Abdominal pain (chronic and recurrent)

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Chapter 1 ABDOMINAL PAIN (CHRONIC AND RECURRENT)

Theodore X. O’Connell

General Discussion

The medical literature uses varied defining criteria for chronic and recurrent abdominal pain. Chronic abdominal pain is now usually defined as long-lasting intermittent or constant abdominal pain of at least 3 months’ duration. Recurrent abdominal pain is defined as at least three bouts of pain, severe enough to affect activities, over a period of at least 3 months. For many years, the term recurrent abdominal pain was used to describe all cases without an identified organic cause. It is now agreed that recurrent abdominal pain is a description, not a diagnosis. The exact prevalence of chronic abdominal pain is not clear, but it seems to account for 2% to 4% of all pediatric office visits, and the prevalence increases with age. In boys, the peak incidence occurs between 5 and 6 years of age, whereas girls have two peaks: one between 5 and 6 years of age and another between 9 and 10 years of age.

A complete history and physical examination are the most important components of the evaluation of any child with chronic abdominal pain. The history is used to assess possible organic causes for the abdominal pain as well as psychosocial factors that may be contributing. The HEADSS mnemonic (home life, education level, activities, drug use, sexual activity, suicide ideation/attempts) is a useful tool to screen for psychosocial problems. The history and physical examination can then be augmented by selected laboratory testing, imaging studies, and empiric therapies.

The two broad categories in the differential diagnosis for chronic abdominal pain in children are organic disorders and functional disorders. In organic disorders, physiologic, structural, or biochemical abnormalities are present. Functional disorders are conditions in which the patient has a variable combination of symptoms without an identifiable structural or biochemical abnormality and for which no specific test exists to establish the diagnosis. Functional gastrointestinal disorders recognized in childhood include functional dyspepsia, irritable bowel syndrome (IBS), functional abdominal pain, abdominal migraine, and aerophagia. The organic and functional categories are not mutually exclusive: both organic and psychological conditions can coexist and interact.

The Rome III diagnostic criteria for functional dyspepsia is defined as all of the following symptoms at least once per week for at least 2 months:

1. Persistent or recurrent pain or discomfort centered in the upper abdomen (superior to the umbilicus)

2. Not relieved by defecation or associated with the onset of a change in stool frequency or stool form (i.e., not IBS)

3. No evidence of an inflammatory, anatomic, metabolic, or neoplastic process that explains the subject’s symptoms

The Rome III diagnostic criteria for irritable bowel syndrome must include all of the following at least once per week for at least 2 months before diagnosis:

1. Abdominal discomfort (an uncomfortable sensation not described as pain) or pain associated with two or more of the following at least 25% of the time:

a. Improvement with defecation
b. Onset associated with a change in frequency of stool
c. Onset associated with a change in form (appearance) of stool

2. No evidence of an inflammatory, anatomic, metabolic, or neoplastic process that explains the subject’s symptoms

The Rome III diagnostic criteria for childhood functional abdominal pain must include all of the following at least once per week for at least 2 months before diagnosis:

1. Episodic or continuous abdominal pain

2. Insufficient criteria for other functional gastrointestinal disorders

3. No evidence of an inflammatory, anatomic, metabolic, or neoplastic process that explains the subject’s symptoms

The diagnosis of childhood functional abdominal pain syndrome must include childhood abdominal pain at least 25% of the time and one or more of the following:

1. Some loss of daily functioning

2. Additional somatic symptoms such as headache, limb pain, or difficulty sleeping

The Rome III diagnostic criteria for abdominal migraine require that all of the following symptoms be present two or more times in the preceding 12 months:

1. Paroxysmal episodes of intense, acute periumbilical pain that lasts for 1 hour or longer

2. Intervening periods of usual health lasting weeks to months

3. The pain interferes with normal activities

4. The pain is associated with two or more of the following:

a. Anorexia
b. Nausea
c. Vomiting
d. Headache
e. Photophobia
f. Pallor

5. No evidence of an inflammatory, anatomic, metabolic, or neoplastic process that explains the subject’s symptoms

The Rome III diagnostic criteria define aerophagia as at least two of the following symptoms occurring at least once per week for at least 2 months:

1. Air swallowing

2. Abdominal distention because of intraluminal air

3. Repetitive belching, increased flatus, or both

Causes of Chronic or Recurrent Abdominal Pain

Abdominal migraine

Abdominal wall pain

Aerophagia

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