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Introduction
Definition and Characteristics
Evaluation
Organic vs.
Functional Abdominal Pain
Treatment
Summary
Introduction
There are few clinical situations as stressful for pediatricians
and pediatric gastroenterologists as the child with chronic abdominal pain.
In the face of mounting frustration over their child’s symptoms, parents
instruct physicians to “leave no stone unturned” in the quest to reach
a definitive diagnosis. I often see children with abdominal pain who have
missed many days, and occasionally, weeks of school. Parents frequently
insist upon the performance of invasive diagnostic studies, despite the
very low likelihood of uncovering a significant problem. In reality, the
chronic abdominal pain syndrome is a common condition that affects 10 to 15
percent of school-aged children between the ages of 5 and 15. Serious underlying
medical or surgical disorders are infrequent, and a functional
cause (not disease-related) is diagnosed in more than 90 percent
of cases. Here, I must reiterate that the term functional is used
to describe pain that is not related to any specific disease process (for
example, ulcers, colitis). Although this problem is not strictly analogous
to any disorder in adults, some physicians have termed functional abdominal
pain the childhood equivalent of irritable bowel syndrome. I emphasize
to families the fact that functional abdominal pain is not a diagnosis
of exclusion. In my practice, I see five to ten patients each week with
typical symptoms described below (I explain to parents that these are symptoms
of disease in a well child). A careful history, physical examination, and
a few simple laboratory studies will effectively rule out important organic
etiologies (identifiable medical causes), including anatomic,
biochemical, and inflammatory causes.
Definition
and Characteristics
Chronic abdominal pain is defined as multiple (more than
three) pain attacks during a continuous three-month period that are sufficient
to alter the normal activities of daily life. If your child is complaining
of stomach pain, typical characteristics of a functional problem include:
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Pain usually occurs at or near the umbilicus, and it often
radiates in a circle around the point of origin.
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Pain is often poorly defined (e.g., sharp or dull), varies
in severity, and may be incapacitating, causing the child to assume a fetal
position (lying down, with knees bent to chest).
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Pain can occur at any time of day and it is not associated
with meals.
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Pain does not improve after a bowel movement.
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Pain does not awaken the child from sleep.
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Pain is not associated with fever, vomiting, diarrhea, or
constipation.
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Pain typically interrupts normal activities.
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Pain is not associated with weight loss or growth disturbance.
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Pain is precipitated or exacerbated by stress, including
both physical and psychological stimuli.
Although family turmoil (marital difficulties, sibling rivalry,
a new baby, etc.), interpersonal problems, or school-related stress are
important precipitating events to be considered, the contribution of psychological
factors may not be readily apparent. Furthermore, I find that many children
with chronic abdominal pain are popular with their peers, involved in numerous
activities, and they are often described as high academic achievers.
Evaluation
In general, if your child fits the above criteria, with
the onset of pain between 5 and 15 years of age, a diagnosis of functional
abdominal pain is most likely. Confirmation is achieved by a normal physical
examination and by obtaining a normal blood count, urine analysis, ESR
(a nonspecific test for inflammation), and negative stool test for blood.
Remember that a diagnosis of functional abdominal pain is a positive
diagnosis. In other words, all other causes of pain do not need to
be thoroughly evaluated (generally by employing invasive diagnostic studies)
before reaching a diagnosis of functional pain. However, if you are concerned
about a particular diagnosis, ask your child’s doctor to consider that
problem. When I am aware of family anxiety about a specific disease, I
will often modify my routine evaluation, in order to rule out that disorder.
Organic
vs. Functional Abdominal Pain
As stated above, if your child is complaining of pain
and fits the above criteria, the odds overwhelmingly favor a nonorganic
diagnosis. Additional testing is rarely required. However, what if your
child doesn’t conform to this description? Here are the considerations
I apply in my practice, when considering an organic cause:
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Pain is present away from the umbilicus.
In general, the farther away from the umbilicus, the higher the likelihood
of an organic cause. However, if the other criteria for functional pain
are met, a nonorganic problem is still most likely.
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Pain usually occurs after meals.
In this case, a problem related to diet might be the cause. In older children
lactose
intolerance (the inability to digest milk sugar may develop
during the second decade) should be considered. Younger children who purposefully
withhold stool may also have increased pain after eating (often because
of toileting anxieties or fears that bowel movements may be painful).
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Pain is relieved by having a bowel
movement. Constipation and stool-withholding may be the problem
here.
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Pain wakes the child from sleep.
This pain characteristic points to an underlying, organic illness. Note,
however, that your child with functional abdominal pain may have difficulty
getting to sleep and may complain of pain immediately upon waking in the
morning.
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Pain is associated with other symptoms.
Children with functional abdominal pain may also complain of headaches
and pains in the arms and legs. This triad of symptoms comprises a classical,
functional syndrome. However, the following problems should alert parents
and pediatricians that an organic process is responsible:
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Fever
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Rectal bleeding
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Poor growth or unexplained weight loss
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Vomiting
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Altered bowel pattern
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Family history of peptic ulcers or inflammatory bowel disease
If any of these problems exist, your child’s pediatrician
may need to perform more extensive diagnostic studies, and he may refer
your child for additional evaluation to a pediatric gastroenterologist.
Treatment
After using the above criteria to reach a diagnosis of
functional abdominal pain, your child’s physician will explain the rationale
for this conclusion. I find that acceptance of a nonorganic diagnosis represents
a significant hurdle that must be overcome before achieving a successful
outcome. Unfortunately, more than a few families will “doctor-shop” in
order to discover an underlying, organic disorder. More often than not,
this practice results in an expensive, uncomfortable, and fruitless search,
while neglecting the true cause of pain. Once a functional diagnosis is
established, the goals of therapy are to:
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Understand and accept the diagnosis of functional abdominal
pain.
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Realize that the problem does not represent a health threat.
By reassuring both the child and parents, and by allaying fears of a serious
disorder, I find that the symptoms will often spontaneously improve. Nevertheless,
some affected children (30 to 50 percent in some series) will ultimately
develop irritable bowel syndrome (another functional diagnosis) as adults.
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Determine factors that may represent stress for your child
and thus initiate or exacerbate symptoms.
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Facilitate both communication and problem-solving.
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Encourage relaxation techniques to cope with symptoms.
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Maintain normal activities, despite the presence of symptoms.
One cautionary note is warranted here. I find that many children
with functional pain are over-programmed, with little idle time for relaxation.
A selective reduction in the endless parade of music lessons, dance classes,
athletic practices, religious training, and so on (in addition to mountains
of homework, especially for students in advanced classes), may alleviate
symptom-causing stress.
Pharmacological interventions (sedatives, antispasmodics)
are rarely needed. When the pain occurs in school, children should be allowed
some quiet time, usually by lying down in the nurse’s office, with the
understanding that they must return to class. I reinforce to families that
functional abdominal pain will not be totally eradicated over the short-term.
The primary goal of treatment, therefore, must focus on maintaining normal
lifestyle and activities, despite recurrent symptoms.
Summary
Chronic abdominal pain is a common problem encountered
during childhood. A specific, causative disease process, however, can only
be diagnosed in less than ten percent of cases. In general, expression
of pain is the consequence of diverse stressful factors. Keep in mind,
however, that the pain is real (albeit not the result of an organic process).
Your child’s doctor can rule out serious underlying disorders by a careful
history and physical examination, and by obtaining a few simple laboratory
tests. The primary goal of therapy is to achieve a normal level of functioning,
despite symptoms. In all cases, both parent and child need to understand
the problem in order to address important stress-related issues and achieve
a successful outcome.
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