Workup of Pediatric Abdominal Pain: Who, What, Why and How Mark B. Stephens, MD MS FAAFP Associate Professor of Family Medicine.Background • 4-25% of all school-aged children complain of abdominal pain severe enough to interfere with daily activities1 • Abdominal pain accounts for 2-4% of all pediatric outpatient visits2 • 13-17% of middle and high-school students experience abdominal pain on a weekly basis3 • 8% of all students have seen a physician in the past year for abdominal pain.3 • Most children will have no organic cause for their pain, even after extensive searching1“Recurrent Abdominal Pain” (RAP) • First described in 1950’s for children with at least 3 episodes of pain significant to interrupt activities occurring over at least a 3 month period.4Rome Criteria (ROME I; ROME II; ROME III) • The Rome criteria were first applied to adult IBS. In 1999, all roads led to Rome, Italy where a consensus conference introduced the world to the concept of FGIDs (Functional GI Disorders) in childhood.ROME II (1999) Diagnostic Criteria for Childhood Functional GastrointestinalDisorders (FGID’s)*The diagnosis of a Childhood Functional Gastrointestinal Disorder (FGID) alwayspresumes the absence of a structural or biochemical explanation for the symptoms. Hereis a breakdown of the 1999 (ROME II) FGIDs:G1.Vomiting G1a. Infant Regurgitation 1. Regurgitation 2+/day for 3+ weeks; 2. No retching, hematemesis, aspiration, apnea, failure-to-thrive, or abnormal posturing 3. 1 to 12 months of age and otherwise healthy 4. No evidence for metabolic, gastrointestinal, or central nervous system disease to explain the symptom.
G1b. Infant Rumination Syndrome 1. At least 3 months of repetitive contractions of the abdominal muscles, diaphragm, and tongue with regurgitation of stomach contents into the mouth, Food is then either expelled or chewed and swallowed. In addition, 3 or more of the following: a. Onset between 3 and 8 months of age; b. Does not respond to management for gastroesophageal reflux disease, anticholinergic drugs, hand restraints, formula changes, and gavage or gastrostomy feedings; c. Unaccompanied by signs of nausea or distress; and/or d. Does not occur during sleep and when the infant is interacting with individuals in the environment. G1c. Cyclic Vomiting Syndrome 1. A history of 3 or more periods of intense nausea and vomiting lasting hours to days, with intervening symptom-free intervals lasting weeks to months. 2. No metabolic, gastrointestinal, or central nervous system structural or biochemical disease to explain symptoms.G2. Abdominal Pain G2a. Functional Dyspepsia In children mature enough to provide an accurate pain history, at least 12 weeks, which need not be consecutive, in the preceding 12 months of: 1. Persistent or recurrent pain or discomfort centered in the upper abdomen (above the umbilicus); 2. No evidence of organic disease (including at upper endoscopy) that is likely to explain the symptoms; and 3. No evidence that dyspepsia is exclusively relieved by defecation or associated with onset of a change in stool frequency or stool form (i.e., not irritable bowel). o G2a1. Ulcer-like Dyspepsia: Pain centered in the upper abdomen is the predominant (most bothersome) symptom. o G2a2. Dysmotility-like Dyspepsia: An unpleasant or troublesome nonpainful sensation (discomfort) centered in the upper abdomen is the predominant symptom; this sensation may be characterized by early satiety, upper abdominal fullness, bloating, or nausea. o G2a3. Unspecified (Nonspecific) Dyspepsia: Symptomatic patients whose symptoms do not fulfill the criteria for either ulcer-like or dysmotility-like dyspepsia.
G2b. Irritable Bowel SyndromeIn children old enough to provide an accurate pain history, at least 12 weeks,which need not be consecutive, of continuous or recurrent symptoms during thepreceding 12 months of:1. Abdominal discomfort or pain that has two out of three features: a. Relieved with defecation; and/or b. Onset associated with a change in frequency of stool; and/or c. Onset associated with a change in form (appearance) of stool.2. There are no structural or metabolic abnormalities to explain the symptoms.Symptoms that support the diagnosis of Irritable Bowel Syndrome • Abnormal stool frequency (for research purposes “abnormal” may be defined as greater than 3 bowel movements per day and less than 3 bowel movements per week); • Abnormal stool form (lumpy/hard or loose/watery stool); • Abnormal stool passage (straining, urgency, or feeling of incomplete evacuation); • Passage of mucus; • Bloating or feeling of abdominal distension.G2c. Functional Abdominal PainAt least 12 weeks of: 1. Continuous or nearly continuous abdominal pain in a school-aged child or adolescent; and 2. No or only occasional relationship of pain with physiological events (e.g., eating, menses, defecation); and 3. Some loss of daily functioning; and 4. The pain is not feigned (e.g., malingering); and 5. Insufficient criteria for other functional gastrointestinal disorders that would explain the abdominal pain.G2d. Abdominal Migraine1. In the preceding 12 months, 3 or more paroxysmal episodes of intense, acutemidline abdominal pain lasting 2 hours to several days, with interveningsymptom-free intervals of weeks to months; and2. Evidence of metabolic, gastrointestinal, and central nervous system structuralor biochemical diseases is absent; and
3. Two of the following features: a. Headache during episodes; b. Photophobia during episodes; c. Family history of migraine; d. Headache confined to one side only; and e. An aura or warning period consisting of either visual symptoms (e.g., blurred or restricted vision) or sensory symptoms (e.g., numbness or tingling), or motor symptoms (e.g., slurred speech, inability to speak, paralysis). G2e. Aerophagia At least 12 weeks, which need not be consecutive, in the preceding 12 months of two or more of the following signs and symptoms: 1. Air swallowing; 2. Abdominal distension due to intraluminal air; and 3. Repetitive belching and/or increased flatus.G3. Functional Diarrhea (also called Toddler’s Diarrhea, chronic nonspecificdiarrhea, irritable colon of childhood) For more than 4 weeks, daily painless, recurrent passage of 3 or more large, unformed stools, in addition to all these characteristics: 1. Onset of symptoms begins between 6 and 36 months of age; 2. Passage of stools occurs during waking hours; and 3. There is no failure-to-thrive if caloric intake is adequate.G4. Disorders of Defecation G4a. Infant dyschezia At least 10 minutes of straining and crying before successful passage of soft stools in an otherwise healthy infant less than 6 months of age. G4b. Functional Constipation In infants and children, at least 2 weeks of: 1. Scybalous, pebble-like, hard stools for a majority of stools; or 2. Firm stools 2 or less times/week; and 3. There is no evidence of structural, endocrine, or metabolic disease. G4c. Functional Fecal Retention
From infancy to 16 years old, a history of at least 12 weeks of: 1. Passage of large diameter stools at intervals < 2 times per week; and 2. Retentive posturing, avoiding defecation by purposefully contracting the pelvic floor. As pelvic floor muscles fatigue, the child uses gluteal muscles, squeezing the buttocks together. Accompanying symptoms may include fecal soiling, irritability, abdominal cramps, decreased appetite and/or early satiety. The accompanying symptoms disappear immediately following passage of a large stool. G4d. Functional Non-retentive Fecal Soiling Once a week or more for the preceding 12 weeks, in a child older than 4 years, a history of: 1. Defecation into places and at times inappropriate to the social context; 2. In the absence of structural or inflammatory disease; and 3. In the absence of signs of fecal retention (listed in G4c above).Not to be outdone; all roads led again to Rome in 2006 for the ROME III consensusconference, where patients are classified first by age range and then by symptom patternor area of symptom. Each domain contains several disorders, each with relatively specificclinical features.Neonate/Toddler (category G) • G1. Infant regurgitation • G2. Infant rumination syndrome • G3. Cyclic vomiting syndrome • G4. Infant colic • G5. Functional diarrhea • G6. Infant dyschezia • G7. Functional constipationChild/Adolescent (category H) • H1. Vomiting and aerophagia: o H1a. Adolescent rumination syndrome; o H1b. Cyclic vomiting syndrome; o H1c. Aerophagia • H2. Abdominal pain–related FGIDs: o H2a. Functional dyspepsia; o H2b. Irritable bowel syndrome; o H2c. Abdominal migraine;
o H2d. Childhood functional abdominal pain • H3. Constipation and incontinence: o H3a. Functional constipation; o H3b. Nonretentive fecal incontinenceIn addition to the helpful taxonomy of the ROME III conference, the AAP recentlypublished the following major recommendations for dealing with abdominal pain inchildren5:Recommendations 1. The term "recurrent abdominal pain" should be avoided. Functional abdominal pain is the most common cause of chronic abdominal pain. It is a specific diagnosis. It must be distinguished from anatomic, infectious, inflammatory, or metabolic causes of abdominal pain. Functional abdominal pain may be categorized as one or a combination of: functional dyspepsia, irritable bowel syndrome, abdominal migraine, or functional abdominal pain syndrome (see table). 2. Functional abdominal pain generally can be diagnosed correctly by family physicians in children 4 to 18 years of age with chronic abdominal pain when there are no alarm symptoms or signs, the physical examination is normal, and the stool sample tests are negative for occult blood. There is no requirement for additional diagnostic evaluation. 3. Alarm symptoms or signs include: involuntary weight loss, deceleration of linear growth, gastrointestinal blood loss, significant vomiting, chronic severe diarrhea, persistent right upper or right lower quadrant pain, unexplained fever, family history of inflammatory bowel disease, or abnormal or unexplained physical findings. These warrant additional diagnostic testing for specific anatomic, infectious, inflammatory, or metabolic causes. Significant vomiting includes bilious emesis, protracted vomiting, cyclical vomiting, or a pattern worrisome to the physician. Alarm signs on physical examination include localized tenderness in the right upper or right lower quadrants, a localized fullness or mass effect, hepatomegaly, splenomegaly, costovertebral angle tenderness, tenderness over the spine, or perianal abnormalities. 4. Testing may also be performed to reassure the patient, parent, and physician of the absence of organic disease, particularly if the pain significantly diminishes the quality of life of the patient. 5. The child with functional abdominal pain is best evaluated and treated in the context of the biopsychosocial model of care. Although psychological factors do not help the clinician distinguish between organic (disease-based) and functional pain, it is important to address these factors in the diagnostic evaluation and management of these children. 6. Education of the family is an important part of treatment of the child with functional abdominal pain. It is often helpful to summarize the childs symptoms and explain in simple language that although the pain is real, there is most likely no underlying serious or chronic disease. It may be helpful to explain that chronic
abdominal pain is a common symptom in children and adolescents, yet few have serious disease. Functional abdominal pain can be likened to a headache, a functional disorder experienced at some time by most adults, which very rarely is associated with serious disease. It is important to provide clear and age- appropriate examples of conditions associated with increased pain sensitivity, such as a healing scar, and manifestations of the interaction between brain and gut, such as the diarrhea or vomiting children may experience during stressful situations (e.g., before school examinations or important sports competitions).7. Reasonable treatment goals should be established, with the main aim being the return to normal function rather than the complete disappearance of pain. Return to school can be encouraged by identifying and addressing obstacles to school attendance.8. Medications for functional abdominal pain are best prescribed judiciously. It is reasonable to consider the time-limited use of medications that might help to decrease the frequency or severity of symptoms. Treatment might include acid- reduction therapy for pain associated with dyspepsia; antispasmodic agents, smooth muscle relaxants, or low doses of psychotropic agents for pain or nonstimulating laxatives or antidiarrheals for pain associated with altered bowel pattern.9. Additional research is needed to fill the large gaps of knowledge on chronic abdominal pain in children.
Recommended Clinical Definitions of Long-Lasting Intermittent or Constant Abdominal Pain in Children Term Clinical DefinitionChronic Long-lasting intermittent or constant abdominal pain that is functional orabdominal pain organic (disease-based)Functional Abdominal pain without demonstrable evidence of a pathologic condition,abdominal pain such as an anatomic, metabolic, infectious, inflammatory, or neoplastic disorder; functional abdominal pain may present with symptoms typical of functional dyspepsia, irritable bowel syndrome, abdominal migraine, or functional abdominal pain syndrome.Functional Functional abdominal pain or discomfort in the upper abdomendyspepsiaIrritable bowel Functional abdominal pain associated with alteration in bowel movementssyndromeAbdominal Functional abdominal pain with features of migraine (paroxysmalmigraine abdominal pain associated with anorexia, nausea, vomiting, or pallor as well as a maternal history of migraine headaches)Functional Functional abdominal pain without the characteristics of dyspepsia,abdominal pain irritable bowel syndrome, or abdominal migrainesyndrome TABLE 1: Definitions for Childhood Abdominal Pain51. Huertas-Ceballos A, Macarthur C, Logan S. Pharmacological interventions for recurrent abdominal pain (RAP) in childhood. Cochrane Database of Systematic reviews (Online) 2002(1):CD003017.2. Starfield B, Hoekelman RA, McCormick M, et al. Who provides health care to children and adolescents in the United States? Pediatrics 1984;74(6):991-7.3. Hyams JS, Burke G, Davis PM, Rzepski B, Andrulonis PA. Abdominal pain and irritable bowel syndrome in adolescents: a community-based study. The Journal of Pediatrics 1996;129(2):220-6.4. Apley J, Naish N. Recurrent abdominal pains: a field survey of 1,000 school children. Archives of Disease in Childhood 1958;33(168):165-70.5. Di Lorenzo C, Colletti RB, Lehmann HP, et al. Chronic Abdominal Pain In Children: a Technical Report of the American Academy of Pediatrics and the North American Society for Pediatric Gastroenterology, Hepatology and Nutrition. Journal of Pediatric Gastroenterology and Nutrition 2005;40(3):249-61.