This document discusses recurrent abdominal pain (RAP) in children. It provides information on the epidemiology, clinical profile, classification, pathophysiology, etiology, alarm symptoms and signs, diagnosis, investigations, and treatment of RAP. Treatment involves ruling out organic causes, reassurance, allowing normal activity, addressing stressors, and may include pharmacological interventions, dietary modifications, and behavioral therapies. The goal is to help the child return to normal activities and improve their pain over time.

1. ABDOMINAL PAIN
A presentation by Dr. Ravi Malik
CMD Radix Hospital
IMA headquaters
DMC medical education convenor
Ex President IMA East Delhi
Chief health news analyst

2. INTRODUCTION
 RAP
 3 episodes over 3 months
 Severe enough
 Inter periods
 No specific cause identified

3. epidemilogy
 10-12% of school aged children.
 Peak incidence at 4-6 years and at 7-12 years.
 Obesity and RAP.
 Fruit consumption and RAP.

4. clinical profile
 Pain in genuine
 Peri-umbilical pain
 Nausea, vomiting
 Pallor
 Headache & limb pains
 Family history

5. classification
• Recurrent abd. pain can be organic or nonorganic.
• Nonorganic(functional) abd pain
• Functional dyspepsia
• Irritable bowel syndrome
• Abdominal migraine
• Aerophagia
• Functional abdominal pain.

6.  Functional dyspepsia
 Pain or discomfort in the upper abdomen
 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 migraine
 Functional abdominal pain syndrome

7. pathophysiology
Gastrointestinal motility -High levels of emotional
stress and abnormalities in autonomic nervous system
which regulate gastrointestinal motility may
contribute.
Visceral hypersensitivity -The intensity of the signals
from the gastrointestinal system is exaggerated.
Abnormal bowel sensitivity to physiological,
psychologic or noxious stimuli may be present. This
may occur following illnesses that cause inflammation
in the intestine (e.g. viral gastroenteritis) or after
psychologically traumatic events.

8. 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 member's
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 child's pain can reinforce the child's
behavior. If parents are worried about child's pain, the
child may become more anxious, and the pain may worsen.
 Parents should pay attention to the child's other activities,
this might satisfy the child's need for attention & reduce the
abdominal pain.

9. etiology
Organic Pain (10%) Non-organic Pain (90%)
Site Flanks, suprapublid Central and often
epigastric
Family History - VE + VE
Psychological History - VE + VE
Headache - VE + VE
Weight Loss - VE + VE
Abnormal Signs - VE + VE
Abnormal Investigations - VE + VE
Alarming Symptoms - VE + VE

10. rop (organic)
 GIT
 Infections – ameba, giardia, dysentry, H. pylori
 Inflamatery – IBD, Hepatitis, appendicitis Dietory
intolerance – lactess
 Constipation
 GI reflux disease
 Acid peptic disease

11. causes of rop (organic)
Urinary tract Gynecological Miscellaneous
Urinary tract Ovarian cyst
infection Abdominal
Urinary calculi epilepsy
Endometriosis
Pelvi-ureteric Physical,
junction Pelvic emotional and
obstruction inflammatory sexual abuse
Chronic disease
pancreatitis

12. alarm symptoms
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

13. alarm signs
 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

14.  Absence of alarm symptoms & signs, a normal physical
examination, and a normal stool hemoccult test is
sufficient for an initial diagnosis of functional
abdominal pain.
 Identifying organic abnormalities by comprehensive
investigations does not necessarily mean that the
explanation for the symptoms is found.
 Organic and non organic causes for RAP can co-exist
in some patients.

15. diagnosis
 RAP should not require an exhaustive series of diagnostic tests to rule out
organic causes of pain.
 History – absence of alarming symptoms
 Meticulous examination
 Other associated symptoms
 Normal investigations

16. investigations in recurrent abdominal pain
Basic investigations (1st line investigations)
 Full blood count
 ESR/C-reactive protein
 Urine analysis & Urine culture
 Stool for ova, cysts and parasites
Second 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

17.  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.

18. abdominal pain treatment
 If the initial evaluation suggests an organic disorder, the likely causes of
pain will be investigated and a treatment plan will be developed.
 Chronic abdominal pain in children is most often caused by a functional
disorder.
 There are a variety of treatments that can be helpful, but no single
treatment is best. Most experts recommend trying several treatments.
 This may require several visits with the doctor, especially if pain has been a
problem for a long time.

19.  The first goal of treatment is to help the child return to
normal activities. A second goal is to improve the
child's pain.
 It may take some time to figure out what is causing the pain
and find the best treatment.
 A functional disorder does not mean that the child does
not have pain or that it's "all in their head".
 It is important to build a good relationship with the
parents, this will allow the doctor to explore stressors, try
various treatments, and continue the evaluation when
necessary.
 Acknowledge that the child's pain is real and offer
sympathy, support, and reassurance. But also take care to
avoid reinforcing the pain by giving it undue attention.

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”
 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.

22. pharmacological management
 Pharmacological treatments are commonly used in an effort to manage
symptoms despite the lack of data supporting their efficacy.
 Antispasmodics & low dose amitriptyline are used.
 Famotidine (an H2-receptor antagonist) is effective in children with
RAP who have predominantly dyspeptic symptoms.
 Pizotifen, a serotonin antagonist, has been found to be effective when
used prophylactically in children with abdominal migraine.
Local remedies: Many local remedies are used to alleviate symptoms in
children with RAP. Peppermint oil found to be very effective in the
treatment of irritable bowel syndrome in children.

23. dietary modifications
 Treatment trials of fibre supplements and lactose
restricting diets reveal a 50% decrease of pain
episodes.
 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, hypnosis, biofeedback, and
psychotherapy help to reduce a child's anxiety levels, help
them to participate in normal activities and help the child
to better tolerate the pain.
 They have been used with the idea that pain behaviors
produce secondary gain (special attention, school
avoidance, etc.) that in future reinforces the pain
behaviors.
 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. relaxation techniques
 Older children and adolescents with functional
abdominal pain can learn brief muscle relaxation
techniques such as deep breathing exercises.
 These techniques should be performed for 10 minutes
at least twice every day, and can also be used during
times of pain.

26. prognosis
 Nearly half of the children with functional RAP
experience pain as adults.
 Other studies have reported development of irritable
bowel syndrome in 25-29% of them in later life.