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RecuRRent AbdominAl PAinDr. Ravi MalikCMD Radix HospitalIMA HeadquatersDMC medical education convenor
INTRODUCTIONRAP 3 episodes over 3 months Severe enough to affect activities Inter periods of well being No specific cause identified
epIDemIOlOgy10-12% of school aged children.Peak incidence at 4-6 years and at 7-12 years.Obesity and RAP.Fruits consumption and RAP.
ClINICal pROfIlePain is genuinePeri-umbilical painNausea, vomitingPallorHeadache & limb painsFamily history
ClassIfICaTION• It can be organic or nonorganic.• Nonorganic(functional) abd pain • Functional dyspepsia • Irritable bowel syndrome • Abdominal migraine • Functional abdominal pain
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
Functional dyspepsia Pain or discomfort in the upper abd. Stomach fullness Bloating Nausea Retching or vomiting.Irritable bowel syndrome
Abdominal migraine Intense abdominal pain Mid-abdomen Anorexia, nausea, vomiting, pallor, headache, or sensitivity to light A family history of migraineFunctional abdominal pain syndrome
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.
Emotional stressPatients 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.
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.
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
alaRm sIgNs (NeeDINg fURTheR INvesTIgaTIONs)Localized tenderness in right upper/lower quadrantLocalized fullness or massHepatomegaly/SplenomegalyJaundiceCostovertebral angle tendernessArthritisSpinal tendernessPerianal diseaseUnexplained physical findingsPallor/RashHernia
DIagNOsIsRAP should not require an exhaustive series of diagnostic tests to rule out organic causesHistory – absence of alarming symptomsMeticulous examinationOther associated symptomsNormal investigationsOrganic & nonorganic may co-exist
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
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.
abDOmINal paIN TReaTmeNTTreat organic cause if present.For functional abdominal pain variety of treatments.Close follow up required.
gUIDelINes fOR maNagemeNT Of ReCURReNT abDOmINal paINRule out organic causeReassurance & education of the family.Discuss the apprehensions of family.Explore stressors.Acknowledge but no undue attention.Avoid psychological labelling.
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”
DRUg TheRapIesPharmacological 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.
DIeTaRy mODIfICaTIONsThere 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.
behavIORal TheRapIesRecommended 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.
pROgNOsIsWith 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.