2. Clinical Definitions
Source:Hyams et.al
1996.
Acute Abdominal Pain:
Less than 4-6 week ,sub acute (less than
12 weeks)Single episode, self limited and treatable
Episodic localized pain, sharp, stabbing
Chronic Abdominal Pain:
Pain of at least 3 months duration; Long
lasting, intermittent or constant that is functional or
organic (disease)
3. Recurrent abdominal pain (Apley and Naish,
1958)
Waxes and wanes
3 episodes in 3 months
Severe enough to affect activities
No organic cause
Functional Abdominal Pain:
Abdominal Pain without evidence of disease/pathologic
process. Can manifest with symptoms typical of functional
dyspepsia, irritable bowel syndrome, abdominal migraine
or functional abdominal pain syndrome.
4. The American Academy of Pediatrics (AAP)
and North American Society for Pediatric
Gastroenterology, Hepatology, and Nutrition
(NASPGHAN) guidelines for the evaluation and
treatment of children with chronic abdominal pain recommend
that:
the term "recurrent abdominal pain" should not be used as a
synonym for functional, psychological, or stress-related
abdominal pain . Functional abdominal pain, which is the
most common cause of chronic abdominal pain, is a
specific diagnosis that must be distinguished from other
causes of abdominal pain (eg, anatomic, infectious,
inflammatory, metabolic) Source: AAP, 2005
5. Abdominal pain: evidence-based data
Incidence
5 % of patients presenting to the pediatric clinic and ED (2 – 12 years
old, <72 hours duration)
1% of patients with abdominal pain had surgical intervention
84 % of patients were diagnosed to have
URI and/or Otitis Media
Pharyngitis
Viral syndrome
Abdominal pain or uncertain etiology
Gastroenteritis
Acute febrile illness
Sickle cell anemia
H S Purpura
7.4% return visit
1.7% hospitalized
11. Visceral Pain
Stretching of nerve fibres
of walls or capsules of
organs
Crampy
Dull
Achy
Often unable to lie
Bilateral innervation
12. Parietal Pain
Parietal peritoneum irritated
Usually anterior abdominal wall
Localised to the dermatome superficial to the site of painful
stimulus
Localized
Tenderness,Guarding,Ridigity,Rebound as peritonities
13.
14.
15. Classification of Pain In Abdomen
A) Organic and Non-organic
B)Etiological
C) Age
D) Location/ quadrant
16.
17. (B)Etiological Classification
Infections: Viruses or bacteria.
Food-related: Food introlarance,food allergies,
eating excessive food, or gas production – any of
these can cause bloating and temporary discomfort,
rapid after eating.
Poisoning: This can range from simple problems
(such as eating soap) to more serious issues like
swallowing iron pills, magnets, coins, botulism from
spoiled food, or an overdose of medications (such as
acetaminophen poisoning [Tylenol]).
Surgical problems: These includeappendicitis or
blockage of the bowels.
24. And don’t forget the history
GI
Past abdominal surgeries, h/o GB disease, ulcers;
FamHx IBD
GU
Past surgeries, h/o kidney stones, pyelonephritis, UTI
Gyn
Last menses, sexual activity, contraception, h/o PID or
STDs, h/o ovarian cysts,
CVS h/o heart disease, CHF,
Other medical history
DM, SCD, Allergies, Recurrent chest infection
Medications
NSAIDs, H2 blockers, PPIs, immunosuppression,
25. Moving on to the Physical Exam
General
Pallor, diaphoresis, general appearance, level of
distress or discomfort, is the patient lying still or
moving around in the bed. Drawing legs up toward to
belly
Ht , weight,Head Circumference (Abnormal
growth and/or involuntary weight loss)
Signs of delyed Puberty
Vital Signs
26. Abdominal Findings
Guarding
Voluntary
Contraction of abdominal musculature in anticipation of
palpation
Diminish by having patient flex knees
Involuntary
Reflex spasm of abdominal muscles
rigidity
Suggests peritoneal irritation
Rebound
Present in 1 of 4 patients without peritonitis
Pain referred to the point of maximum tenderness when
palpating an adjacent quadrant is suggestive of peritonitis
Rovsing’s sign in appendicitis
27. Rectal exam
Most important
Gross blood or melena indicates a GI Bleeding
Examination of Genitalia
Other system
R/S - Pnemonia
CVS –CHD,Murmur
Pelvic Exam-Vaginal disharge ,Plapable masses
28. Diagnostic Tools
Rome III Criteria
Essential Investigations : according to symptoms e.g.
- CBC
- U A , Stool exam
- LDG, Amylase ,lipase
- Ultrasound
- Barium study
- Gastric emptying time test ,Intestinal transit time
,Colonic transit time test
- Hydrogen breath test: lactose ,lactulose,glucose
- Endoscopy
- Skin Prick test
- Urea Breath test
29. Imaging
Depends what you are looking for!
Abdominal series
3 views: upright chest, flat view of abdomen, upright view of
abdomen
Limited utility: restrict use to patients with suspected obstruction or
free air
Ultrasound
Good for diagnosing,
Good for pelvic pathology
CT abdomen/pelvis
Non-contrast for free air, renal colic,, bowel obstruction
Contrast study for abscess, infection, inflammation, unknown cause
MRI
Most often used when unable to obtain CT due to contrast issue
30. Recommendation of North American
Society for Pediatric Gastroenterology,
Hepatology and Nutrition
Additional diagnostic evaluation is not required in
children without alarm symptoms
Testing may be carried out to reassure children and their
parents
31. What are the predictive values of diagnostic
tests?
There is no evidence to suggest that the use of
ultrasonographic examination of the abdomen and pelvis in
the absence of alarm symptoms has a significant yield of
organic disease .
There is little evidence to suggest that the use of endoscopy
and biopsy in the absence of alarm symptoms has a
significant yield of organic disease .
There is insufficient evidence to suggest that the use of
esophageal pH monitoring in the absence of alarm
symptoms has a significant yield of organic disease .
32. PITFALLS:
• Incomplete exams (rectals, pelvics and genital exams)
• Incomplete histories
• Missing abnormal vitals
• Relying on labs
• Relying on imaging
• Not performing serial exams
• Infant, the pregnant, altered or psychiatric patients
• “Constipation” “GERD” “Gastroenteritis” and “UTI”
33. Simple advice & Health Education
Home Care
Most of the time, you can wait for your child to get
better and use home care remedies. If you are worried or
your child’s pain is getting worse or lasts longer than 24
hours, call your health care provider.
Offer sips of water or other clear fluids.
Suggest that your child try to pass stool.
Avoid solid foods for a few hours. Then try small amounts
of mild foods such as rice, applesauce, or crackers.
Do not give your child foods or drinks that are irritating to
the stomach.
34. Avoid:Caffeine Carbonated beverages,Citrus,Dairy productsFried, or
greasy foods,High-fat foods,Tomato products
Do not give aspirin, ibuprofen, acetaminophen without first asking your
child's health care provider.
To prevent many types of abdominal pain:
Avoid fatty or greasy foods.
Drink plenty of water each day.
Eat small meals more often.
Exercise regularly.
Limit foods that produce gas.
Make sure that meals are well-balanced and high in fiber. Eat plenty of
fruits and vegetables.
35. WHEN TO CONTACT A MEDICAL
PROFESSIONAL
Abdominal pain does not go away in 24 hours
Is a baby younger than 3 months and has diarrhea or vomiting
Is unable to pass stool, especially if the child is also vomiting
Is vomiting blood or has blood in the stool (especially if the blood is maroon or dark, tarry
black)
Has sudden, sharp abdominal pain
Has a rigid, hard belly
Has had a recent injury to the abdomen
Is having trouble breathing
Abdominal pain that lasts 1 week or longer, even if it comes and goes.
A burning sensation during urination
Diarrhea for more than 2 days
Vomiting for more than 12 hours
Fever over 100.4 degrees F
Poor appetite for more than 2 days
Unexplained weight loss
36.
37. DICTUM
All child of non-verbal age presenting with Significant
Pain should be considered to have abdominal pathological
until proven otherwise.
39. Non Organic Cause
Rome III criteria, 2006
Functional dyspepsia
Irritable bowel syndrome
Functional abdominal pain
Functional abdominal pain syndrome
Abdominal migraine
- No evidence of an inflammatory, anatomical,
metabolic or neoplastic process
- Criteria fulfilled at least once a week for at least two
months before diagnosis
40. Dyspepsia = Epigastric discomfort
14 year old boy with two month history
Bothersome post-prandial fullness
Early satiation
Epigastric pain
Epigastric burning
Normal physical examination
Normal screening labs
CBC
Hepatobiliary enzyme tests
IgA and tTG
Lipase or amylase
Stool for occult blood
41. What should we do next?
Recommend endoscopy
when
Vomiting or weight loss
Positive screening test
Low yield test
Often, does not relieve
anxiety
Should we do radiologic
testing?
Obstructive symptoms or
signs
Should we do testing for
H. pylori?
Family history
Acute symptoms
42. How effective is therapy for dyspepsia?
Proton pump inhibitor
< 50% response
No increase in response to high doses
Anti-helicobacter
10-15% response
No improvement with repeated courses
Prokinetic agents
Side effects frequent
Antispasmodics
No benefit
Antidepressants
No benefit
43. Irritable Bowel Syndrome
Abdominal discomfort or
pain associated with 2 or
more of the following at
least 25% of the time
Improvement with
defecation
Onset associated with a
change in stool frequency
Onset associated with a
change in stool consistency
No evidence of another
disorder
Present for two months or
more
44. What is effective therapy for IBS?
Dietary changes
Lactose restriction
Gluten restriction
Medications
Loperamide
Low dose TCA
Psychosocial support
Most effective
No side effects
Fiber supplements
Lactose restriction
Vitamin D restriction
Low calcium intake
Oral antibiotics
Anticholinergics
Probiotics
45. What is the role of gluten restriction?
Gluten sensitive enteropathy = celiac disease. Eat a
gluten free diet.
Gluten sensitivity or intolerance.
GI symptoms associated with gluten intake
Early age of onset.
46. Functional abdominal pain syndrome
1. Continuous or nearly continuous abdominal pain
2. Little to no relationship of pain with eating, defecation, or
menses
3. Some loss of daily functioning
4. The pain is not feigned (e.g., malingering)
5. Does not fit another functional gastrointestinal disorder
6. Duration = prior last 2 months with symptom onset at least
6 months before
47. Paroxysmal episodes of intense, acute periumbilical
pain that lasts for one or more hours
Intervening periods of usual health lasting weeks to
months
The pain interferes with normal activities
The pain is associated with two or more of the
following:
- Anorexia
- Nausea
- Vomiting
- Headache
- Photophobia
- Pallor
Criteria fulfilled two or more times in the preceding 12
months
ABDOMINAL MIGRAINE
48. Treatment
Deal with psychological factors
Educate the family (an important part of
treatment)
Focus on return to normal functioning rather than
on the complete disappearance of pain
Best prescribe drugs judiciously as part of a
multifaceted, individualised approach, to relieve
symptoms and disability
50. Treatment of Acid-related disorders
H2-receptor Antagonists:
Ranitidine (2-4 mg/kg/d up to 150 mg bid),
Famotidine (1-1.2 mg/kg/d up to 20 mg bid)
PPI:
Omeprazole (0.8 mg/kg/d;effective dose range
of 0.3-3.3 mg/kg/d),
Lansoprazole (0.8 mg/kg/d)
Cytoprotective Agents:
Sucralfate(40-80 mg/kg/d up to 1 g qid)
Rabemipride ( 1 x 3 )
51.
52.
53. Abdominal Pain Clinical Pearls
Significant abdominal tenderness should never be attributed to
gastroenteritis
Incidence of gastroenteritis in the Older child are very low
Always perform genital examinations when lower abdominal pain is
present – in males and females, in young and old
Aways perform Rectal Examination
Bilious vomiting consider abdominal pathology unless until proved
Severe pain should be taken as an indicator of serious disease
Pain awakening the patient from sleep should always be considered
signficant
Sudden, severe pain suggests serious disease
Pain almost always precedes vomiting in surgical causes; converse is
true for most gastroenteritis and NSAP
A lack of free air on a chest xray does NOT rule out perforation
Signs and symptoms of PUD, gastritis, reflux and nonspecific
dyspepsia have significant overlap.
