RECURRENT ABDOMINAL PAIN IN CHILDREN

1

Khaled Hawwas

An 11 year old female presented on 15/8/2012 with :

Right sided abdominal pain, right loin pain. No urinary symptoms-regular bowel habit. Significant weight loss in the last 6 month. 2 month back, she attend medical care and

suspected to have UTI or appendicitis. U/S done : bilateral mild renal pelvis dilation

,no masses, reviewed by general surgeon and reported free.

2

One month back ,she visited causality because of abdominal pain, mid cycle pain, appendix abscess was suspected and was seen by surgeon ---non specific abdominal pain.

Lactulose was given as? Constipation. 2 weeks back, again , she got lower

abdominal pain and renal colic, pelvic inflammatory disease, abdominal migraine were suspected—referred to gynecologist---free

3

She lives with her mother 29 year old and father 34 year old.

Recently seeing her friends less than usual. Frequently sent home from school in the

last 6 month as she was feeling tired. Missed her exam through illness. Currently in school holiday.

Social history

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Paternal grandmother underwent bowel resection for Chron s disease .

Grand father is known to have recurrent renal stone.

Mother has migraine.

Family history

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No pallor or jaundice, no fever , hydrated. GIT: tender right inguinal fossa with fullness. tender right loin,no masses or

guarding. normal bowel sound. Other systemic examination was normal. CBC, liver& kidney functions—normal. CRP, ESR& electrolytes –normal. Urine routine was suggestive of uti. ?????????

Pysical examination & investigations:

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1.TERMINOLOGY AND DEFINITION2.EPIDEMILOGY & ETIOLOGY

PATHOPHYSIOLOGY 3.EVALUATION AND DIAGNOSIS4.MANAGEMENT5.PROGNOSIS

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OUTLINE OF PRESEN TATION

Chronic and recurrent abdominal pain are common symptoms in children and adolescents .

Chronic abdominal pain can be organic or nonorganic, depending on whether a specific etiology is identified.

Nonorganic or functional abdominal pain refers to pain without evidence of anatomic, inflammatory, metabolic, or neoplastic abnormalities.

Overlap between chronic and recurrent abdominal pain exists.

TERMINOLOGY

8SOURCE: J.APLEY

Chronic abdominal pain is defined by pain of at least two to three months' duration.

Recurrent abdominal pain is one of the most common recurrent pain syndromes in childhood.

The classic definition is based upon four criteria◦ 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

DEFINITION

9Source:Hyams et.al 1996.

The exact incidence and prevalence of chronic abdominal pain is not known.

There are reports of chronic abdominal pain affecting 9-15% of children.

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

It affect 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.

EPIDEMIOLOGY

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Chronic abdominal pain◦ Long-lasting intermittent or constant abdominal

pain that is functional or organic. Functional abdominal pain

◦ Abdominal pain without demonstrable evidence of pathologic condition, such as anatomic, metabolic, infectious, inflammatory or neoplastic disorder. Functional abdominal pain can manifest with symptoms typical of functional dyspepsia, irritable bowel syndrome, abdominal migraine or functional abdominal pain syndrome.

Recommended Clinical Definitions

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The American Academy of Pediatrics (AAP) and North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition (NASPGHAN) guidelines for the evaluation and treatment of children with chronic abdominal pain recommend that the term "recurrent abdominal pain" should not be used for functional, psychological, or stress-related abdominal pain .

12source: American Academy of

Paed.2005

Diagnostic criteria satisfy criteria for childhood functional abdominal pain and 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.

CHILDHOOD FUNCTIONAL ABDOMINAL PAIN SYNDROME 

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CHILDHOOD FUNCTIONAL GI DISORDERS: CHILD/ADOLESCENT

◦ Vomiting and aerophagia

◦ Cyclic vomiting syndrome◦ Aerophgia

◦ Functional dyspepsia

◦ Irritable bowel syndrome◦ Abdominal migraine◦ Childhood functional

abdominal pain ◦ Constipation and

incontinence ◦ Functional constipation

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The traditional concept that motility disorders alone have an important role in functional pain has not been confirmed.

It is believed that visceral hypersensitivity leading to abnormal bowel sensitivity to stimuli (physiologic, psychologic) might have a more dominant role in functional abdominal pain .

PATHOPHYSIOLOGY

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PATHOGENESIS OF FUNCTIONAL BOWEL DISEASE

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Children who have RAP tend to exhibit one of three clinical presentations:

◦ Isolated paroxysmal abdominal pain.◦ Abdominal pain associated with symptoms of

dyspepsia.◦ Abdominal pain associated with an altered bowel

pattern.

Clinical Presentations of RAP

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Common symptoms associated with recurrent abdominal pain

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(AAP) and (NASPGHAN) guidelines for the evaluation and treatment of children with chronic abdominal pain recommend history, physical examination, and stool testing for occult blood to identify potential indications of an organic etiology.

The technical review found little or no evidence to suggest that ultrasonography, endoscopy, or esophageal pH monitoring increase the yield of organic disease in the absence of "alarm findings”.

EVALUATION

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Evaluation and Diagnosis ALARM SYMPTOMS USUALLY NEEDING FURTHER INVESTIGATIONS

Pain that wakes up the child

from sleep Persistent right upper or

right lower quadrant pain Significant vomiting (bilious

vomiting, projectile vomiting, cyclical vomiting)

Unexplained fever Genitourinary tract

symptoms Dysphagia

Chronic severe diarrhea or nocturnal diarrhea

Gastrointestinal blood loss Involuntary weight loss Deceleration of linear

growth Delayed puberty Family history of

inflammatory bowel disease, celiac disease, and peptic ulcer disease

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ALARM SIGNS Needing Further Investigations

Localized tenderness in the right upper quadrant

Localized tenderness in the right lower quadrant

Localized fullness or mass

Hepatomegaly Splenomegaly

Jaundice Costovertebral angle

tenderness Arthritis Spinal tenderness Perianal disease Abnormal or

unexplained physical findings

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Laboratory studies may be unnecessary if the history and physical examination lead to a diagnosis of functional abdominal pain.

Nonetheless, medical tests can reassure the patient and family, and at times the physician, if there is significant functional disability and poor quality of life.

Contd.

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A complete blood cell count, sedimentation rate, C-reactive protein, basic chemistry, celiac panel, stool culture, stool test for ova and parasites, and urinalysis are reasonable screening studies.

The risk of celiac disease may be 4 times higher in these patients compared with the general population.

Elevated stool calprotectin levels usually suggest an inflammatory etiology.

Contd.

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If indicated, an ultrasound examination of the abdomen can give information about kidneys, gallbladder, and pancreas; with lower abdominal pain, a pelvic ultra sonogram may be indicated

An upper GI x-ray series is indicated if one suspects a disorder of the stomach or small intestine.

Helicobacter pylori infection does not seem to be associated with chronic abdominal pain, but in patients with symptoms suggesting gastritis or ulcer, an H. pylori test (fecal H. pylori antigen) may be performed.

Contd.

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Breath hydrogen testing is done for ruling out lactose or sucrose malabsorption.

Lactose intolerance is so common that the finding may be coincidental, and the clinician must be cautious in attributing chronic abdominal pain to this condition.

Esophagogastro-duodenoscopy is indicated with symptoms suggesting persistent upper GI pathology.

.

Contd.

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The two broad categories in the differential diagnosis for chronic or recurrent abdominal pain in children and adolescents are

◦ Organic disorders — Conditions in which physiologic, structural, or biochemical abnormalities are present.

◦ Functional disorders — Functional conditions are those for which no specific test exists with which to make the diagnosis.

Differential Diagnosis

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Common organic causes of chronic or recurrent abdominal pain include◦ Constipation.◦ carbohydrate malabsorption.◦ musculoskeletal pain.◦ parasitic infection.◦ Dysmenorrhea.◦ peptic disorders (eg, reflux esophagitis, gastritis,

gastric and duodenal ulcers.◦ H. pylori infection.

Organic Disorders

27Dern M.S 1999

◦Less common causes include: Urinary tract infections, inflammatory bowel

disease, and pelvic inflammatory disease. Other, rare causes must also be considered; they

include gallstones , kidney stones , late presentation of malrotation or volvulus , heavy metal poisoning , psoas abscess, meconium ileus, imperforate hymen with hematocolpos , ovarian neoplasm , pancreatic injury, familial Mediterranean fever , hypercalciuria , tuberculosis , and hereditary angioedema .

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Contd.

Functional disorders — Functional disorders are conditions in which the patient has a variable combination of symptoms without any readily identifiable structural or biochemical abnormality.

Several functional gastrointestinal disorders of childhood are recognizable .◦ Functional dyspepsia◦ Irritable bowel syndrome (IBS)◦ Functional abdominal pain◦ Abdominal migraine◦ Aerophagia

Functional Disorders

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Dyspepsia is pain or discomfort that is centered in the upper abdomen(ulcer- like). Discomfort may be characterized by fullness, early satiety, bloating, nausea, or vomiting( dysmotility- like).

Organic causes of dyspepsia symptoms include acid-related disease (esophagitis, gastritis, duodenitis), H. pylori, eosinophilic esophagitis, eosinophilic gastroenteritis, Crohn's disease, and celiac disease.

Functional Dyspepsia

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The pathophysiology of functional dyspepsia is not clear.

Abnormalities in gastric electrical rhythm, delayed gastric emptying, reduced gastric volume response to feeding, and antroduodenal dysmotility have been demonstrated in some children and adolescents .

Abnormal motor function, visceral sensitivity, and psychosocial factors have been studied as possible contributing factors in adults.

Contd.

31source:Cucchiara S,et al, 1992

No signs or symptoms reliably differentiate functional dyspepsia from upper gastrointestinal inflammatory, structural, or motility disorders.

Symptoms of dyspepsia usually generate a more extensive diagnostic evaluation .

Contd.

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IBS is characterized by chronic abdominal pain and altered bowel habits in the absence of any organic cause.

Organic causes that should be considered include Giardia, urinary tract infection, carbohydrate intolerance, inflammatory bowel disease, eosinophilic gastroenteritis, and celiac disease

Irritable Bowel

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IBS occurs infrequently before late adolescence and may be preceded by a long history of constipation or an episode of gastroenteritis.

The diagnosis of IBS can be made on the basis of symptoms; it need not be a diagnosis of exclusion .

Contd.

34source:Thabane M,et al, 2010

Children who have IBS have a lowered rectal pain threshold and disturbed rectal contractile response to meals .

Adolescents who have IBS-type symptoms

have higher anxiety and depression scores than do those without such symptoms .

Contd.

35source:Halac U,et al 2010

The symptoms in some children do not meet the diagnostic criteria for IBS or functional dyspepsia, or consistent with organic illness.

Functional abdominal pain may be associated with visceral hyperalgesia, reduced threshold for pain, abnormal pain referral after rectal distension, or impaired gastric relaxation response to meals.

Functional Abdominal Pain

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Abdominal migraine is characterized by recurrent episodes of abdominal pain, typically midline or poorly localized, dull and moderate to severe in intensity.

Pain is associated with at least two additional features that may include anorexia, nausea, vomiting, and pallor.

Abdominal Migraine

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Aerophagia is excessive air swallowing that causes:

◦ progressive abdominal distension ◦ may interfere with dietary intake

Aerophagia

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The most important component of the treatment is reassurance and education of the child and family.

The child and family need to be reassured that no evidence of a serious underlying disorder is present.

The family and the child with functional pain might worry about the inability to identify an organic cause and may be resistant to a diagnosis of nonorganic disease.

MANAGEMENT

39

Explanation in simple language that although the pain is real, there is no underlying serious disorder usually alleviates the anxiety in the patient and family.

Children of families that do not accept a functional cause of the symptoms are more likely to have persistent somatic complaints and school absences.

Contd.

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Treatment goals should be set for return to

function and minimizing pain. Cognitive-behavioral therapy is helpful in

the short term for managing pain and functional disability.

Relaxation techniques have been useful in some children with functional pain.

Time-limited use of medications .

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Contd.

The commonly used medications include acid suppressants for dyspepsia symptoms, antispasmodics, and low-dose amitriptyline.

For chronic abdominal pain with IBS symptoms, antidiarrheals and nonstimulating laxatives are used. Peppermint oil for 2 wk improves IBS symptoms in children.

There is no evidence that lactose-restricted diet and fiber supplements decrease the frequency of attacks in chronic abdominal pain in children.

Proton pump inhibitors or visceral muscle relaxants (anticholinergics) have been used empirically but are often unhelpful in the absence of specific indication.

Contd.

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THERAPYDEFINITION OF

DISORDEREFFECTIVENESS

Cognitive behavioral (family)

therapy

Recurrent abdominal pain

Beneficial

FamotidineRecurrent abdominal pain and dyspeptic

symptomsInconclusive

Added dietary fiberRecurrent abdominal

painUnlikely to be beneficial

Lactose-free dietRecurrent abdominal

painUnlikely to be beneficial

Peppermint oilIrritable bowel

syndromeLikely to be beneficial

AmitriptylineFunctional GI

disorders, Irritable bowel syndrome

Inconsistent results

Lactobacillus B Irritable bowel Unlikely to be beneficial

Patients who have ulcer-like dyspepsia are treated for 4 to 6 weeks with H2-receptor antagonists.

Patients who have dysmotility-like dyspepsia are treated for 4 to 6 weeks with prokinetic agents.

In fact, there are no objective data to support such a treatment.

Specific Treatment

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There are no prospective studies of the outcome of any of the various presentations of functional abdominal pain.

Retrospective studies suggest that organic disease rarely is masked in the context of a functional disorder.

Once functional abdominal pain is diagnosed, subsequent follow-up rarely identifies an occult organic disorder.

PROGNOSIS of RAP

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After 5 years, approximately one third of children with RAP will have resolution of their pain, one third will continue to complain of the same symptoms, and another one third will have a different recurrent pain complaint.

Outcome

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Up to date; Evaluation of the child and adolescent with chronic abdominal pain. Last literature review 19.1: January 22-6-2011. diagnostic criteria for functional gastrointestinal disorders at childhood (ages 4-18 years).

Clinical Report: New recommendations for treating children with chronic abdominal pain. Subcommittee on Chronic Abdominal Pain of the American Academy of Pediatrics. Pediatrics March 2006 .

Cochrane database of systematic reviews has ongoing reviews of psychosocial, dietary and pharmacological interventions.

REFERENCES

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THANK YOU

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