Recurrent abdominal pain: common and chronic symptoms

Educational Objectives

The goal of this lecture is to improve diagnosis and management of abdominal pain. After hearing and assimilating this program, the clinician will be better able to:

1. Determine whether a patient with recurrent abdominal pain (RAP) needs further investigation for organic causes.

2. Explain the causes and probable course of RAP to patients and parents.

3. Recognize family-related factors that may contribute to RAP.

Summary

Original definitions and categories: definition of recurrent abdominal pain (RAP; Apley 1959)  —  child >3 yr of age, >3 episodes, duration >3 mo, and severe enough to affect activity; Rome II (1999)  —  criteria for functional gastro­intestinal (GI) disorders associated with pain; based on expert consensus; grouped into functional abdominal pain (FAP), irritable bowel syndrome, functional dyspepsia, and abdominal migraine; Rome III (2006)  —  functional dis­orders in children and adolescents grouped into vomiting and aerophagia, abdominal pain-related functional GI dis­orders (FGIDs), and constipation and incontinence; abdominal pain-related FGIDs further grouped into functional dyspepsia, irritable bowel syndrome, abdominal migraine, and childhood FAP

Functional GI Disorders

Diagnostic criteria: episodic or continuous abdominal pain; insufficient criteria for other FGIDs; no evidence of in­flammatory, anatomic, metabolic, or neoplastic process; criteria fulfilled at least weekly for ³2 mo; loss of daily functioning; additional somatic symptoms such as headache, limb pain, and difficulty sleeping; rationale for Rome III definitions  —  only 0% to 7% of patients met Rome II criteria; encourage diagnosis on basis of clinical pattern, rather than on exclusion by costly testing; allow focus on more specific phenotypes; however, most literature still uses original RAP definition

Incidence and characteristics: 9% to 15% of population; peak incidence in boys 5 yr to 6 yr; 2 peaks in girls at 5 yr to 6 yr and 9 yr to 10 yr; periumbilical most common, though sometimes reported in lower abdominal; most fre­quently characterized as cramping or dull aching pain; frequency usually reported as several times weekly (rarely occurs daily); duration commonly minutes to >1 hr; common associated symptoms include pallor, tiredness, an­orexia without weight loss, dizziness, headache, vomiting, enuresis, fever <100.5°F, diarrhea, and constipation

Family history: family members often have other complaints, especially abdominal (eg, higher incidence of RAP, migraine, peptic ulcer disease, “nervous breakdown,” appendectomy); marital discord; depression, maternal health problems, and somatization common in family members

Characterization of patients: classic presentation  —perfectionistic; sensitive; “high-strung”; anxious over­achiever; data from controlled studies  —  patients typically dependent, fearful, have low self-esteem, anxious, and/or have history of stressful family or life events; Raymer (1984) found similarities between patients with in­flammatory bowel diseases and RAP, and that both groups differed from controls

Theories of Etiology of RAP

Apley: noted prevalence of dilated pupils and postulated that patients with RAP have autonomic dysfunction

Levine: characterized patients with RAP as anxious; emphasized need to avoid missing detection of organic disease

Davidson: emphasized dyskinesia and constipation

Multiple others: believed carbohydrate or lactose intolerance may play role; not supported as causal in studies; Late 1980s: dysmotility

Early 1990s: papers cited abnormal intestinal permeability (claimed patients with RAP absorbed more material given orally than controls); Helicobacter pylori  —  not found to be causative

DiLorenzo: evaluated visceral sensitivity of patients with RAP using intra-abdominal inflation of balloons; found that those with RAP experienced pain at lower levels of inflation (ie, had greater sensitivity)

Hyams: proposed biopsychosocial model preferred by speaker; model treats RAP as multifactorial; includes organic tendencies, but allows major role for psychosocial issues

Conclusions: RAP occurs in heterogeneous population with spectrum of mild organic, functional, and mental health disorders; visceral hypersensitivity may play role

Outcomes: long-term study by Campo  —  used control group of patients who underwent tonsillectomy and adenoid­ectomy; employed interviews and standardized tests; average follow-up 11 yr; all children with RAP had increased anxiety and increased use of health care system continuing into adulthood; study by Crushell (2003)  —  showed that parental acceptance of biopsychosocial model associated with good outcome; in patients with persistent pain, only 1 of 14 parents accepted model vs 11 of 14 parents in recovered patients; emphasizes need to work with parents

Organic Causes of RAP

Background: infrequently missed; 100 of 1464 patients in study by Cox and 3 of 161 patients in Mayo Clinic study had demonstrable organic etiology; short list of diseases to rule out  —  includes inflammatory bowel diseases, espe­cially Crohn disease (characterized by fall-off in growth, anemia, and diarrhea); urinary tract disorders, such as ure­teropelvic junction obstruction (characterized by flank rather than abdominal pain); recurrent pancreatitis suggested by family history and increased lipase; gallbladder disease (suggested by, eg, elevated liver enzymes) and peptic ulcer disease (suggested by nocturnal pain and emesis) rare in children; recurrent midgut volvulus rare, but consider in young child with emesis; carbohydrate intolerance detected using dietary history

Clues to organic cause: peripheral (not central) pain; nocturnal pain; weight loss; growth decline; meal-related symptoms; emesis; hematochezia; healthy family environment; no family history of abdominal pain; “low-key” per­sonality; regular school attendance; child keeps eyes open during abdominal examination; abnormal examination; ab­normal laboratory tests; alarming symptoms (per North American Society for Pediatric Gastroenterology)  —  right upper or right lower quadrant pain; dysphagia; emesis; GI bleeding; nighttime stools; family history of inflammatory bowel disorders, celiac disease, or peptic ulcer disease; nocturnal pain, arthritis; perirectal disease; weight loss; fall-off in growth; delayed puberty; fever

History and examination: history most important part of evaluation; taking good history helps prevent overinvesti­gation; ask about specifics of pain; search for clues to organic disorders; explore family history and dynamics; con­sider other complaints (eg, headache, dizziness, fatigue, weakness, limb pain); complete examination allows reassurance of parents; look for normal growth, nutrition, and overall health; hunt for clues to organic disease; treating constipation may improve pain; when unable to make diagnosis, examine patient during acute episode

Screening tests: complete blood count, erythrocyte sedimentation rate, C-reactive protein, albumin (good marker for nutritional health), total protein, amylase, lipase, liver function tests, occult blood in stool, and urinalysis (although urinary tract infection uncommon cause of RAP); unnecessary tests  —  computed tomography, magnetic resonance imaging, endoscopy, abdominal sonography, and H pylori

Treatment: acknowledge pain as real (can use headache as example of real pain not serious and not treated with sur­gery); review with parents long-term studies showing that patients do well; demystify RAP for parents; remember that random tests turn up normal variants; medications  —  anticholinergics, selective serotonin reuptake inhibitors, and other antidepressants used in nonrandomized trials; single controlled trial for irritable bowel syndrome sup­ports efficacy of peppermint oil; try histamine receptor blockers or proton pump inhibitors; encourage return to nor­mal activity, especially school; work with parents and patient; treat constipation and address stress in family; provide support and close follow-up; form allegiance with family; remain available; take time to align parents with recommended treatment program

Questions and Answers

Testing for celiac disease in patient with normal stools: celiac disease underdiagnosed; perform new antibody tests if patient has weight loss or fall-off in growth; presentation with RAP alone uncommon

Role of x-rays (kidney, ureter, and bladder) in routine screening: finding of constipation common, but generally not diagnostic; probiotics work well for diarrhea, but data on efficacy for RAP unavailable

Analgesia: acetaminophen permissible, but avoid narcotics and nonsteroidal anti-inflammatory drugs; hyoscyamine (eg, Levsin, Anaspaz, Levbid) often prescribed by gastroenterologists, but unproven

Role of food allergies: rare as cause of RAP without other symptoms, eg, diarrhea, meal-related symptoms, difficulty swallowing; such symptoms possibly indicative of eosinophilic esophagitis

Readings

Suggested Reading

Banez GA: Chronic abdominal pain in children: what to do following the medical evaluation. Curr Opin Pediatr 2008;20:571-5; Centers for Disease Control and Prevention: Managing acute gastroenteritis among children. Atlanta, GA. Centers for Disease Control, US Department of Health and Human Services: 2003; Chiou E, Nurko S: Functional abdominal pain and irritable bowel syndrome in children and adolescents. Therapy 2011;8:315-331; Czyzewski DI et al: The interpretation of Rome III criteria and method of assessment affect the irritable bowel syndrome classification of children. Aliment Pharmacol Ther 2011;33:403-11; Duf­ton LM et al: Self-reported and laboratory-based responses to stress in children with recurrent pain and anxiety. J Pediatr Psychol 2011;36:95-105; Freedman SB et al: Oral ondansetron for gastroenteritis in a pediatric emergency department. N Engl J Med 2006;354:1698-705; Gartner JC: Abdominal Pain. In: Charles A. Pohl et al. Pediatrics on Call (Lange On Call). New York, NY: McGraw Hill, 2006; Gottsegen D: Complementary, holistic, and integrative medicine: recurrent abdominal pain. Pediatr Rev 2010;3:e36-9; Hyams JS: Irritable bowel syndrome, functional dyspepsia, and functional abdominal pain syndrome. Adolesc Med Clin 2004;15:1-15; Jenny C et al: Analysis of missed cases of abusive head trauma. JAMA 1999;282:621-6; Noe JD, Li BU: Navi­gating recurrent abdominal pain through clinical clues, red flags, and initial testing. Pediatr Ann 2009;38:259-66; Roslund G et al: The role of oral ondansetron in children with vomiting as a result of acute gastritis/gastroenteritis who have failed oral rehydration therapy: a randomized controlled trial. Ann Emerg Med 2008;52:22-29; Scharff L: Recurrent abdominal pain in children: a review of psychological factors and treatment. Clin Psychol Rev 1997;17:145-66; Silen W: Cope’s Early Diagnosis of the Acute Abdomen. 22nd ed. New York, NY: Oxford University Press, 2010; Spandorfer PR: Subcutaneous rehydration: updating a traditional tech­nique. Pediatr Emerg Care 2011; 27:230-6; Spandorfer PR et al: Oral versus intravenous rehydration of moderately dehydrated children: a randomized, controlled trial. Pediatrics 2005;115:295-301. Strum JJ et al: Ondansetron use in the pediatric emergency department and effects on hospitalization and return rates: are we masking alternative diagnoses? Ann Emerg Med 2010;55:415-22; Wendland M et al: Functional disability in paediatric patients with recurrent abdominal pain. Child Care Health Dev 2010;36:516-23.

 

Disclosures

In adherence to ACCME Standards for Commercial Support, Audio-Digest requires all faculty and members of the plan­ning committee to disclose relevant financial relationships within the past 12 months that might create any personal con­flicts of interest. Any identified conflicts were resolved to ensure that this educational activity promotes quality in health care and not a proprietary business or commercial interest. For this program, the faculty and planning committee reported nothing to disclose.

Acknowledgements

Dr. Gartner was recorded at Pediatrics for the Primary Care Physician, held June 24-26, 2011, in Amelia Island, FL, and sponsored by Nemours Children’s Clinic. To attend the next Pediatrics for the Primary Care Physician, please visit www.pedseducation.org. The Audio-Digest Foundation thanks the speaker and the sponsor for their co­operation in the production of this program.

CME/CE INFO

Accreditation:

The Audio- Digest Foundation is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

The Audio- Digest Foundation designates this enduring material for a maximum of 0 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Audio Digest Foundation is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center's (ANCC's) Commission on Accreditation. Audio Digest Foundation designates this activity for 0 CE contact hours.

Lecture ID:

PD571701

Expiration:

This CME course qualifies for AMA PRA Category 1 Credits™ for 3 years from the date of publication.

Instructions:

To earn CME/CE credit for this course, you must complete all the following components in the order recommended: (1) Review introductory course content, including Educational Objectives and Faculty/Planner Disclosures; (2) Listen to the audio program and review accompanying learning materials; (3) Complete posttest (only after completing Step 2) and earn a passing score of at least 80%. Taking the course Pretest and completing the Evaluation Survey are strongly recommended (but not mandatory) components of completing this CME/CE course.

Estimated time to complete this CME/CE course:

Approximately 2x the length of the recorded lecture to account for time spent studying accompanying learning materials and completing tests.

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