RECURRENT ABDOMINAL PAIN IN CHILDREN

1. APPROACH TO RECURRENT
ABDOMINAL PAIN RAP
Dr.Vivek Maheshwari
Assitant Professor
Department of Paediatrics

2. Recurrent Abdominal Pain
Recurrent Abdominal Pain (RAP) is one of the most common medical problems in
children. It is also the condition in which the exact cause of pain can
not be identified in the majority of cases. Most of these patients turn out to
have a functional problem. It is seen in almost 10 -
15% of school going children. About 10% of children with RAP may
be having a serious underlying condition. Hence proper evaluation is very important for
diagnosis & management of this problem.
 Diagnostic criteria of RAP (Aply –Naish Criteria)
× At least 3 episodes of significant abdominal pain occurring over 3 months.
× There should be a clear symptom free interval between the episodes.
× Severe pain lasts for at least 3 minutes.
× Between 5 & 15 years of age.
Symptoms are maximum between 5 & 7 years & tend to subside around 10 years.
 RAP is a symptom & not a diagnosis, functional or organic cause or both can co exis
t.

3.  Etiology of RAP
× Non - organic (Functional): 90%.
× Organic: 10%.
 NASPGHAN (North American Society of Pediatric Gastroenterology, Hepatolo
gy& Nutrition) Classification
× Chronic abdominal pain: Long lasting intermittent or constant abdominal pa
in that is functional or organic.
× Functional
abdominal pain: No anatomic, metabolic, infectious, inflammatory or neoplastic l
esions.
× Types of Functional Abdominal Pain
- Functional dyspepsia: Upper abdominal like pain.
-
Irritable bowel syndrome: Functional abdominal pain with alteration in bowel
movements.
- Abdominal migraine.
- Functional abdominal pain syndrome.

4. Red Flag Signs (Pointers to Organic Pain)
 Age < 5 years.
 Nocturnal pain.
 Recurrent vomiting / Bilous vomiting/GI bleed.
 Unexplained fever.
 Associated symptoms like headache, pallor, anorexia, c
onstipation etc.
 Significant weight loss.
 Deceleration of linear growth.
 Organomegaly.
 Joint swelling.
 Family history of Inflammatory bowel disease.

6. RAP with Dyspeptic Pain
 Recurrent pain in the upper abdomen, feeling full
earlier than expected when eating.
 May be
associated with anorexia, nausea, belching & heart burn.
 Endoscopy normal.
 Delayed gastric emptying is likely mechanism.
 As
per Apley’s law, the chance of an organic pathology is high when
the pain is away from the umbilicus.
 25%
may be having an underlying pathology like GERD, peptic ulcer, H.
Pylori, gastritis etc.
 Should be thoroughly evaluated.
 75% functional.
 25% organic like GERD, peptic ulcer, H. Pylori, Giardiasis, Pancre
atitis, Cholecystitis, appendicitis etc.

7. RAP with Altered Bowel Habits
 Functional (75%).
 Organic (25%) like Celiac disease, Abdomen tuberculosi
s, HIV, Crohn disease, Food allergies etc.
 Pain in abdomen, diarrhea & constipation alone or in
an alternating pattern are characteristics.
RAP wit Paroxysmal peri - umbilical pain
 Functional >95%.
 Organic 5% like Abdominal tuberculosis,
IBD, renal colic, Abdominal migraine,
Abdominal epilepsy etc.

8. Clinical features of Functional Recurrent Abdominal Pain
(FRAP)
John Apley has aptly summarized the features as follo
ws:
 Slightly underweight.
 Intelligence: Normal.
 Psyche: Emotionally disturbed.
 Personality: Timid & anxious.
 Family history: Psychological problems.
 5 – 15 years common age.
 More in females.

9. Characteristics of FRAP are a follows:
 Site of pain
× The most common site is periumbilical or mid epigastric.
× The pain is away from the umbilicus, the more likely it is of organic pathology.
 Type of Pain
× Usually transient & intermittent, lasts only for a few minutes, rarely for 1 - 3 hours.
× Colicky or cramping. Sometimes it may be dull & continuous.
 Intensity of Pain
× May be mild or very severe.
× Child may cry, double over or sit with knees drawn to the chest.
× He may press the abdominal wall to get relief.
× No radiation.
× Not related to meals.
 Nocturnal Pain
× Once the child is asleep, he never gets up in the night with pain.
× If a child gets up in the middle of the night with pain, it is almost always due to a
n organic cause.
 Role of stress
Role of stress is considered significant in a case of FRAP.
 Associates symptoms
× Nausea & vomiting may be present, but the bilious vomiting points to an organic ca
use.
× Headache, pallor, anorexia & constipation are common associated symptoms.

10. Points to be asked in History
 Duration
Functional abdominal pain is usually defined as episodic abdominal pain over 3 months or more.
 Restriction of daily activities
Restriction of daily activities & absenteeism from school indicates degree of severity in pain.
 Site of Pain
× Functional abdominal pain is usually periumbilical.
× Pain away from periumbilical region favours organic cause.
 Any precipitating or aggravating factor
FRAP is not related to meals, physical activity, defecation, urination or menstruation.
 Nocturnal pain
Nocturnal pain indicates organic pathology.
 Effect of medicines
Antacids, H2 inhibitors, analgesics & antispasmodics usually are not effective.
 Condition between the episodes
Otherwise active and healthy.
 Bowel habit
Altered bowel habit like diarrhea, constipation or nocturnal bowel movements suggest an organic c
ause.
 Appetite
Appetite remains normal in FRAP.
 Loss of weight
Loss of weight indicates an organic disease.
 Family history of migraine, inflammatory Bowel Disease, favours organic etiology.

11. Following signs should be looked for
 Anaemia (IBD, Helminthiasis, lead poisoning).
 Rash / palpable purpura & arthritis (HSP).
 Iridocyclitis & arthritis (IBD).
 Jaundice (Cholelithasis).
 Right lower quadrant mass (appendicitis).
 Left lower quadrant mass (fecal mass) (constipation).
 Perianal fissure or ulcerations (IBD, constipation).
 Spincal lesions - Neurological signs.
 Hepatosplenomegaly (Abdominal TB, HIV).

12. Organic Common causes of RAP
 Intestinal causes
× Congenital
- Malrotation
- Strangulated hernia
× Acquired
- Constipation.
- Post operative adhesions.
 Inflammatory causes
× HSP
× Crohn disease.
× Peptic ulcer disease.
 Vascular causes
× Abdominal migraine.
× Bowel ischemia.

13.  Hepatobiliary diseases
× Gall stones.
× Cholecystitis.
× Choledochal cyst.
× Sclerosing cholangitis.
 Chronic pancreatitis
 Renal causes
× Recurrent UTI.
× Urolithiasis.
 Metabolic causes
× Diabetic ketoacidosis.
× Lead poisoning.
 Other causes
× Spinal cord tumor
× Porphyria.
× Chronic congestive cardiac failure

14. Type of Pain
Visceral
Parietal
Refered

15. Visceral Pain
Stretching of nerve fibres
of walls or capsules of
organs
 Crampy
 Dull
 Achy
Often unable to lie
Bilateral innervation

16. 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

19. ClassificationofPainInA
b
d
o
m
e
n
A) Organic and Non-organic
B)Etiological
C) Age
D) Location/ quadrant

21. (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.

22. Medical
Genitourinary causes
Urinary tract infection
Urinary calculi
Dysmenorrhea
Mittelschmerz
Pelvic inflammatory disease
Threatened abortion
Ectopic pregnancy
Ovarian/testicular torsion
Endometriosis
Hematocolpos
Liver, spleen, and biliary tract
disorders
Hepatitis
Cholecystitis
Cholelithiasis
Splenic infarction
Rupture of the spleen
Pancreatitis
• GASTROINTESTINAL
Gastroenteritis
Appendicitis
Mesentric
lymphadenitis
Constipation
Abdominal
truma Intestinal
obst Peritonitis

23. • Metabolic disorders
Diabetic ketoacidosis
Hypoglycemia
Porphyria
Acute adrenal insufficiency
Hematologic disorders
Sickle cell anemia
Henoch-Schönlein purpura
Hemolytic uremic syndrome
• Pulmonary causes
Pneumonia
Diaphragmatic
• Drugs and toxins
Erythromycin
Salicylates
Lead poisoning
Venoms
• Miscellaneous causes
Abdominal epilepsy
Gilberts syndrome
Familial Mediterranean fever
Sickle cell crisis
Lead poisoning
HSP
Angioneurotic edema
Acute intermittent porphyria

24. (C)Classification as per age

25. (D) Classification as per Quadrant

26. 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

27. Pharmacologic treatment approach
Medicines:
Acid lowering agents
Mucoprotective drugs
Motility regulators
Laxatives
Analgesics
Probiotics
Gas adsorbants
Dietary and life style change
Psychotherapy

28. 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 )

31. 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.

32. Daughter of an anesthetist
Referred for “recurrent abdominal pain” for past 2
years
History mainly given by mother and
when allowed (!) by father; the child
mainly kept fiddling with her “mobile”
On examination:
Medium built,
No anemia, cyanosis, jaundice, lymphnodes
P/A
3

33. 3

34. Should we accept the diagnosis of RAP
made elsewhere, or investigate this case
further? Why?
34

35. Let usseewhat
different kinds
of abdominal
painsthis
younglady
couldhave……
Acute
Organic
Inorganic/ Idiopathic/
functional
Chronic
Organic
Inorganic/ Idiopathic/
functional
Here again there may be
many variations
35

36. One hasto becareful.
Goo......d history
Attention to body
language
Thoroughphysical
Meticulousfollow-up
36

37. Pain distant from the
umbilicus
Pain that awakens the
child
Significant vomiting or
diarrhea
Associated fever
Organic pain
37

38. • Family historyof
organicdiseases
• Involuntaryweight
loss,slowed linear
growth, ordelayed
puberty
• Systemic
involvement Organic pain
38

39. Localized fullness
or mass effect
Organomegaly
Localized
tenderness
Perianal
abnormalities
Organic pain
39

40. ◦Anemia
◦Gastrointestinal
blood loss
◦Elevated ESR
◦Altered LFTs
◦Abnormal Urine
examination
Organic pain
Urine
40

41. 11
Organic pain
Organic pain

42. Functional abdominal pain will have none
of these.
42
Different types of idiopathic/ inorganic
pains
•Recurrent abdominal pain
•Chronic abdominal pain
•Functional abdominal pain

43. Common understanding of Recurrent
abdominal Pain
43
History of at least three episodes of pain
Pain sufficiently severe to affect activities
Episodes occur over a period of three months
No known organic cause
Hyams et.al 1996.

44. Recurrent abdominal
pain is usually central
44

45. Functional abdominal pain
45
For practical purpose .....
it is a type of pain which affects a particular
GI function but there is no organic cause
that could be found.

46. So.. Functional pain could be..
46
Functional dyspepsia (Rome III criteria, 2006)
•Epigastric Localization
•Persistent or recurrent
•Associated with eating;
•Nausea, vomiting, heartburn, oral
regurgitation,
•Early satiety, excessive hiccups and
belching.
No evidence of underlying organic problem

47. Functional Abdominal Pain
47
Irritable bowel syndrome
Functional abdominal pain associated
with alteration in bowel movements
Symptoms of altered bowel pattern
include:
diarrhea, constipation, or a sense of
incomplete evacuation.

48. Abdominal migraine
◦Paroxysmal abdominal
pain
◦Anorexia, nausea,
vomiting or pallor
◦Maternal history of
migraine headaches
48

49. Functional abdominal pain syndrome
49
•Functional abdominal pain without
the characteristics of dyspepsia,
irritable bowel syndrome, or
abdominal migraine.
•Have at least 25% of the time one or
more of the following.
• Some loss of daily function.
• Additional somatic symptoms such as
headache, limb pain, or difficulty
sleeping

50. •"recurrent abdominal pain"
should not be used as a
synonym for functional,
psychological, or stress-
related abdominal pain .
American Academy of Paed.2005
50

51. Are these pains common? Should
a pediatrician bother about them?
51

52. EPIDEMIOLOGY
Chronic abdominal pain affecting 9-15% of
children.
13% of middle school and 17% of high
school children have weekly complaints
of abdominal pain.
In a study of 1,000 school-age children,
RAP affected males & females equally up
to 9 yrs. of age, the incidence in females
increased such that between 9 & 12 yrs.,
the female-to-male ratio was 1.5:1.
52

53. EVALUATION
AAP and NASPGHAN guidelines:
History, physical examination, and stool
testing for occult blood to identify
potential indications of an organic
etiology.
Thorough physical examination
.....” USG, endoscopy, or esophageal pH
monitoring not helpful in the absence of
"alarm findings”.
53

54. Management of functional abdominal
pains
54
Reassurance and education of the child
and family.
Symptomatic treatment.

55. Outcome
After 5 years,
1/3 of children with RAP will have
resolution of their pain,
1/3 continue to complain of the same
symptoms, and
1/3 will have a different recurrent pain
complaint.
55

56. 26
Coming back to our case..
Since the pain was located in epigastrium
Vomiting, and with
Epigastric tenderness
This was taken as a case of APD.
Dietary history was remarkable.
For past three months, she had
eaten only and only junk food!
Diet was changed,
PPI were given, and
The patient counselled
Now she is free from here all complaints.

57. Summary
57
Of various types of abdominal pains, a large
minority have pain without identifiable cause or
significant consequences.
To sit on them, you must satisfy yourself by way
of meticulous history, physical and follow-up
Detailed investigations are not necessary for
these “functional pain”

58. SUMMARY AND CONCLUSIONS
58
Chronic abdominal pain is defined by pain of at least three months'
duration, although some clinicians consider pain of more than one t
two months' duration to be chronic.
Recurrent abdominal pain is defined by more than three episodes o
pain that are sufficiently severe to affect activity and that occur over
the course of at least three months.