Abdominal Pain in the Pediatric Clinic

Amanda Lee MD

Doernbecher Children’s Hospital

Oregon Health & Science University

Division of Pediatric Gastroenterology

OHSU

Objectives

• Elicit the history for a pediatric patient with abdominal pain• Focus on chronic abdominal pain (> 2 months)

• Identify alarm signs and symptoms to prompt further work-up

• Initiate the work-up for a pediatric patient with abdominal pain

• Manage common causes of abdominal painOHSU

Abdominal Pain

• One of the most common childhood complaints

• Many causes, often self-limited and benign

• Rule out life-threatening causes• Bowel obstruction, perforation, hemorrhage

• Consider non-gastrointestinal causes• Urologic, musculoskeletal, infectiousOHSU

Case 1

• 15-year-old male with a 6-month history of abdominal painOHSU

History

• Pain Characteristics• Onset, duration, location, quality, aggravating and alleviating factors

• Associated Symptoms• Nausea, vomiting, dysphagia, anorexia

• Bowel Movements• Diarrhea, constipation, hematochezia, melena

• Review of Systems• Weight loss, fatigue, fevers, headaches, mouth sores, rashes, jaundice,

arthralgias, urinary symptoms, menstrual history in females

• Psychosocial

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Case 1: History

• Pain Characteristics• Periumbilical, cramping • Began 6 months ago, progressing in severity and frequency

• Associated Symptoms• Poor appetite, nausea when pain is severe

• Bowel Movements• Loose, 4-5 per day, urgency, nocturnal stools 3 times per week for the last month• No pain relief after stooling

• Review of Systems• 10 lb unintentional weight loss, fatigue

• Family History notable for father with ulcerative colitis

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Case 1: History

• Pain Characteristics• Periumbilical and lower abdomen, cramping • Began 6 months ago, progressing in severity and frequency

• Associated Symptoms• Poor appetite, nausea when pain is severe

• Bowel Movements• Loose, 4-5 per day, urgency, nocturnal stools 3 times per week for the last month• No pain relief after stooling

• Review of Systems• 10 lb unintentional weight loss, fatigue

• Family History notable for father with ulcerative colitis

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Physical Exam

? Vital Signs including height, weight, BMI

? General Appearance: body habitus, pallor, development

? HEENT: presence of aphthous ulcers

? Abdomen: focal tenderness, distension, hepatomegaly, splenomegaly, masses

? Perianal/rectal: skin tags, fissure, fistula

? Skin: rashes, jaundice

? Musculoskeletal: arthritis

? Lymphadenopathy

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Case 1: Physical Exam

• Growth: 10 lb weight loss since well check one year ago, decline in height percentiles from 75th to 50th

• General: thin, tired-appearing, mild pallor, pre-pubertal

• Abdomen: soft, non-distended, +mild tenderness to palpation diffusely, no masses or hepatosplenomegaly

• Perianal: irregular, non-tender perianal skin tag at 7 o’clock OHSU

Red Flags

• Bilious or severe, intractable vomiting

• Blood in stool• Chronic diarrhea

• 3+ loose stools/day > 2 weeks

• Symptoms wake patient from sleep

• Localized pain (RLQ, RUQ, LLQ)• Dysphagia or odynophagia• Frequent infections

• Unexplained fevers• Delayed puberty• Unintentional weight loss• Decrease in height velocity• Physical exam findings

• Oral ulcers• Arthritis• Rashes• Focal abdominal tenderness or mass• Organomegaly• Perianal: deep fissure, fistula, large or

inflamed skin tag

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Further Evaluation

• Complete blood count with differential (CBC)

• Comprehensive metabolic panel (CMP)• Electrolytes, glucose, BUN, creatinine, AST, ALT, bilirubin, albumin, total protein

• Erythrocyte sedimentation rate (ESR)

• C-reactive protein (CRP)

• Celiac serologies• Anti-tissue transglutaminase IgA, total IgA

• Stool studies to consider • Fecal calprotectin• Stool infectious studies • Fecal occult blood

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Case 1: Further Evaluation

• CBC notable for hemoglobin 11.2 g/dL (normal 12-16 g/dL), normal MCV

• CMP notable for albumin 3.3 g/dL (normal 3.4-5.4 g/dL)

• CRP 15 mg/L (normal < 1)

• ESR 42 mm/hr (normal < 30)

• Anti-TTG IgA negative

• Stool negative for infectious pathogens

• Fecal calprotectin elevated to 750 μg/g

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Case 1: Summary

• Chronic, progressive periumbilical and lower abdominal pain

• Chronic diarrhea with nocturnal symptoms

• Unintentional weight loss

• Delayed puberty

• Family history of inflammatory bowel disease

• Normocytic anemia, hypoalbuminemia, elevated serum and stool inflammatory markers

• Presentation concerning for inflammatory bowel disease

• Peds GI referral

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Case 2

• 13-year-old female with abdominal painOHSU

Case 2: History

• Pain Characteristics• Onset 6 months ago after the family had a stomach bug

• Sharp periumbilical pain

• Occurs 2-3 times per week, often post-prandial, lasts 30 minutes to 2 hours

• Alleviated by listening to music, sleep, passing stool

• Exacerbated by stress (ex. school exams) and eating fast foodOHSU

Case 2: History

• Bowel Movements• Vary from firm and difficult to pass to loose; 1-3 times daily; no blood; no

nocturnal stooling

• Associated Symptoms• Occasional nausea

• Review of Systems• Positive: fatigue, occasional tension-type headaches, anxiety

• Negative for fevers, mouth sores, vision/eye problems, joint pain or swelling, rashes, unintentional weight loss, urinary changes; normal menses

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Case 2: Physical Exam

• Growth: normal, gaining weight and height at 75th percentiles

• Unremarkable physical examOHSU

Functional Gastrointestinal Disorders (FGID)Disorders of Gut-Brain Interaction (DGBI)

Alteration in the Brain-Gut Axis• Central, autonomic, and

enteric nervous systems• Neuroendocrine system• Immune system• MicrobiotaChanges in • Visceral sensitivity• Motility• CNS processing

Mayer and Tillisch, 2011

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Biopsychosocial Model of Pain

Environmental

Gut microbiota

Medications

Infections

Diet

Psychosocial

Coping skills

Social support

Reinforcement

Distraction

Response

Biological

Genes

Motility

Visceral sensitivity

Mucosal function

Immune system

Allergies

Inflammation

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FGID / DGBI

• Introduce concept early

• NOT diagnoses of exclusion

• Rome IV criteria• Functional abdominal pain (not otherwise specified)• Irritable bowel syndrome• Functional dyspepsia• Abdominal migraine

• Validate their pain, build rapport, educate• NOT “all in your head,” but rather a disturbance in the complex brain-gut axis

• Further evaluation warranted if any red flags

• Pediatric GI referral more than welcome

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True or False?

You must rule out organic etiologies of abdominal pain

before diagnosing a functional GI disorder.

False

Functional and organic disorders can co-exist.

True

Psychological comorbidities are common in both organic and functional disorders.

True

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Rome IV Criteria for Functional Abdominal Pain Disorders

Functional Dyspepsia

• 1 or more of the following, at least 4 days per month

• Post-prandial fullness

• Early satiety

• Epigastric pain or burning not associated with defecation

• Criteria fulfilled for at least 2 months before diagnosis

Irritable Bowel Syndrome

• Abdominal pain at least 4 days per month associated with 1 or more:

• Related to defecation• A change in frequency of stool• A change in form/appearance of stool

• If constipated, pain does not resolve with resolution of constipation

• Criteria fulfilled for at least 2 months before diagnosis

Abdominal Migraine

• Paroxysmal episodes of intense, acute periumbilical, midline, or diffuse abdominal pain lasting 1 hour or more

• Episodes separated by weeks to months

• Incapacitating pain

• Stereotypical pattern

• Associated with 2 or more: anorexia, nausea, vomiting, headache, photophobia, pallor

• Criteria fulfilled at least 6 months before diagnosis

Functional Abdominal Pain NOS

• Episodic or continuous abdominal pain that does not occur solely during physiologic events

• Insufficient criteria for FD, IBS, AM

• Criteria fulfilled for at least 2 months before diagnosis

After appropriate evaluation, the symptoms cannot be fully explained by another medical condition.

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FGID/DGBI: Management

• Behaviors• Participation in rather than avoidance of activities• Sleep• Exercise

• Psychological• Coping skills, stress management• Clinical hypnosis• Cognitive behavioral therapy

• Diet• Avoid triggers, ex. lactose, excess fructose

• Medications• Regulate stools (laxatives, fiber)• Anti-spasmotics, ex. enteric-coated peppermint, hyoscyamine• Target visceral hypersensitivity, ex. amitriptyline • Others: cyproheptadine, probiotics, herbals, acid suppression

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Case 3

• 5 year old boy with abdominal painOHSU

Case 3: History

• Pain Characteristics• Began 3 months ago when he started kindergarten• Periumbilical and lower abdomen• 4 days per week, variable timing • Improves after stooling

• Bowel Movements• 2-3 per week, hard, sometimes large caliber• Toilet-trained but withholds at school and during play• Fecal smearing 1-2 times/week• Blood on toilet paper noted twice

• Associated Symptoms, Review of Systems• Overweight, normal development, good appetite but dislikes vegetables, active

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Case 3: Constipation

• Education• Pathophysiology of functional constipation• Rare to have underlying pathologic cause

• Behaviors• Avoid withholding• Post-prandial toilet sitting• Foot support

• Diet• Fiber (age + 5-10 grams)• Fluid

• Medications• Bowel clean-out if long-standing constipation• Maintenance regimen• Wean slowly

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Imaging

• Utility depends on suspected diagnosis

• Abdominal x-ray • Not needed to diagnose constipation

• Ultrasound• Cholelithiasis, ovarian pathology, hydronephrosis, mass

• CT• Urgent evaluation for acute process or concerning exam,

ex. abscess, perforation, mass

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Case 4

• 11-year-old boy with periumbilical painOHSU

Case 4: History

• Pain Characteristics• 3 months of symptoms• Periumbilical, dull• Occurs all the time, increase in frequency to daily • Exacerbated by eating, particularly with dairy• No relief with acid suppression

• Bowel Movements• Soft, sometimes loose, 1-2 daily, no blood

• Associated Symptoms, Review of Systems• Decreased energy, occasional headaches• No weight gain in 6 months, decrease in height percentiles from 50th to 25th

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Case 4

• Further workup due to poor growth • CBC: microcytic anemia

• CMP: normal

• Elevated anti-tissue transglutaminase IgA

• CRP, ESR normal

• Concern for celiac disease

• Refer to pediatric GI

• Continue gluten in the diet until celiac diagnosis confirmed with endoscopy with duodenal biopsies.

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Case 5

• 12-year-old girl with epigastric painOHSU

Case 5: History

• Pain Characteristics• 2 months, burning, post-prandial epigastric pain, exacerbated by greasy and spicy

foods

• Associated Symptoms• Early satiety, burning chest pain, acid brash • A few episodes of nausea with vomiting after a heavy meal• No dysphagia or odynophagia

• Bowel Movements• Soft, easily passed, 1-2 times daily, no melena or hematochezia

• Review of Systems• Positive for headaches, taking ibuprofen 3 times per week • Negative for weight loss, fevers, fatigue; onset of menses 4 months ago

OHSU

Pain LocationEpigastrico Gastritis o Peptic ulcero GERDo Esophagitiso Pancreatitiso Hepatobiliary (or RUQ)

RLQo Appendicitiso Mesenteric adenitiso Crohn’s disease

Periumbilicalo Constipationo Irritable bowel

syndrome (IBS)o Abdominal migraineo Functional

abdominal paino Celiac diseaseo IBDo HSP, Volvulus, early

appendicitis, gastroenteritis, DKA, Strep

Lower Abdomen or Pelvico IBSo Colitiso Constipationo Testicular torsiono Ovarian torsiono Dysmenorrheao Ectopic pregnancy

Acute cholecystitis scapulaPancreatitis back

Visceral pain receptors: not well-localized

Abdominal Wallo Musculoskeletalo HerniaOHSU

Epigastric Pain

• Gastroesophageal reflux disease (GERD)

• Functional dyspepsia

• Peptic ulcer disease• NSAIDs

• Gastritis

• H. pylori

• Esophagitis• Eosinophilic esophagitis, esp. if atopic

• Hepatobiliary • Consider ultrasound

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Epigastric Pain

• Histamine-2 receptor antagonists• Fast acting, tachyphylaxis

• Proton pump inhibitors• Better acid suppression than H2RA• 30 minutes before a meal• CYP2C19 variable metabolism

• Cyproheptadine• Good for nausea, early satiety

• Referral to GI• Refractory to acid suppression, hematochezia or melena, high suspicion for H. pylori

(household contact, endemic region), any red flag or otherwise

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Take-Home Points

• Many causes of abdominal pain • Benign to life-threatening

• Non-gastrointestinal etiologies

• Elicit pain characteristics, bowel movements, associated symptoms

• Look for red flags that warrant additional workup• Growth

• Functional gastrointestinal disorders are most common• Education, psychological, diet, medications

• Referrals to pediatric GI welcome

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Thank You

References

Hyams JS, Di Lorenzo C, Saps M, et al. Childhood functional gastrointestinal disorders: Child/adolescent. Gastroenterology 2016; 150:1456.

Mayer EA and Tillisch K. The Brain-Gut Axis in Abdominal Pain Syndromes. Annu Rev Med. 2011; 62. OHSU