Recurrent Abdominal Pain

After completing this article, readers should be able to: Recurrent abdominal pain (RAP) is a frequent and troublesome complaint in childhood and adolescence, and the search for a cause and a credible approach to management can be taxing for both family and physician. The term “recurrent abdominal pain” was coined by the British pediatrician John Apley, who first published on the subject in 1958. His definition included at least three attacks of pain occurring over a period of 3 months that were severe enough to affect activities and for which no organic cause was identified. In practice, the definition may include any child or adolescent who has RAP for which the family seeks medical attention and explanation, even if the duration of the pain does not adhere strictly to the Apley definition. The definition explicitly excludes the many causes of acute abdominal pain, which lie outside the scope of this review.There is wide variation in the threshold of severity and frequency that must be crossed before a family will seek medical attention for a child who has RAP. Inevitably, parents want a clear explanation and reassurance that no sinister causes lurk undetected, and the clinician wants to oblige but often lacks the conviction that organic causes have been excluded. The most difficult challenge for the clinician is to determine to what extent diagnostic studies should be employed before the label “recurrent abdominal pain” is applied. Whereas abdominal pain may be the chief manifestation of a large number of precisely defined illnesses, more than 90% of the time a “disease” will not be defined and the family will be left with a “functional” explanation. In spite of extensive study and a vast literature base, RAP remains an elusive symptom in search of an etiology. How to diagnose and manage this common pediatric problem constitutes the subject of this review.RAP has been reported to occur in 10% to 15% of children between the ages of 4 and 16 years. A community-based study of 500 adolescents (mean age, 15.5 y) revealed that 13% to 17% experienced weekly pain, which in 20% of cases was severe enough to affect activities. There clearly is an overlap between the “normal” population that may experience recurrent pain symptoms but not complain sufficiently to seek medical attention and others who have a seemingly similar degree and frequency of pain and do come for assessment. Many sociocultural, familial, and emotional factors determine a child’s response to pain, and these also will affect the likelihood of seeking medical attention to explain and treat the problem. Although Apley and others have reported RAP to be the most common pain syndrome of childhood, headaches and limb pains appear to have an equal prevalence.In a study of 1,000 school-age children, RAP affected males and females equally up to 9 years of age. After 9 years, the incidence in females increased such that between 9 and 12 years, the female-to-male ratio was 1.5:1. The overall incidence appears to peak at 10 to 12 years. RAP is rare among children younger than 5 years of age, and an organic cause must be considered even more carefully in this younger age group. The vast literature published on this subject reveals no evidence of changes in the incidence or clinical profile of this common pediatric pain syndrome; it seems to be here to stay.The origins of abdominal pain are complex and do not lend themselves to a single model of causation. Numerous organic disorders lead to abdominal pain; in most, the pathophysiology is related to inflammation (eg, Crohn disease) or distension or obstruction of a hollow viscus (eg, obstructive uropathy). Most studies indicate that fewer than 10% of children who present with RAP have an identifiable organic etiology.The exact mechanism of pain remains unclear in the majority of children in whom no organic cause can be identified. The most typical pattern of periumbilical pain so characteristic of RAP appears to be visceral in origin, probably originating in the small intestine or colon. To date, no pattern of consistent motility disturbance has been identified in any subgroup of patients experiencing nonorganic abdominal pain. Emotions, cognitive processes, and other central nervous system influences may modulate the perception of pain to produce an altered awareness of the discomfort from these visceral sensations. This “visceral hyperalgesia” describes a heightened awareness of sensations that might not be perceived or expressed as pain in other children.Models that try to relate psychological influences in a primary causal manner (emotional stress leads to RAP) are too simplistic. However, stress can cause recognized physiologic effects, such as increased cortisol levels, sympathetic tone, and tachycardia, so it is entirely plausible that it could exert physiologic effects on the gut through altered motility or some other as yet unidentified mechanism.Oft-repeated assumptions that children who have RAP are anxious, perfectionist, socially unskilled, and self-conscious have taken on an aura of validity that is unsupported by objective evidence. Several case-control studies have failed to demonstrate significant differences for a range of measures of psychological distress between groups of children who have “functional” RAP and those who have a demonstrable organic cause for their pain. Others contradict these studies, showing that those who have RAP have higher levels of anxiety and depression than do “well” children. Illness or pain clearly causes anxiety and distress, but this must be distinguished from invoking “stress” as a source of primary causation. There are no objective methods of measuring stress, and what seems to be a source of stress for one child (eg, birth of a sibling, upcoming athletic or music competition) may be of no apparent emotional consequence for another child of the same age. As in adults, some children seem to “buckle under stress” and become anxious and emotionally distressed; others facing the same challenge become invigorated and rise to new heights of effort and achievement.For some children, anxiety and emotional stress seem to manifest in a range of pain complaints, of which abdominal pain and headache are the two most common. Parents sometimes can date the onset of the pain to a specific time, such as the beginning of a new school year or a marriage breakup. Family dynamics and individual coping styles influence the way in which children express or even acknowledge their pain. Some families encourage their children to express pain in ways that unwittingly may reinforce the complaint.The tripartite classification proposed by Barr may be the most helpful method of categorizing children who present with RAP. This classification includes: 1) those who have organic disease, 2) those who have a clear psychogenic etiology such as depression or school phobia, and 3) the traditional “functional” group in which neither organic disease nor a clear psychogenic etiology is manifest.The majority of children who have RAP are considered to have a functional etiology. The problem of defining functional RAP is daunting. In its simplest form, the concept encompasses all causes that do not have an identifiable organic etiology. Most typically, the pain occurs in episodes that are periumbilical, self-limited, unrelated to meals or activities, and rarely if ever sufficient to awaken the child from sleep. The growth pattern and findings on the physical examination are normal. The degree of interference with normal activities and school attendance may seem out of proportion to the frequency and severity of the episodes as described. It has been observed wryly that “Organicity of pain is inversely proportional to the number of school absences.”Some children who have RAP manifest many of the characteristics associated with irritable bowel syndrome (IBS), as defined in adults. The criteria for making this diagnosis are: 1) abdominal pain relieved by defecation, 2) more frequent stools at the onset of the pain, 3) altered stool form (hard or loose or watery), 4) passage of mucus, and 5) associated bloating or abdominal distension. To define this syndrome requires a degree of detail regarding bowel function that the clinician will find difficult to elicit from children, who are notoriously reluctant to reveal or discuss their bowel habits. In adults, the division is made between those who have constipation-dominant and diarrhea-dominant symptoms. There is some evidence that altered intestinal motility, mediated by peptides excreted by both gut and brain, plays a role in the etiology of IBS. There are no laboratory markers; the diagnosis rests on the history. Although some clinicians include constipation under the diagnostic category of IBS, most recognize it as a separate diagnosis.Many factors lead to constipation in children, the foremost of which is dietary. Modern diets are replete with highly processed starches, and many children shun fruits, vegetables, and higher-fiber foods. An unwillingness by some children to take the time to evacuate their bowels completely, coupled in some cases with a reluctance to use school washrooms, can seriously compound this problem. Sometimes the role of constipation as a major contributing factor to abdominal pain will be clear, with the parent noting that the child goes days between bowel movements and that the stool is bulky and hard. Often the pediatrician faces the problem of ferreting out this diagnosis in the face of inadequate history; the parent is unaware of the child’s bowel pattern and the child is tight-lipped and unwilling to discuss the matter in any detail. Findings on abdominal and rectal examinations may not confirm this diagnostic suspicion; a plain abdominal radiograph may be needed.There may be a long latency between onset of symptoms and a confirmed diagnosis of inflammatory bowel disease (IBD). Although ulcerative colitis often presents with abdominal pain associated with hematochezia and tenesmus, the early symptoms of Crohn disease may be more insidious and nonspecific. Abdominal pain and diarrhea may be intermittent, and the clinician must be alert to the presence of lethargy, growth and pubertal delay, and extraintestinal manifestations such as oral, joint, and perirectal involvement. With the widespread availability of endoscopy, a diagnosis usually can be made promptly.The frequency with which incomplete absorption of lactose and other carbohydrates produces RAP in children is unclear, as are outcomes in several large and well-conducted studies. Initial enthusiasm for this diagnosis as a significant cause for RAP has waned. A wide range of racial/ethnic groups—Asian, Jewish, Mediterranean, and African-Americans—are predisposed to lactase deficiency, with incidences reported as high as 60% to 80%. Lactose ingestion will cause symptoms of bloating, loose stools, and cramping abdominal pain in those who are affected. It appears to be an uncommon cause of RAP in the absence of other gastrointestinal symptoms. The diagnosis is made most reliably by breath hydrogen testing. If this diagnostic tool is unavailable, it is reasonable to use lactase-treated milk products or a complete restriction of milk products for several weeks as a therapeutic trial. It is important to recognize that lactose intolerance results simply in carbohydrate maldigestion; it is not, per se, a cause of malnutrition or growth failure.The discovery of H pylori has changed the approach to diagnosis and treatment of peptic ulcer disease. Epidemiologic evidence indicates that this infection is more prevalent among those living in low socioeconomic circumstances, so infection rates are significantly higher in less developed nations. Even in developed countries, the prevalence of H pylori infection is approximately 40%. However, the great majority of affected individuals have no signs or symptoms; they have infection but no disease.The intense interest in H pylori has generated numerous tests and treatments that, unfortunately, are being used in excess of their established benefits and often counter to the best interests of the patient.Several lines of evidence indicate that H pylori infection alone rarely is the cause of abdominal pain in children unless peptic ulcer disease is present. A meta-analysis of more than 40 published reports shows strong evidence for an association between H pylori gastritis and duodenal ulcer disease in children, but weak or no evidence for an association between H pylori infection and RAP. Serologic studies have shown that antibodies to H pylori occur with similar prevalence among children who do and do not have RAP. In a large multicenter study from Germany, symptom assessment could not distinguish between children who had H pylori gastritis and those who had “functional” RAP. Symptoms improved or resolved in 87% of children in whom H pylori was eradicated successfully, but also in 93% of those in whom eradication failed and in 80% of those who had “functional” RAP. H pylori-associated peptic ulcer disease should be suspected when abdominal pain is primarily epigastric; when it awakens the child from sleep; and when it is associated with anorexia, nausea, recurrent vomiting, anemia, or gastrointestinal bleeding. Although abdominal pain is common in children, peptic ulcer disease is very uncommon; therefore, testing for H pylori should not be part of the preliminary evaluation of a child who has RAP.Given the important distinction between H pylori infection and disease, engaging in a fishing expedition for evidence of H pylori infection is not an appropriate strategy for investigating RAP. 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