Recurrent Abdominal Pain in Children

Recurrent abdominal pain (RAP) in children was defined and identified because it was recognised that it was very common, very disruptive to families and most often not accompanied by easily definable organic pathology. It is a condition comprising both organic and functional disorders and is therefore clinically challenging to diagnose and treat.

Apley, a Bristol paediatrician, and Naish defined recurrent abdominal pain (RAP) in 1958 as abdominal pain that:

• Waxes and wanes
• Occurs with three episodes within a three-month period of time
• Is severe enough to affect a child's activities

It is of significance because:

• It is one of the most common symptoms in childhood worldwide.
• It is responsible for considerable morbidity, missed school days and high use of health resources.
• It is made up of functional disorders (those which cannot be explained by structural or biochemical disorders) and organic disorders. Apley recorded that only 8% of patients with RAP had, after extensive investigation, any organic pathology.²
• Diagnostic uncertainty, chronicity and increasing parental anxiety often follow the unremitting and disruptive course of the condition. This can make management by GPs and paediatricians very difficult, time-consuming and expensive.

There are problems with the definition of RAP and it has been criticised over the years, often because it includes both organic and functional conditions.

The placement of conditions such as irritable bowel syndrome (IBS) within the diagnostic umbrella of RAP is helpful. Many recent studies now identify a significant proportion of patients with RAP as either clearly having IBS or going on to develop IBS.^2,3 Recurrent pain at other sites is common as well but the abdomen is the most common site for recurrent pain. There is considerable overlap between recurrent headache and recurrent abdominal pain.⁴

• Recurrent abdominal pain (RAP) is a common symptom in children. It occurs in as many as 10% of children.
• An organic cause is found in few of these patients. However differences in prevalence of organic disease are found depending on the population studied and the criteria used. It may be as low as 5% in the general population and as high as 40% in paediatric gastroenterology outpatients.
• It is still the case that the paucity of organic pathology in these patients has led to the conclusion that psychological factors are important. However, this is not always reflected in the results of studies which do not always demonstrate differences in emotional and behavioural scores in the patients with organic pathology and in those without.⁵
• It occurs most commonly between age 4 and 14 years. Some studies show within this age range peaks in incidence at 4-6 years and at 7-12 years.¹
• Girls are probably affected more often than boys.
• Incidence appears similar in different socioeconomic groups, although low socioeconomic status is cited by some as a factor increasing incidence.¹
• Recently an association between obesity and RAP has been reported.⁶ Diet may also play a part. A recent study reported an inverse correlation between fruit consumption and RAP.⁶ It is apparent that many factors are involved, consistent with the concept of a biopsychosocial model for illness.^1,7

• Sexual abuse. Little is known about the association with sexual abuse, but studies do confirm that the duration of symptoms is longer in children who were victims of sexual abuse.¹
• Parental anxiety in the first year of life is associated with chronic abdominal pain before age six years. This may be because the anxiety prompts a response which strengthens recurrence of pain.¹
• Family factors are important and children with a parent with gastrointestinal problems are more likely to have RAP.
• From the published studies it seems that the causes of RAP are multifactorial. A biopsychosocial model has been proposed which suggests a concept which acknowledges a complex interplay between many different factors. This is useful when considering management (ranging from behavioural treatments to pharmacological ones) and when explaining the condition to parents and children.

History

A good history is traditionally the cornerstone of diagnosis. It is not yet possible to define a questionnaire or diagnostic tool but the attempts are interesting and enlightening. Ultimately they may yield a helpful diagnostic questionnaire but, at the moment, there is no substitute for a careful and thorough history.

• The history should include an analysis of the pain.
  • Site of pain.
  • Quality and nature of pain.
  • Information on the timing and duration of pain.
  • Whether pain is relieved by defaecation or not.
  • It is particularly important to ask about any associations with the pain and particularly the effect on daily living.⁸
• The history should encompass inquiry about:
  • Gastrointestinal symptoms including bowel habit.
  • Genitourinary symptoms.
  • Family history. This is particularly important in recurrent abdominal pain (RAP). There may be a history of illness in siblings.⁹ There is an association with family history of depression.¹⁰ A family history of RAP is very likely (if positive, the incidence of RAP in the children is six times greater). Migraine, peptic ulcer, depression, appendectomy and convulsions are also more common in the families of children with RAP.
  • Past medical history. It is important to review any past illnesses, hospital admissions, relevant perinatal and neonatal history.

Examination

There are no good data evaluating the diagnostic value of physical examination.¹ However, careful and thorough examination is generally recommended, particularly when first seen. Typically there may be vague tenderness but no guarding or rigidity. It can be reassuring to parents to see that this is done and to discuss findings, including the reassurance of normal findings. Examination should include at least the following:

• Height and weight
• General examination
• Abdominal examination

Discriminating between organic and functional causes of RAP

The traditional view

• Children presenting with RAP are unlikely to have organic disease.
• Diagnostic triage is entirely appropriate in primary healthcare.
• Diagnosis can be difficult. However, discriminating organic from functional disorders is achieved with a good history and without protracted examinations and investigations. Simple tests such as urine testing are usually all that is required.
• The history helps to exclude organic causes and identifies important factors which may be triggering the pain.
• The diagnostic process may be followed also in part to reassure parents.
• It can be difficult to reassure parents when the pain continues and diagnostic uncertainty exists.

Recent perspectives¹

Whilst there is acceptance of the traditional approach, it should be remembered that:

• There is a long list of possible causes for recurrent abdominal pain. It is not possible categorically to exclude them all with definitive testing or investigation.
• The distinction between so-called organic disease, functional disorders and emotional factors can be difficult. Frequently there is overlap between physical and emotional illness and the two may coexist.
• The history in children can be difficult. There may be difficulties describing the pain and localising it once the pain has passed. The child's vocabulary may limit description but there may also be emotional and psychological barriers to the process of history taking.

It is perhaps not surprising that a committee of American paediatric gastroenterologists recently concluded that there were no diagnostic tools to distinguish functional from organic abdominal pain.¹ They recommend further diagnostic testing only in children with alarm symptoms or signs, such as those outlined in the table above. They recommend abandoning the term 'recurrent abdominal pain'.

The list of possible causes is long but the list of probable causes is shorter.

• Probable causes of recurrent abdominal pain (RAP):
  • RAP with no organic cause is the most likely
  • IBS
  • Abdominal migraine
  • Periodic syndrome
  • Constipation
  • Mesenteric adenitis
  • Urinary tract infections
• Possible causes of RAP. A long list is possible, but the following are worthy of mention:
  • Hydronephrosis
  • Urolithiasis¹¹
  • Pancreatitis
  • Meckel's diverticulum
  • Peptic ulcer disease
  • Henoch-Schönlein syndrome
  • Bezoar
  • Coeliac disease
  • Crohn's disease
  • Ulcerative colitis
  • Aerophagy
  • Liver and gall bladder disease
  • Splenic disease
  • Familial Mediterranean fever
  • C1 esterase inhibitor deficiency
  Remember other nonabdominal causes:
  • Referred pain:
    • Pleura/pneumonia
    • Testes/ ovaries
  • Metabolic:
    • Diabetes and diabetic complications (including diabetic ketoacidosis)
    • Porphyria
    • Lead poisoning
  • Infection:
    • Tuberculosis
    • Rheumatic fever
    • Brucellosis
    • Typhoid
  • Neurological:
    • Tumours
    • Encephalitis
    • Epilepsy

Investigations may be required to exclude particular conditions suggested by the history and examination. It is useful to pursue further diagnostic testing only in the presence of alarm symptoms.¹ Such tests include comprehensive metabolic screening, stool analysis, inflammatory markers and other laboratory tests. These help identify conditions such as inflammatory bowel disease and coeliac disease. Extensive investigations are not usually indicated or helpful. No studies have evaluated the usefulness of common laboratory tests.¹ These basic tests are often recommended:

• FBC
• ESR or CRP
• Coeliac disease serology - IgA anti-tissue transglutaminase antibodies (tTGAs)
• Urinalysis and microscopy
• Stool examination for parasites
• Plain abdominal X-ray

Many tests may be done selectively, but it is worth considering that many tests when studied do not discriminate between functional and organic pain. As such they should not be used in an attempt to 'screen' for organic disease. Further tests which may be used include:

• Abdominal ultrasound
• Endoscopy
• Testing for Helicobacter pylori

In fact, studies show positive results for each of these tests equally in control groups and in the patients with chronic abdominal pain.¹

There are associations with migraine, IBS, psychiatric disorders (anxiety, depression).¹⁰

Recurrent abdominal pain (RAP) will require follow-up and may need referral. It cannot be dealt with in a single consultation.
Most children with RAP have mild symptoms which are successfully managed in primary care.¹ A detailed plan of management will depend on diagnosis. It is likely that a significant part of management will involve discussion, explanation and reassurance. A specific treatment or intervention cannot be recommended because none has yet been identified.¹A summary of these is as follows:¹

• Beneficial treatments include:
  • Cognitive-behavioural therapy (CBT). Studies show clear beneficial effects for RAP.
  • Family therapy. Often part of CBT approach and effective.
  • Peppermint oil. Studies show benefit for IBS.
  • Pizotifen. This appears to be beneficial for abdominal migraine (Rome II criteria).
• Inconclusive or unhelpful treatments include:
  • Famotidine for RAP and dyspepsia.
  • Additional dietary fibre for RAP.
  • Lactose-free diet for RAP.
  • Lactobacillus GG for RAP.

• Many of the studies on prognosis relate to hospital practice not primary care.¹
• It is generally more likely that children with recurrent abdominal pain will develop chronic abdominal symptoms in adulthood and as many as 30% may continue thus.¹
• Many will continue to suffer from IBS.^2,5,12,13
• There is evidence that children with chronic abdominal pain are more likely to have emotional and psychiatric disorders later in life.¹
• Generally speaking, however, follow-up studies show that parental factors rather than the psychological characteristics of the child are more important when predicting persistence of abdominal pain.¹
• Possible risk factors for chronicity:
  • Age may be a factor although studies are inconclusive. Presentation under age six has been reported as a risk factor.
  • History of more than six months before presentation.
  • Family history of emotional factors. There is evidence that parental functional problems, stressful life events and sexual abuse are all associated with persistence of functional abdominal pain.
  • Anxiety, depression and severity of pain have not been linked to persistence of functional abdominal pain.
  • Eating and sleeping problems, phobias, nocturnal enuresis and other such factors have been cited. These may reflect emotional factors within the family.
• Acceptance by parents of the role of psychological factors in the maintenance of symptoms is strongly associated with recovery.

1. Berger MY, Gieteling MJ, Benninga MA; Chronic abdominal pain in children. BMJ. 2007 May 12;334(7601):997-1002.
2. El-Matary W, Spray C, Sandhu B; Irritable bowel syndrome: the commonest cause of recurrent abdominal pain in children. Eur J Pediatr. 2004 Oct;163(10):584-8. [abstract]
3. Hyams JS, Treem WR, Justinich CJ, et al; Characterization of symptoms in children with recurrent abdominal pain: resemblance to irritable bowel syndrome. J Pediatr Gastroenterol Nutr. 1995 Feb;20(2):209-14. [abstract]
4. Galli F, D'Antuono G, Tarantino S, et al; Headache and recurrent abdominal pain: a controlled study by the means of the Child Behaviour Checklist (CBCL). Cephalalgia. 2007 Mar;27(3):211-9. [abstract]
5. Nygaard EA, Stordal K, Bentsen BS; Recurrent abdominal pain in children revisited: irritable bowel syndrome and psychosomatic aspects. A prospective study. Scand J Gastroenterol. 2004 Oct;39(10):938-40. [abstract]
6. Malaty HM, Abudayyeh S, Fraley K, et al; Recurrent abdominal pain in school children: effect of obesity and diet. Acta Paediatr. 2007 Apr;96(4):572-6. [abstract]
7. Stafford B, Troha C, Gueldner BA; Intermittent abdominal pain in a 6-year-old child: the psycho-social-cultural Curr Opin Pediatr. 2009 Jun 10. [abstract]
8. Roth-Isigkeit A, Thyen U, Stoven H, et al; Pain among children and adolescents: restrictions in daily living and triggering factors. Pediatrics. 2005 Feb;115(2):e152-62. [abstract]
9. Guite JW, Lobato DJ, Shalon L, et al; Pain, disability, and symptoms among siblings of children with functional abdominal pain. J Dev Behav Pediatr. 2007 Feb;28(1):2-8. [abstract]
10. Campo JV, Di Lorenzo C, Chiappetta L, et al; Adult outcomes of pediatric recurrent abdominal pain: do they just grow out of it? Pediatrics. 2001 Jul;108(1):E1. [abstract]
11. Polito C, La Manna A, Signoriello G, et al; Recurrent Abdominal Pain in Childhood Urolithiasis. Pediatrics. 2009 Nov 9. [abstract]
12. Walker LS, Guite JW, Duke M, et al; Recurrent abdominal pain: a potential precursor of irritable bowel syndrome in adolescents and young adults. J Pediatr. 1998 Jun;132(6):1010-5. [abstract]
13. Pace F, Zuin G, Di Giacomo S, et al; Family history of irritable bowel syndrome is the major determinant of persistent abdominal complaints in young adults with a history of pediatric recurrent abdominal pain. World J Gastroenterol. 2006 Jun 28;12(24):3874-7. [abstract]