Recurrent abdominal pain in children

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Dr Hemal Dave, 2nd year resident, Karamsad Medical collegeDR. Manoj K Ghoda

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12 FDaughter of an anesthetistReferred for “recurrent abdominal pain” for past 2 years

History mainly given by mother and when allowed (!) by father; the childmainly kept fiddling with her “mobile”

On examination:

Medium built,No anemia, cyanosis, jaundice, lymphnodes

P/A

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Should we accept the diagnosis of RAP made elsewhere, or investigate this case further? Why?

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Let us see what different kinds of abdominal pains this young lady could have……

Acute

OrganicInorganic/ Idiopathic/

functional

Chronic

OrganicInorganic/ Idiopathic/

functional

Here again there may be many variations

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One has to be careful.

Goo......d historyAttention to body languageThorough physicalMeticulous follow-

up

Pain distant from the umbilicus

Pain that awakens the child

Significant vomiting or diarrhea

Associated fever

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Organic pain

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• Family history of organic diseases

• Involuntary weight loss, slowed linear growth, or delayed puberty

• Systemic involvement

Organic pain

Localized fullness or mass effect

Organomegaly Localized

tenderness Perianal

abnormalities

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Organic pain

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◦Anemia◦Gastrointestinal blood loss◦Elevated ESR◦Altered LFTs◦Abnormal Urine examination

Organic pain

Urine

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Organic painOrganic pain

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Functional abdominal pain will have none of these.

Different types of idiopathic/ inorganic pains

•Recurrent abdominal pain

•Chronic abdominal pain

•Functional abdominal pain

Common understanding of Recurrent abdominal Pain

History of at least three episodes of pain Pain sufficiently severe to affect activities Episodes occur over a period of three months No known organic cause

Hyams et.al 1996.

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Recurrent abdominal pain is usually central

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Functional abdominal pain

For practical purpose .....

it is a type of pain which affects a particular GI function but there is no organic cause that could be found.

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So.. Functional pain could be..

Functional dyspepsia (Rome III criteria, 2006)

•Epigastric Localization•Persistent or recurrent•Associated with eating;•Nausea, vomiting, heartburn, oral regurgitation, •Early satiety, excessive hiccups and belching.

No evidence of underlying organic problem

Functional Abdominal Pain

Irritable bowel syndrome

Functional abdominal pain associated with alteration in bowel movements

Symptoms of altered bowel pattern include: diarrhea, constipation, or a sense of

incomplete evacuation.

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Abdominal migraine

◦Paroxysmal abdominal pain

◦Anorexia, nausea, vomiting or pallor

◦ Maternal history of migraine headaches

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Functional abdominal pain syndrome

•Functional abdominal pain without the characteristics of dyspepsia, irritable bowel syndrome, or abdominal migraine.

• Have at least 25% of the time one or more of the following.

• Some loss of daily function. • Additional somatic symptoms such as headache, limb pain, or difficulty sleeping

•"recurrent abdominal pain" should not be used as a synonym for functional, psychological, or stress-related abdominal pain .

American Academy of Paed.2005

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Are these pains common? Should a pediatrician bother about them?

EPIDEMIOLOGY

Chronic abdominal pain affecting 9-15% of children.

13% of middle school and 17% of high school children have weekly complaints of abdominal pain.

In a study of 1,000 school-age children, RAP affected males & females equally up to 9 yrs. of age, the incidence in females increased such that between 9 & 12 yrs., the female-to-male ratio was 1.5:1.

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EVALUATION

AAP and NASPGHAN guidelines: History, physical examination, and stool

testing for occult blood to identify potential indications of an organic etiology.

Thorough physical examination .....” USG, endoscopy, or esophageal pH

monitoring not helpful in the absence of "alarm findings”.

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Management of functional abdominal pains

Reassurance and education of the child and family.

Symptomatic treatment.

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Outcome

After 5 years,

1/3 of children with RAP will have resolution of their pain,

1/3 continue to complain of the same symptoms, and

1/3 will have a different recurrent pain complaint.

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Coming back to our case..

Since the pain was located in epigastriumVomiting, and withEpigastric tenderness

This was taken as a case of APD.Dietary history was remarkable.

For past three months, she had eaten only and only junk food!

Diet was changed,PPI were given, and The patient counselled

Now she is free from here all complaints.

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Summary

Of various types of abdominal pains, a large minority have pain without identifiable cause or significant consequences.

To sit on them, you must satisfy yourself by way of meticulous history, physical and follow-up

Detailed investigations are not necessary for these “functional pain”

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Thanks

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SUMMARY AND CONCLUSIONS

Chronic abdominal pain is defined by pain of at least three months' duration, although some clinicians consider pain of more than one to two months' duration to be chronic.

Recurrent abdominal pain is defined by more than three episodes of pain that are sufficiently severe to affect activity and that occur over the course of at least three months.

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