Abdominal Pain

NINUNG RD KUSUMAWATI
 Recurrent abdominal pain

Apley and Naish 1958: abdominal pain that occurs for at

least 3 episodes within 3 months and is severe enough to
affect a childs activities

Organic and psikogenic + dysfunctional

Dysfunctional functional ROME III : Functional

Gastrointestinal Disorder (FGID)
Cause of Childrens Chronic Abdominal Pain

Functional
Infants/toddlers
Regurgitation
Rumination syndrome
Cyclic vomiting
Infant colic
Functional diarrhea
Infantile dyschezia
Functional constipation
 Cont

Child/adolescent
Functional vomiting/aerophagia
Rumination syndrome
Cyclic vomiting
Functional abdominal pain syndrome
Functional dyspepsia
IBS/abdominal migraine
Functional constipation
 Cont

Organic
Gastrointestinal
Oesophageal : GERD, oesophagitis
Stomach : Peptic ulcer, HP, gastritis
Intestinal : Giardiasis, amoebiasis,
helminthiasis, IBD, Lactose intolerance,
coeliac disease
Surgical : Malrotation, intususeption, small
bowel lymphoma, post surgical
adhesion
Hepatobiliary : Choledochal cyst, cholelithiasis,
choledocholithiasis, SOL
Pancreas : Pancreatitis
 Cont

Non-gastrointestinal
Renal : UTI, Obs Uropathy
Pelvic : PID, ovarian pathology
Haematological : Leukemia
Vaskuler : Henoch-Schonlein Purpura
Metabolic : Diabetic ketoacidosis,
porphyria, lead poisoning
 Chronic abdominal pain
> 3 months

STEP I
History : site and characteristic
of pain, predominant symptom
Physical examination

Alarm symptom not Alarm symptom

present (functional present (organic abd
abd pain) pain)

Level 1
Complete blood count,
peripheral smear, urine and
stool examination
Level 1a
Level 1 + Abdomen USG, renal
Step II and liver function tests, sugar,
Investigation amylase, lipase, Mantoux test,
chest and abdomen X-ray, coeliac
serology
 Level II
GI endoscopy, CT
abdomen, barium
studies, laparoscopy,
- Reassurance MRCP, motility studies,
- Involved doctoring breath test
- Parent education
- Dietary modification
- Appropriate drugs Level III
- Cognitive behavioral EEG, screening for
therapy porphyria, lead levels
- Regular and diligent
follow up
Step III
Management Treat the cause
FUNCTIONAL GASTROINTESTINAL DISORDER

Functional gastrointestinal disorders (FGID) are

defined as :

a variable combination of chronic or recurrent

gastrointestinal symptoms not explained by

structural or biochemical abnormalities.
In order to avoid unnecessary tests a conservative
approach is appropriate.

Alarm symptoms, signs, and features should make the

physician suspect that the pain has an organic background

In the absence of alarm symptom, pain is very likely to

have a functional origin and therefore most tests will be
unnecessary
ALARM SYMPTOMS
FUNCTIONAL GASTROINTESTINAL DISORDER
ABDOMINAL PAIN RELATED FGID DIAGNOSTIC APPROACH
 Functional Dyspepsia

Definition:

Dyspepsia is pain or discomfort localized in the upper

abdomen.

Symptoms may vary including fullness, early satiety,

bloating, nausea, retching, and vomiting.

No signs or symptoms reliably differentiate functional

dyspepsia from upper gastrointestinal organic disorders
Functional dyspepsia can have two presentation types, ulcer-like and
dysmotility-like

Ulcer-like dyspepsia children experience upper abdominal pain as

the dominant complaint, and it often is relieved by food or antacid
therapy.

In dysmotility-like dyspepsia, pain is not the dominant symptom; the

primary complaints are nausea, early satiety, postprandial fullness,
retching, vomiting, and a sense of bloating.
 Characteristics of functional dyspepsia

There are no symptoms or signs that distinguish functional

dyspepsia reliably from upper GI inflammatory, structural,
or motility disorders.

For this reason, symptoms of dyspepsia should generate a

more extensive diagnostic evaluation.
 Criteria to define dyspepsia in children

Major criteria Minor criteria

Recurrent vomiting (at least 3/ month) Chronic nausea

Epigastric abdominal pain
Early satiety
Excessive belching/ hiccups
Anorexia/ weight loss
Heartburn
Periumbilical abdominal pain
Oral regurgitation
Positive family history of peptic ulcer
disease,dyspepsia, or irritable
syndrome
Children who have a constellation of sign and/or symptoms
that include 2 major criteria, 1 major and 2 minor criteria or
4 minor criteria should be investigated to rule out the
organic etiology of dyspepsia.
 Work Up Study Purpose
Complete blood count (CBC), Evaluate anemia, eosinophilia and infection
with differential white blood cell Count

Liver function tests Rule out liver and biliary tract disorders

Stool Ova and parasite Rule out paracitic infection

Sedimentation rate If increased, rule out inflammatory bowel

disease

Amilase and Lipase Rule out pancreatitis

Liver USG Possibility of gallstones/ right upper quadrant

pain

Hydrogen breath test Evaluate for lactose intolerance and small

bowel bacterial overgrowth

Endoscopy Rule out esophagitis, gastritis, duodenitis or

Helicobacter pylori infection
 Functional Dyspepsia

Must include all of the following:

Persistent or recurrent pain or discomfort centered in the

upper abdomen (above the umbilicus)

Not relieved by defecation or associated with the onset of

a change in stool frequency or stool form (ie, not IBS)

No evidence of an inflammatory, anatomic, metabolic, or

neoplastic process that explains the subjects symptoms
 Treatment of Functional Dyspepsia

Avoidance of nonsteroidal anti-inflammatory drugs

Avoidance of foods that aggravate symptoms:
Caffeine Spicy foods
Fruit juices Fatty foods
H2 blockers
Proton pump inhibitors
Prokinetic drugs:
Domperidone
Erythromycin
Cisapride
Psychological behavioural intervention
 Abdominal Migraine

Abdominal migraine is characterized by recurrent paroxysmal episodes

of acute, periumbilical and noncolicky pain associated with anorexia,
nausea, vomiting, headache, and pallor.

The origin of abdominal migraine is linked to other functional disorders

like migraine headache and cyclic vomiting syndrome

Familial aggregation and response to antimigraine drugs, support the

diagnosis.
 Abdominal Migraine

A number of digestive and extradigestive conditions

including renal colic, recurrent pancreatitis
choledocholithiasis, familial Mediterranean fever, Crohns
disease, and porphyria, must be ruled out before
establishing the diagnosis of abdominal migraine.
 Abdominal Migraine

Must include all of the following:

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

Intervening periods of usual health lasting weeks to months

The pain interferes with normal activities

The pain is associated with 2 or more of the following:

Anorexia, Nausea, Vomiting, Headache, Photophobia, Pallor

No evidence of an inflammatory, anatomic, metabolic, or neoplastic process

considered that explains the subjects symptoms

All five criteria must be fulfilled at least twice in the preceding 12 months
Treatment of Abdominal Migraine

Avoidance of foods containing:

Caffeine

Nitrites

Amines

Behavioural intervention

Drugs:

Pizotifen

Propanolol

Cyproheptadine

Sumatriptan
 Childhood Functional Abdominal Pain

Children with recurrent abdominal pain episodes that do not fulfil the
previous categories but in whom organic pathology has been
reasonably excluded fall within this category .

Functional abdominal pain diagnosis can be difficult to establish as

there are no specific criteria .

Routine investigations are not required in every patient. Depending on

the signs, symptoms, age, and gender of the patient
Characteristic Features of Functional Abdominal Pain

Functional abdominal pain is the most common cause of

paroxysmal periumbilical pain in children.

Pain episodes begin gradually and last less than 1 hour in

50% of patients and less than 3 hours in 40%.

Continuous pain is described in fewer than 10% of patients.

The child usually is unable to describe the pain.

Points to periumbilical region.

No radiation of the pain.

Childhood Functional Abdominal Pain

Differential diagnosis include a wide range of digestive and

nondigestive diseases such as :

coeliac disease

inflammatory bowel disease

food intolerances,

Helicobacter pylori infection

eosinophilic enteritis

chronic pyelonephritis

parasite infestation.
Childhood Functional Abdominal Pain

Must include all of the following:

Episodic or continuous abdominal pain

Insufficient criteria for other FGIDs

No evidence of an inflammatory, anatomic, metabolic, or

neoplastic process that explains the subjects symptoms

All three criteria must be fulfilled at least once perweek for at

least 2 months
 Investigations in patients with
suspected functional abdominal pain
Treatment of Childhood Functional Abdominal Pain

Psychosocial intervention

Tricyclic antidepressants
Childhood Functional Abdominal Pain Syndrome

Must include childhood functional abdominal pain at least

25% of the time and 1 or more of the following:

Some loss of daily functioning

Additional somatic symptoms such as headache, limb

pain, or difficulty sleeping

Criteria must be fulfilled at least once per week for at

least 2 months
 Irritable Bowel Syndrome

Irritable bowel syndrome (IBS) is characterized by episodes of

recurrent abdominal pain temporally associated with altered bowel
habits: either constipation or diarrhoea

If the child fulfils the diagnostic criteria no further investigations are

required.

Aetiology of IBS is multifactorial and not completely understood

Most of these patients symptoms improve if they manage to reduce or

dominate the stress intervening factors.
 Irritable Bowel Syndrome

Must include all of the following:

Abdominal discomfort (an uncomfortable sensation not described

as pain) or pain associated with 2 or more of the following at least
25% of the time:

a. Improved with defecation

b. Onset associated with a change in frequency of stool

c. Onset associated with a change in form (appearance) of stool

No evidence of an inflammatory, anatomic, metabolic, or neoplastic

process that explains the subjects symptoms
 .
AETIOLOGY of IBS
Treatment of Irritable Bowel Syndrome

Peppermint oil

Psychological behavioural intervention

 Aerophagia

Must include at least two of the following

1. Air swallowing

2. Abdominal distension due to intraluminar air

3. Repetitive belching and/or increased flatus

 Other Disorder

Other prevalent disorders that usually present with chronic

abdominal pain and diarrhoea or constipation include:

lactose intolerance, coeliac disease, food allergies,

inflammatory bowel disease, and giardiasis