Paediatrics: Recurrent abdominal pain

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.

Causes

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.

Presentation

Non-organic disease

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.

Organic cause

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.

Management

History

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.

Full examination

Investigation

• 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.

Treatment

Non-organic disease

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.

Organic disease

Treat the underlying cause.

Prognosis

Approximately 25% of children with functional recurrent abdominal pain continue to have pain or headaches in adulthood. Functional sequelae are common.

Abdominal migraine

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.

 Treatment

•  Dietary: avoid citrus fruits, chocolate, caffeine-containing drinks (e.g.cola), solid cheeses.
• Pharmacological: pizotifen, sumatriptan, gabapentin, or amitriptyline may be helpful.