections may also be a key factor.8,9
Red Flags and Diagnostic Clues
There are many organic causes of recurrent abdominal pain that may be classified according to the frequency of presentation and the localization of pain severity. The most common organic causes of chronic abdominal pain are listed in Table 1.
Common Organic Causes of Chronic Abdominal Pain
For decades, diagnostic “red flags” have been used as clues to distinguish organic and functional disorders of the gastrointestinal tract. Recently, however, new data suggest that differentiating organic and functional abdominal pain based on a few clinical signs may be unreliable and that not all red flags are of equal diagnostic value.10
Perhaps the most valuable red flags are those that emerge from the patient's history and physical examination, in which diseases and conditions associated with abdominal pain that merit referral for medical or surgical evaluation and treatment are promptly recognized. For example, the presence of blood in the stool is commonly associated with intestinal inflammation, and necessitates an evaluation for infectious, inflammatory diseases or the presence of intestinal polyps. Anal fissures should lead to an assessment for Crohn's disease. Unexplained periodic fever is a worrisome sign that should prompt a referral for evaluation for inflammatory bowel disease, malignancy, and rheumatoid disorders. Unintentional weight loss is also concerning and should prompt evaluations for tuberculosis, rheumatoid disease, inflammatory bowel disease, celiac disease, and other types of inflammatory and infectious enteropathies. Frequent emesis, in particular bilious vomiting, suggests the presence of partial obstruction or intermittent intussusception. Constipation and abdominal distension are associated with strictures or narrowing of the large intestine; lymphoma can present as a mass palpable in the abdomen. The presence of right upper quadrant and epigastric pain warrants evaluation for gallbladder disease, peptic ulcer disease, gastritis (including Helicobacter pylori infection), and chronic pancreatitis. Hematuria, dysuria, and flank pain suggest pyelonephritis or ureteral obstruction.
During the physical examination, jaundice, pallor, a mass palpable in the abdomen, hepatomegaly, splenomegaly, and diffuse lymphadenopathy are worrisome signs suggestive of chronic conditions such as infections, autoinflammatory diseases, or malignancy. Rashes, especially vasculitic or purpuric rashes, suggest systemic vasculitis that can also involve the gastrointestinal tract. Patients with family histories of inflammatory bowel disease, celiac disease, H. pylori infection, polyposis, or pancreatitis should be examined carefully, recognizing that the prevalence rates of these diseases are increased in patients with family histories of these disorders.
Functional Abdominal Pain Disorders in Children and Adolescents
Functional gastrointestinal disorders are classified according to the Rome IV criteria that was recently articulated in a consensus statement for this condition.11 In short, the criteria indicate that patients with functional gastrointestinal disorders have recurrent symptoms not attributable to an inflammatory, neoplastic, or metabolic cause. Patients with functional gastrointestinal diseases lack the red flag signs and symptoms described above and have a normal physical examination.
The Most Common Conditions
Functional dyspepsia is described as the presence of upper abdominal discomfort or pain, early satiety, and postprandial fullness occurring at least weekly or 4 or more times per month.11 Pain and discomfort due to functional dyspepsia are not relieved by defecation.
Recently, two variants of functional dyspepsia were adopted from the adult literature.11,12 The first variant of functional dyspepsia—postprandial distress syndrome—presents with early satiety, bloating, belching, and postprandial nausea. The second variant of functional dyspepsia—epigastric pain syndrome—presents with an epigastric burning sensation without a retrosternal component. Neither postprandial distress syndrome nor epigastric pain syndrome is relieved with defecation.12
Irritable bowel syndrome is abdominal pain or discomfort that occurs at least 4 days per month.11 Pain is either related to defecation or associated with a change in the consistency or frequency of the stool.
Functional abdominal pain presents as episodic or continuous abdominal pain occurring at least 4 times per month.11 Functional abdominal pain does not occur in association with normal physiological events, such as menses, without other criteria for functional gastrointestinal disorders.
Childhood functional abdominal pain syndrome often occurs with other somatic symptoms, such as a headache, limb pain, or difficulty sleeping.11 In more than 25% of pediatric patients with functional abdominal pain, there is some loss of daily functioning.11
An abdominal migraine is defined as the occurrence of paroxysmal episodes of acute and intense periumbilical abdominal pain lasting for more than 1 hour. Abdominal migraine episodes are separated by periods of weeks to months of no symptoms. Pain in abdominal migraines interferes with normal activities and is associated with two or more of the following symptoms: anorexia, nausea, vomiting, headaches, photophobia, and pallor.11
The tests most commonly performed during the first clinic visit for evaluation of recurrent abdominal pain include a complete blood count, a serum metabolic panel, an erythrocyte sedimentation rate, a urinalysis, fecal occult blood and, in some selected cases, fecal calprotectin.13 Abdominal radiographs have a low yield, but may be helpful when masses or constipation are suspected. Abdominal ultrasonography is helpful when pain localizes to the right upper quadrant, when a mass is detected, or when kidney stones are suspected. If these studies are normal, then referral to a pediatric gastroenterologist for specialty studies (Table 2) should be considered.
Specialty Studies and Procedures Ordered by a Pediatric Gastroenterologist
Management and Reassurance
In patients with functional abdominal pain, providing the parents with explanations that help them understand the pathophysiology of recurrent pain is a mainstay of therapy. Successfully providing reassurance requires adequate time during the clinic visit for parents to discuss their concerns. An important facet of the discussion about functional abdominal pain is establishing end goals that include modification of factors and behaviors that trigger and perpetuate abdominal pain, as well as those intended to increase resiliency and coping skills.
Diet and Nutrition
Appropriate dietary and nutritional counseling are important objectives of the clinic visit. An accurate recollection of the patient's diet should be documented in the medical record. Disease-specific dietary modifications can then be recommended. Particular attention should be paid to the types and quantities of carbohydrates in the recommended diet. For patients with irritable bowel syndrome and functional abdominal pain, the low FODMAPs (Fermentable Oligo-saccharides, Di-saccharides, Mono-saccharides And Polyols) diet has gained popularity. The low FODMAPs diet reduces the amount of dietary short-chain carbohydrates that induce gas production, leading to distention of the large intestine, bloating, and abdominal pain.19 For patients with functional abdominal pain, food components to avoid include: fructose-containing fruits and juices, honey, high fructose corn syrup, lactose and lactose-containing dairy products; fructans contained in wheat, onion, and garlic; galactans contained in beans, lentils, and legumes such as soy; polyols, such as sorbitol, mannitol, xylitol, and maltitol, which are often used as sweeteners; and stone fruits, such as avocado, apricots, cherries, nectarines, peaches, and plums. Wheat and other gluten-containing products should be excluded from the diets of patients with nonceliac gluten sensitivity.20
Medications and Pharmacology
Several medications have been used in treating chronic abdominal pain. The decision to prescribe medication to a patient with abdominal pain should be individualized, and the side-effect profile of all medications should be discussed. The most common medication categories used include antiacids, antisecretory, antispasmodics, antidepressants (tricyclic antidepressant amitriptyline), antihistamines, and anticonvulsants. Antispasmodics (including peppermint oil) are also used commonly in these patients; during a short course, less than 8 weeks, their efficacy is superior to placebo.21 The side effects of antispasmodic therapies include constipation and urinary retention. In a trial, the use of citalopram led to modest clinical improvement over the placebo.22 Despite evidence supporting the use of tricyclic antidepressants for treatment of functional abdominal pain, the efficacy of tricyclic antidepressant therapy is only modestly better than placebo, 63% versus 47%;23 behavioral changes and suicidal ideation are possible side effects. Cyproheptadine, an antihistamine, is often prescribed as an effective treatment for functional abdominal pain;24,25 side effects include sedation and weight gain.
There are reports that holistic and psychological therapies have roughly the same rates of improvements as medications.26 Parents should be aware that there is a high probability that the patient will improve without medication, as evidenced by the substantial placebo effect found in the management of functional abdominal pain (the placebo effect alone may account for 9%–53% of patient improvement).27
Studies have found that the use of psychological therapies, such as gut-induced hypnotherapy, cognitive-behavioral therapy, hypnotherapy, and visual imagery, may be superior to standard pharmacological therapies for treatment of functional abdominal disease.28–30
In general, chronic abdominal pain improves in 15% to 25% of patients.31 A proportion of patients develop other functional syndromes such as irritable bowel syndrome.6 The presence of perpetuating factors, including dysfunctional families, the presence of comorbidities, and family reinforcing behaviors, contribute to the persistence of recurrent abdominal issues.32
Recurrent abdominal pain is frequently seen in the pediatric primary care and gastroenterology practice. Although a detailed history and physical examination are enough to make a diagnosis in most cases, careful attention is necessary to exclude red flag signs. Pain management should be individualized, and multiple therapeutic resources are available.
- Starfield B, Hoekelman RA, McCormick M, et al. Who provides health care to children and adolescents in the United States?Pediatrics. 1984;74(6):991–997.
- Dhroove G, Chogle A, Saps M. A million-dollar work-up for abdominal pain: is it worth it?J Pediatr Gastroenterol Nutr. 2010;51(5):579–583. doi:10.1097/MPG.0b013e3181de0639 [CrossRef]
- Rasquin A, Di Lorenzo C, Forbes D, et al. Childhood functional gastrointestinal disorders: child/adolescent. Gastroenterology. 2006;130(5):1527–1537. doi:10.1053/j.gastro.2005.08.063 [CrossRef]
- Pensabene L, Talarico V, Concolino D, et al. Postinfectious functional gastrointestinal disorders in children: a multicenter prospective study. J Pediatr. 2015;166(4):903–907. doi:10.1016/j.jpeds.2014.12.050 [CrossRef]
- Devanarayana NM, Rajindrajith S, Benninga MA. OP-20 the association between adverse life events and abdominal pain-predominant functional gastrointestinal disorders. J Pediatr Gastroenterol Nutr. 2015;61(4):517–518. doi:10.1097/01.mpg.0000472224.86421.3d [CrossRef]
- Horst S, Shelby G, Anderson J, et al. Predicting persistence of functional abdominal pain from childhood into young adulthood. Clin Gastroenterol Hepatol. 2014;12(12):2026–2032. doi:10.1016/j.cgh.2014.03.034 [CrossRef]
- van Tilburg MA, Levy RL, Walker LS, et al. Psychosocial mechanisms for the transmission of somatic symptoms from parents to children. World J Gastroenterol. 2015;21(18):5532–5541. doi:10.3748/wjg.v21.i18.5532 [CrossRef]
- Mayer EA, Tillisch K. The brain-gut axis in abdominal pain syndromes. Annu Rev Med. 2011;62:381–396. doi:10.1146/annurev-med-012309-103958 [CrossRef]
- Farmer AD, Aziz Q. Visceral pain hypersensitivity in functional gastrointestinal disorders. Br Med Bull. 2009;91:123–136. doi:10.1093/bmb/ldp026 [CrossRef]
- Gijsbers CF, Benninga MA, Schweizer JJ, Kneepkens CM, Vergouwe Y, Büller HA. Validation of the Rome III criteria and alarm symptoms for recurrent abdominal pain in children. J Pediatr Gastroenterol Nutr. 2014;58(6):779–785.
- Hyams JS, Di Lorenzo C, Saps M, Shulman RJ, Staiano A, van Tilburg M. Functional disorders: children and adolescents. Gastroenterology. 2016; doi:10.1053/j.gastro.2016.02.015 [CrossRef]. [Epub ahead of print]
- Schurman JV, Singh M, Singh V, Neilan N, Friesen CA. Symptoms and subtypes in pediatric functional dyspepsia: relation to mucosal inflammation and psychological functioning. J Pediatr Gastroenterol Nutr. 2010;51(3): 298–303.
- Holtman GA, Lisman-van Leeuwen Y, Reitsma JB, Berger MY. Noninvasive tests for inflammatory bowel disease: a meta-analysis. Pediatrics. 2016;137(1). doi:10.1542/peds.2015-2126 [CrossRef]. [Epub ahead of print]
- Cristofori F, Fontana C, Magistà A, et al. Increased prevalence of celiac disease among pediatric patients with irritable bowel syndrome: a 6-year prospective cohort study. JAMA Pediatr. 2014;168(6):555–560. doi:10.1001/jamapediatrics.2013.4984 [CrossRef]
- Kansu A, Kuloğlu Z, Demir A, Yaman ATurkish Celiac Study Group. Yield of coeliac screening in abdominal pain-associated functional gastrointestinal system disorders. J Paediatr Child Health. 2015;51(11):1066–1070. doi:10.1111/jpc.12929 [CrossRef]
- Meijer CR, Shamir R, Mearin ML. Coeliac disease and noncoeliac gluten sensitivity. J Pediatr Gastroenterol Nutr. 2015;60(4):429–432. doi:10.1097/MPG.0000000000000708 [CrossRef]
- Iwanczak F, Siedlecka-Dawidko J, Iwanczak B. Gallbladder contractility in children with functional abdominal pain or irritable bowel syndrome. Pol Merkur Lekarski. 2013;35(205):14–17.
- Korterink JJ, Benninga MA, van Wering HM, Deckers-Kocken JM. Glucose hydrogen breath test for small intestinal bacterial overgrowth in children with abdominal pain-related functional gastrointestinal disorders. J Pediatr Gastroenterol Nutr. 2015;60(4):498–502. doi:10.1097/MPG.0000000000000634 [CrossRef]
- van Tilburg MA, Felix CT. Diet and functional abdominal pain in children and adolescents. J Pediatr Gastroenterol Nutr. 2013;57(2):141–148. doi:10.1097/MPG.0b013e31829ae5c5 [CrossRef]
- Gibson PR, Shepherd SJ.Evidence-based dietary management of functional gastrointestinal symptoms: the FODMAP approach. J Gastroenterol Hepatol. 2010;25(2):252–258. doi:10.1111/j.1440-1746.2009.06149.x [CrossRef]
- Poynard T, Regimbeau C, Benhamou Y. Meta-analysis of smooth muscle relaxants in the treatment of irritable bowel syndrome. Aliment Pharmacol Ther. 2001;15(3):355–361. doi:10.1046/j.1365-2036.2001.00937.x [CrossRef]
- Roohafza H, Pourmoghaddas Z, Saneian H, Gholamrezaei A. Citalopram for pediatric functional abdominal pain: a randomized, placebo-controlled trial. Neurogastroenterol Motil. 2014;26(11):1642–1650. doi:10.1111/nmo.12444 [CrossRef]
- Jackson JL, O'Malley PG, Tomkins G, Balden E, Santoro J, Kroenke K. Treatment of functional gastrointestinal disorders with antidepressant medications: a meta-analysis. Am J Med. 2000;108(1):65–72. doi:10.1016/S0002-9343(99)00299-5 [CrossRef]
- Madani S, Cortes O, Thomas R. Cyproheptadine use in children with functional gastrointestinal disorders. J Pediatr Gastroenterol Nutr. 2016;62(3):409–413. doi:10.1097/MPG.0000000000000964 [CrossRef]
- Sadeghian M, Farahmand F, Fallahi GH, Abbasi A. Cyproheptadine for the treatment of functional abdominal pain in childhood: a double-blinded randomized placebo-controlled trial. Minerva Pediatr. 2008;60(6):1367–1374.
- Rutten JM, Korterink JJ, Venmans LM, Benninga MA, Tabbers MM. Nonpharmacologic treatment of functional abdominal pain disorders: a systematic review. Pediatrics. 2015;135(3):522–535. doi:10.1542/peds.2014-2123 [CrossRef]
- Saps M, Biring HS, Pusatcioglu CK, Mintjens S, Rzeznikiewiz D. A comprehensive review of randomized placebo-controlled pharmacological clinical trials in children with functional abdominal pain disorders. J Pediatr Gastroenterol Nutr. 2015;60(5): 645–653. doi:10.1097/MPG.0000000000000718 [CrossRef]
- Vlieger AM, Menko-Frankenhuis C, Wolfkamp SC, Tromp E, Benninga MA. Hypnotherapy for children with functional abdominal pain or irritable bowel syndrome: a randomized controlled trial. Gastroenterology. 2007;133(5):1430–1436. doi:10.1053/j.gastro.2007.08.072 [CrossRef]
- Youssef NN, Rosh JR, Loughran M, et al. Treatment of functional abdominal pain in childhood with cognitive behavioral strategies. J Pediatr Gastroenterol Nutr. 2004;39(2):192–196. doi:10.1097/00005176-200408000-00013 [CrossRef]
- Rutten JM, Vlieger AM, Frankenhuis C, et al. Gut-directed hypnotherapy in children with irritable bowel syndrome or functional abdominal pain (syndrome): a randomized controlled trial on self exercises at home using CD versus individual therapy by qualified therapists. BMC Pediatr. 2014;14:140. doi:10.1186/1471-2431-14-140 [CrossRef]
- Gieteling MJ, Bierma-Zeinstra SM, Passchier J, Berger MY. Prognosis of chronic or recurrent abdominal pain in children. J Pediatr Gastroenterol Nutr. 2008;47(3):316–326. doi:10.1097/MPG.0b013e31815bc1c1 [CrossRef]
- Mulvaney S, Lambert EW, Garber J, Walker LS. Trajectories of symptoms and impairment for pediatric patients with functional abdominal pain: a 5-year longitudinal study. J Am Acad Child Adolesc Psychiatry. 2006;45(6):737–744. doi:10.1097/10.chi.0000214192.57993.06 [CrossRef]
Common Organic Causes of Chronic Abdominal Pain
||Helicobacter pylori, NSAIDs gastropathy, IBD
||Anemia, positive FOB
||Stool H. pylori, EGD
|Small bowel colon
||HS purpura, NSAIDs gastropathy
||Stool giardia ELISA
||Diarrhea, weight loss, anemia, constipation
||TTG IgA, IgA total
||Intussusception, Meckel's diverticulum
||US, Meckel's diverticulum, CT
||Weight loss, vomiting
||MRE, endoscopy, CT
||Severe pain crisis
||Stricture, polyps masses
||Anemia, weight loss, vomiting
||CT, MRE, endoscopy
||Gallstones, choledochal cyst, hepatitis
||Jaundice, RUQ pain
||US, transaminitis, cholestasis
||Acute recurrent, chronic
||Vomiting, weight loss
||CT, elevated lipase
||Hematuria, back pain
||UA, US, CT
||Hematuria, back pain
||UA, US, CT
||Menstrual cycle abnormalities
||Ovarian cyst, endometriosis
||Menstrual cycle abnormalities
||Constipation, vomiting, weight loss
||Reproducibility with pressure
||Angioedema, circumferential jejunitis
||Vomiting, weight loss
||CT, MR, UGI
Specialty Studies and Procedures Ordered by a Pediatric Gastroenterologist
Celiac antibodies in patients at risk for gluten enteropathy.14,15 In children, abdominal pain and chronic diarrhea are the most common symptoms of nonceliac gluten enteropathy16
Upper endoscopy for patients with epigastric pain, heartburn, vomiting, or hematemesis, or when inflammatory bowel disease is suspected
Colonoscopy for patients suspected of having inflammatory bowel disease because of weight loss, fevers, chronic diarrhea, or blood or mucous in the stool
HIDA scan in patients with right upper quadrant abdominal pain in whom biliary dyskinesia is suspected17
Glucose or lactulose breath test when bacterial overgrowth is suspected in patients with irritable bowel syndrome18