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Recurrent Abdominal Pain In Children by: FRANCIS SUNARYO, M.D. PEDIATRIC GASTROENTEROLOGIST PEDIATRIC SPECIALTY CENTER AT SAINT BARNABAS MEDICAL CENTER Recurrent abdominal pain is one of the most common reasons that parents seek medical attention for their child. As many as 10 to 15 percent of school-aged children are believed to suffer chronic abdominal pain severe enough to affect their normal activities. Although there can be many possible causes, in most cases there is no evidence of disease. Young patients are said to have Functional Gastrointestinal (GI) Disorders. Depending on the pattern of the symptoms, the physician may label the condition as one of the following:irritable bowel syndrome (IBS), functional dyspepsia, abdominal migraine, aerophagia or functional abdominal pain syndrome. Examining the Conditions InIBS, the pain is associated with changes in bowel habits such as diarrhea or constipation, feeling of incomplete evacuation, passage of mucus or a feeling of bloating. The abdominal pain is usually in the lower abdomen and is relieved by bowel movement. IBS is more common in adolescents. Children with IBS seem to have more digestive problems when stressed or anxious than healthy children do. Some children first develop symptoms after a stressful event, a viral illness, problems with school, or problems occurring in the family. In spite of the long duration of symptoms, the child continues to grow and develop normally. In functional dyspepsia the pain is centered in the upper abdomen. The discomfort is associated with eating, nausea, occasional vomiting, feeling full easily and excessive belching. As with IBS, functional dyspepsia is often preceded by a viral illness. Aerophagia or air swallowing can produce abdominal discomfort accompanied by abdominal distention, repetitive belching increased gas or flatulence. It is frequently associated with stressful events or anxiety in the child’s life. This condition can be made worse by consumption of carbonated beverages or by chewing gum. Inabdominal migraine the pain is episodic. Often it is very intense and can last for several hours to several days with the child feeling completely fine in between episodes. Headache and sensitivity to light often occur during the episodes. The child can experience an aura or warning period consisting of blurred or restricted vision, numbness or tingling sensation preceding the onset of the attack. Family history of migraine is common. The most common presentation of Functional GI Disorders is functional abdominal painsyndrome. In this condition the pain is usually around the bellybutton area. It can occur at any time and is usually not associated with eating. It very rarely awakens the child from sleep. The pain is usually brief or fleeting. During the attacks, the child may be doubling over, grimacing, crying or clenching and pushing on the abdomen. Again, as with other forms of functional GI disorders, the child’s growth is maintained and weight is not affected and the physical exam is normal. The exact cause of functional pain is not known. There is evidence to suggest that alteration in the processing of the sensory signals coming from the intestine leads to heightened sensitivity to normal digestive activities. Gas in the intestine or the mere presence of stools in the rectum, which do not normally cause pain, are painful to children with functional GI disorders. The Possibility of Disease Although most children with chronic recurrent abdominal pain do not have evidence of a disease, the possibility of other medical problems (e.g. Crohn’s disease, ulcerative colitis, peptic ulcer, gastroesophageal reflux disease, celiac disease and many other diseases) need to be considered if they also present with any of the following warning signs:
Family history of inflammatory bowel disease or peptic ulcer Testing and Treatment Children with recurrent abdominal pain who are well otherwise, with a normal physical exam, need only minimal testing. Blood test, urine analysis and culture, and if there is diarrhea, stool sample to check for bacteria and parasites, are commonly performed. A trial of a lactose-free diet or a breath test may be recommended if lactose intolerance is suspected. However, if there are "warning signs," more extensive investigations are needed. These tests may include upper GI and small bowel x-rays, abdominal ultrasound, CT scan, endoscopy of the esophagus and stomach, or colonoscopy. Once an underlying medical cause has been ruled out, treatment often begins with dietary changes. Beverages containing caffeine and foods high in fat can be limited in the diet. Foods that contain poorly absorbable carbohydrates, such as highfructose corn syrup and sorbitol (found in apple and pear juice, sugarless gum) should be eliminated because they may be associated with increased gas production and intestinal distention. Children with constipation may benefit from a diet with increased fiber. If the children continue to have symptoms in spite of dietary changes, a variety of medications can be used. Antispasmodic medications may be used for children who have IBS with diarrhea as the predominant symptom. The potential side effects of antispasmodics include dry mouth, constipation and blurred vision. For those with dyspepsia, treatment with medication to decrease stomach acid secretion may be helpful. Low dose antidepressant medications are the next line of therapy for patients with IBS, functional abdominal pain syndrome and dyspepsia. These medications work by altering the processing of pain in the brain and its effect on intestinal motility. The potential side effect is sleepiness. There are newer IBS medications for adults that are not yet approved by the FDA for use in children pending studies showing efficacy and safety of these medications in pediatric population. Social Stressors Finally, children with functional bowel disorders frequently have social stressors such as school, peer relationship or family problems, that need to be identified. Once they are recognized we need to focus on helping and supporting the child to deal with the stress. For children who have missed many school days, the parents and school need to work together to identify and address the obstacles to school attendance. The child may initially return to school for part of the day, and gradually increase the attendance to full time over a period of time. Consultation with a behavioral specialist/child psychologist may be needed depending on the circumstances. For a referral to a Saint Barnabas pediatric gastroenterologist, please call 1-888-SBMC-DOC. [ top ] |
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