Abdominal pain

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  • 1. RecuRRent AbdominAl PAinDr. Ravi MalikCMD Radix HospitalIMA HeadquatersDMC medical education convenor
  • 2. INTRODUCTIONRAP 3 episodes over 3 months Severe enough to affect activities Inter periods of well being No specific cause identified
  • 3. epIDemIOlOgy10-12% of school aged children.Peak incidence at 4-6 years and at 7-12 years.Obesity and RAP.Fruits consumption and RAP.
  • 4. ClINICal pROfIlePain is genuinePeri-umbilical painNausea, vomitingPallorHeadache & limb painsFamily history
  • 5. ClassIfICaTION• It can be organic or nonorganic.• Nonorganic(functional) abd pain • Functional dyspepsia • Irritable bowel syndrome • Abdominal migraine • Functional abdominal pain
  • 6. eTIOlOgy Organic Pain (10%) Non-organic Pain (90%)Site Flanks, suprapubic Central and often epigastricFamily History - VE + VEPsychological History - VE + VEHeadache - VE + VEWeight Loss +VE - VEAbnormal Signs +VE - VEAbnormal Investigations +VE - VEAlarming Symptoms + VE - VE
  • 7. Functional dyspepsia Pain or discomfort in the upper abd. Stomach fullness Bloating Nausea Retching or vomiting.Irritable bowel syndrome
  • 8. Abdominal migraine Intense abdominal pain Mid-abdomen Anorexia, nausea, vomiting, pallor, headache, or sensitivity to light A family history of migraineFunctional abdominal pain syndrome
  • 9. Rap (ORgaNIC)GIT Infections – ameba, giardia, dysentry, H. pylori Inflammatory-IBD, Hepatitis, appendicitis Constipation GI reflux disease Acid peptic disease
  • 10. CaUses Of RapUrinary tract (ORgaNIC) Gynecological MiscellaneousUrinary tract Ovarian cystinfection AbdominalUrinary calculi epilepsy EndometriosisPelvi-ureteric Physical,junction Pelvic emotional andobstruction inflammatory sexual abuse diseaseChronicpancreatitis
  • 11. paThOphysIOlOgyGastrointestinal motility- High levels of emotional stress and abnormalities in autonomic nervous system may contribute.Visceral hypersensitivity-Intensity of signals from GIT is exaggerated.Abnormal bowel sensitivity to physiological, psychologic or noxious stimuli may be present.May occur following viral gastroenteritis or after psychologically traumatic events.
  • 12. Emotional stressPatients can sometimes date the onset of pain to a specific stressful event, such as change in school, birth of a sibling or separation of parents, family members illess.Higher levels of anxiety and depression are found in patients with RAP than in healthy children.Starting school may also trigger recurrent abdominal pain.
  • 13. Psychological factors:-A child can develop chronic abdominal pain related to his or her need for attention.Parental response to childs pain can reinforce the childs behavior. If parents are worried about childs pain, the child may become more anxious, and the pain may worsen.Parents should pay attention to the childs other activities, this might satisfy the childs need for attention & reduce the abdominal pain.
  • 14. alaRm sympTOms (NeeDINg fURTheR INvesTIgaTIONs) Features that suggest an organic disorder may include one or more of the following: Pain that awakens the child, Significant vomiting/constipation/bloating Persistent right upper/lower quadrant pain Unexplained fever Dysphagia Chronic severe diarrhea G.I. blood loss Unintentional weight loss or slowed growth Delayed puberty Pain/ bleeding with urination Family H/O inflammatory bowel disease, celiac or peptic ulcer disease
  • 15. alaRm sIgNs (NeeDINg fURTheR INvesTIgaTIONs)Localized tenderness in right upper/lower quadrantLocalized fullness or massHepatomegaly/SplenomegalyJaundiceCostovertebral angle tendernessArthritisSpinal tendernessPerianal diseaseUnexplained physical findingsPallor/RashHernia
  • 16. DIagNOsIsRAP should not require an exhaustive series of diagnostic tests to rule out organic causesHistory – absence of alarming symptomsMeticulous examinationOther associated symptomsNormal investigationsOrganic & nonorganic may co-exist
  • 17. INvesTIgaTIONs IN ReCURReNT abDOmINal paINBasic investigations (1st line investigations) Full blood count ESR/C-reactive protein Urine analysis & Urine culture Stool for ova, cysts and parasitesSecond line investigations Plain X-ray abdomen LFT & KFT Celiac panel Abdominal ultrasound Breath hydrogen test for lactose intolerance Tests for Helicobacter pylori Barium follow through Esophageal manometry and pH-metry Upper and lower gastrointestinal endoscopy Intravenous urogram/micturition cystourethrogram
  • 18. Only basic urine, stool and blood examinations are recommended to exclude organic causes in the diagnosis of RAP.Ultrasound scanning, extensive radiographic evaluation and invasive investigations like endoscopy in these children are rarely diagnostic or cost effective.Presence of an abnormal test result alone does not pinpoint to a diagnosis unless it is clinically relevant.
  • 19. abDOmINal paIN TReaTmeNTTreat organic cause if present.For functional abdominal pain variety of treatments.Close follow up required.
  • 20. gUIDelINes fOR maNagemeNT Of ReCURReNT abDOmINal paINRule out organic causeReassurance & education of the family.Discuss the apprehensions of family.Explore stressors.Acknowledge but no undue attention.Avoid psychological labelling.
  • 21. gUIDelINes fOR maNagemeNT Of ReCURReNT abDOmINal paIN-(II)Allow normal activity.Establish regular follow-up system of return visits to monitor the symptoms.Be available Assure parents that you are available to see the child if changes occur or the parents become anxious.Allow appropriate time, in an unrushed environment for them.Make judicious use of “second opinions”
  • 22. DRUg TheRapIesPharmacological treatments are commonly used in an effort to manage symptoms despite the lack of data supporting their efficacy.Usually a part of the multidisciplinary approach.Commonly used medications include acid suppressants for dyspepsia symptoms, antispasmodics & low dose amitriptyline .For chronic abdominal pain with IBS symptoms, antidiarrheals and nonstimulating laxatives are used.Peppermint oil found to be very effective in the treatment of irritable bowel syndrome in children.PPIs and anticholinergics are often unhelpful.
  • 23. DIeTaRy mODIfICaTIONsThere is no evidence that lactose-restricted diet and fiber supplements decrease the frequency of attacks in chronic abd. pain.In some children, there are foods, drinks, and medicines that make symptoms worse.Common triggers include: High-fat foods, Caffeine & foods that increase gas (beans, onions, raisins, bananas, apricots, prunes, cabbage, cauliflower, broccoli etc.)Medicines that can cause upset stomach include aspirin and ibuprofen etc.
  • 24. behavIORal TheRapIesRecommended for children or adolescents with functional abdominal pain that has severely impacted activities of daily living.Cognitive-behavioral therapy is help full in short term for managing pain and functional disability.Relaxation techniques, hypnosis, biofeedback, and psychotherapy help to reduce a childs anxiety levels, help them to participate in normal activities and to better tolerate the pain.A significant improvement of symptoms and fewer school absences in children with RAP following a short period of cognitive behavioral family treatment is reported.
  • 25. pROgNOsIsWith this approach, approximately 30% to 60% of children have resolution of their pain.Remainder continue to exhibit symptoms and go on to be adults with abdominal pain, anxiety, or other somatic disorders.Other studies have reported development of irritable bowel syndrome in 25-29% of them in later life.