Recurrent abdominal pain in children

Dr Vijay Kundal
Children have recurrent abdominal pain when there are at least three episodes of abdominal pain, which are severe enough to affect activities, over a period of three months. These children are diagnosed with recurrent or chronic abdominal pain after a period of one or two months of symptoms. The pain may be continous  that occurs on a daily basis or  intermittent. The pain may occur in any part of the abdomen, but, generally  classified as upper abdominal pain around the belly button or in the lower abdomen.
Causes of  abdominal pain
Recurrent abdominal pain in children  is classified in one of three groups. In the  first group,  there is a structural, biochemical abnormality that is described by clinical examination or testing. Examples includes peptic ulcer disease, inflammatory bowel disease, infections, gynecologic pathology, and kidney disease. These conditions generally are seen in about 10% to 20% of children with recurrent abdominal pain.
The second group includes “functional gastrointestinal diseases.” These diseases have a standard set of symptoms, but on investigations, no organic disease can be found. The two most common conditions are irritable bowel syndrome and functional dyspepsia. Patients in the third group also have functional abdominal pain (no obvious disease can be found). However, their symptoms are not as readily describable as the symptoms associated with irritable bowel syndrome or functional dyspepsia.  Somatization  is often more prominent in the third group. Somatization is the phenomenon of experiencing and communicating physical distress and symptoms, which are not explained by physical findings, and seeking extra medical care for the symptoms.
Age group in recurrent abdominal pain
Research   has shown that abdominal pain is a very common problem. Up to 75% of middle school and high school students have abdominal pain over the course of the year, with almost 1 in 5 having the pain on at least 6 occasions. From 15% to 25% of younger school age children also may complain of recurrent abdominal pain. Abdominal pain accounts for up to 5% of visits to pediatric surgeon clinics.
Diseases associated with recurrent abdominal pain
Recurrent abdominal pain may be due to specific organic disease in about 10% to 20% of children. However, the majority of kids with recurrent abdominal pain have no obvious disease. But, it is also rare to find children who fake symptoms. Nonetheless, the lack of definite abnormalities on testing often leads to a sense of frustration and anxiety on the part of the child, the guardian, and, occasionally, the care takers. Although it is not known the exact way that symptoms are caused in irritable bowel syndrome and functional dyspepsia-two common causes of recurrent abdominal pain-there are several hypothesis. The most accepted theory is that in both of these conditions, there is “visceral hypersensitivity.” This means that the intensity of the signals from the gastrointestinal system, which travel by nerves to the brain is exaggerated. This may occur following illnesses that cause inflammation in the intestine (e.g., viral gastroenteritis), or they may occur following psychologically trauma such as physical or sexual abuse. This visceral hypersensitivity is thought to lead to symptoms when the intestine undergoes peristalsis (motility or movement) or when it is distended by gas or stool. In some patients with functional dyspepsia, it is thought that even normal amounts of acid in the upper small intestine may cause discomfort.
Common findings
Irritable bowel syndrome occurs in both children and adults. The clinical symptoms include recurrent abdominal pain  around the umbilicus/belly button or the lower abdomen, that is associated with abnormalities in passing motion. Lower abdominal symptoms may include constipation, diarrhea, or a variable symptoms of defecation. Mostly, the pain is relieved by defecation. Patients often complain of a sense of rectal urgency, and they may have a sense of incomplete evacuation following a bowel movement. They often complain of bloating, dizziness, and, occasionally, nausea.
In functional dyspepsia, the discomfort is around the upper abdomen. The discomfort may be pain-like or  having burning sensation. Some individuals may complain of a sense of nausea or upper abdominal fullness after meals. Another important cause of recurrent functional abdominal pain is an abdominal migraine. Here, the child develop severe abdominal pain at mid night or early morning. It  may be accompanied by vomiting, and there may be a history of headaches. In about 30% of the cases, there is a family history of migraine headaches.
Diagnosis of  recurrent abdominal pain
Recurrent abdominal pain is diagnosed based on a patient’s history and clinical examination. There are no specific tests to diagnose it. It is the responsibility of the doctor and the family to use a cost-sensitive approach to this problem. However, when there are associated warning signs of a more serious disease, further investigations are recommended. The warning signs include the following:
* Weight loss *  Persistent vomiting
* Blood in the stool * Fever * Arthritis * Certain types of rash * Growth failure * Defective pubertal development * Difficulty swallowing * Night time awakening from the abdominal pain * Family history of inflammatory bowel disease (e.g., Crohn’s disease, ulcerative colitis)
Depending upon the child’s specific history and the physical findings, the doctor may get certain investigations such as complete blood count, erythrocyte sedimentation rate to look for inflammation in the body, serum biochemistry, and possibly, radiographic studies and an ultrasound. In the presence of diarrhea, a flexible sigmoidoscopy or a colonoscopy frequently is performed. In the presence of upper gastrointestinal symptoms, an upper endoscopy commonly is done. An additional diagnostic consideration for the symptoms is lactose intolerance. This condition is found in all ethnic groups, but it is more common in African-American, Latino, and Asian populations. It is diagnosed with a non-invasive procedure called a breath hydrogen test.
Treatment of abdominal pain
During the course of the evaluation, if a specific disease is found, then appropriate treatment is given. More often,  the clinician will diagnose functional abdominal pain. If irritable bowel syndrome is diagnosed, reassurance is offered, and the patient and the family are informed that no serious or threatening disease exists. If there are specific triggering factors associated with the symptoms, such as school or family difficulties, then these issues need to be addressed.
If the child has diarrhea as a important symptom, then medications, such as dicyclomine, which slow down bowel transit are used. Low doses of medications, referred to as tricyclic antidepressants, also are used. However, these medications are not used as antidepressants; they are used to decrease the intensity of the pain signals coming from the gastrointestinal system to the brain. Dietary manipulation by increasing dietary fiber can also be beneficial.
Functional dyspepsia is treated with medications (e.g., ranitidine, cimetidine, omeprazole, and lansoprazole) that reduce the secretion of acid in stomach. Low dose tricyclic antidepressants also may be used for severe functional dyspepsia. Patients can only be labelled as having functional dyspepsia after disease has been ruled out by an upper gastrointestinal endoscopy.
In cases of functional abdominal pain, where reassurance, diet, and medications do not help, a psychologist may help with biofeedback and pain control.
Prevention of abdominal pain
Recurrent abdominal pain cannot be prevented. If the child has recurrent abdominal pain that is caused by a specific organic disease, then that disease needs to be treated. Certain diseases tend to run in families, such as peptic ulcer disease (which is caused by an infectious agent, Helicobacter pylori) and inflammatory bowel disease. Functional gastrointestinal disorders, especially irritable bowel syndrome, also may run in families; however, these disorders are so common that it is difficult to determine a particular mode of inheritance.
(The author is Consultant Neonatal & Pediatric Surgeon at DMC Hospital, Ludhiana)