Paediatrics: Recurrent abdominal pain
Defined as more than two discrete episodes in a 3mth period interfering with school and/or usual activities.
Recurrent abdominal pain
- Defined as more than two discrete episodes in a 3mth period interfering with school and/or usual activities.
- Incidence: 10–15% of school-age children.
No organic cause is found in 90%. Organic causes include constipation; dietary indiscretion; food intolerance (lactose or fructose); irritable bowel syndrome; psychogenic pain; peptic ulcer (H. pylori); coeliac disease; abdominal migraine (cyclic vomiting syndrome); gallbladder disease; renal colic; dysmenorrhea; UTI; mittelschmerz; and physical or sexual abuse.
This form occurs in a thriving, generally well-child; with short episodes of peri-umbilical pain, good appetite, no other GI symptoms, no family history of migraine or coeliac disease, and a normal examination. Co-existent symptoms such as headache and fatigue are common and this is often referred to as recurrent abdominal pain syndrome.
Likely if the presentation is different to above or child <2yrs. ‘Red flag’ symptoms include weight loss, diarrhoea, blood per rectum, joint symptoms, skin rashes, family history of inflammatory bowel disease, or coeliac disease.
Ethnic origin (lactase deficiency occurs in dark-skinned races), atopy, relationship to eating, precipitating events (e.g. cow’s milk introduction in milk protein enteropathy), social history (e.g. start of school, parental separation), and family history.
- If the non-organic disease is likely: no or very little investigation is needed,e.g. FBC, ESR/CRP, U&E, LFT, coeliac antibody screen, urine M, C&S, faecal M, C&S (if there is a recent history of foreign travel).
- If the organic disease is likely: investigate as above, plus consider hydrogen breath test (lactose intolerance); C13 breath test (Helicobactor pylori); US; barium radiology; upper and lower GI endoscopy.
Confident reassurance; education that condition is common and pain is genuine (just like headaches); personal support; avoidance of associated stressful events (e.g. bullying); acknowledgement of symptom, whilst at the same time downplaying pain; minimize secondary gains from abdominal pain, e.g. school avoidance; increased dietary fibre intake may be beneficial;
formal psychotherapy in complex and resistant cases. Multidisciplinary support and engagement of the family are essential.
Treat the underlying cause.
Approximately 25% of children with functional recurrent abdominal pain continue to have pain or headaches in adulthood. Functional sequelae are common.
Abdominal pain is associated with pallor, headaches, anorexia, nausea, +/– vomiting. The condition overlaps with the periodic syndrome and cyclic vomiting syndrome. There is usually a strong family history of migraine.
- Dietary: avoid citrus fruits, chocolate, caffeine-containing drinks (e.g.cola), solid cheeses.
- Pharmacological: pizotifen, sumatriptan, gabapentin, or amitriptyline may be helpful.