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Current Paediatrics (2004) 14, 593597

Recurrent abdominal pain

C.H. Spray

Department of Paediatric Gastroenterology, Bristol Royal Hospital for Children, Upper Maudlin Street,

Bristol BS2 8BJ, UK

Summary Recurrent abdominal pain is common, affecting up to one-third ofschool-aged children and adolescents. It often causes significant anxiety amongstparents and child as normal family life is frequently interrupted. Similarly, doctorsoften have difficulty in knowing who and how much to investigate. Although organicdisease needs to be considered, the majority of these children have functionalgastrointestinal disorders that can be classified according to the symptom-basedRome II criteria (classification for functional gastrointestinal disorders). At least halfof the children (who have no organic disease) have symptoms compatible withirritable bowel syndrome. Hence the child and family see the diagnosis of afunctional disturbance as a positive rather than a negative diagnosis resulting fromexclusion of an organic disease. By identifying the functional disorder, appropriate

treatment may be initiated without extensive and unnecessary investigations.r 2004 Elsevier Ltd. All rights reserved.

Practice points

Functional gastrointestinal disorders (FGID)are the most common cause of recurrentabdominal pain

FGID can be classified by Rome II symptom-based criteria

Up to 50% of children with FGID will haveirritable bowel syndrome according to symp-tom-based criteria

Unnecessary investigations are avoided ifsymptoms of recurrent abdominal pain(RAP) can be classified into one of the FGIDgroups

By standardizing the definition of FGID,study outcomes from different centres canbe compared directly

Research directions

The pathogenesis of FGID needs to befurther elucidated

The role of early childhood risk factors andfamily history need further evaluation

Treatment of FGID including specific drugmodalities need to developed

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KEYWORDSRecurrent abdominalpain;Functionalgastrointestinaldisorders;Irritable bowelsyndrome

0957-5839/$ - see front matterr 2004 Elsevier Ltd. All rights reserved.doi:10.1016/j.cupe.2004.08.003

Tel.: +44-117-342-8828; fax: +44-117-342-8831.E-mail address: [email protected]

(C.H. Spray).
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The relationship between Helicobacter py-loriand RAP needs to be further established

Improvement in understanding of psychoso-cial processes and the role of psychosocialintervention needs clarification

Introduction

The terms recurrent abdominal pain (RAP) andchronic abdominal pain are interchangeable. Bothterms are descriptive in nature and do not reflect aspecific underlying cause. However, most peopleassume the causes to be functional rather thandue to an underlying disease. Functional symp-toms are defined as those that occur in theabsence of anatomic abnormality, inflammation ortissue damage and are within the range of expected

behaviours for the body.

1

RAP was first defined byApley in the 1950s as intermittent abdominal painin children between the ages of 4 and 16 years thatpersisted for more than 3 months (not necessarilyconsecutive) and affected normal daily activity. Hefound that only eight cases out of 100 children whohad been referred to the hospital with RAP had anorganic cause.2 However, a recent similar studyfrom the same geographical area found 30% ofchildren referred to a regional gastrointestinaldepartment with RAP had underlying organicpathology.3 The increase in children identifiedwith organic disease may be as a result of newly

developed investigations such as endoscopy andthe identification of new diseases, such asthose caused by Helicobacter pylori (H. pylori).However, the most common cause of RAP is stillfunctional in the majority of cases. In 1997, asymptom-based classification for functional gas-trointestinal disorders (FGID) was developed,known as the Rome II criteria.4 A thoroughhistory and examination is required to identify thepossibility of organic disease (Table 1). In theabsence of any red flag signals (Table 2), apositive diagnosis of FGID can be made and

classified according to symptoms. Some cases veryclearly fit the definition of FGID and no furtherinvestigations are warranted. However, others mayneed further investigation, but this needs to beperformed in a systematic way and directed byclinical suspicion.

Irritable bowel syndrome

The Rome criteria adopted the symptom-basedcriteria for irritable bowel syndrome (IBS) used in

adults based on the Manning criteria (Table 3).5

However, there are only a few studies validatingthe Rome II criteria in the diagnosis of IBS inchildren.3,6,7 In those children who did not haveorganic disease, a diagnosis of IBS was possibleusing the symptom-based classificationin 51% and68% in the two prospective studies,3,6 making IBS

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Table 1 Common organic diseases associatedwith recurrent abdominal pain.

Inflammatory bowel diseaseCoeliac diseaseInfection (e.g. Giardia)Carbohydrate malabsorptionPancreatic insufficiencyHepatic diseaseGallbladder diseaseUrinary tract diseaseGastro-oesophageal refluxGastritis Non-steroidal anti-inflammatory drugs Helicobacter pylori Crohns disease

Gastric/duodenal ulcer

Table 2 Red flag signals.

Weight lossGrowth delayPubertal delayPerianal diseasetags/fissures/abscessPositive family history for gastrointestinal diseasePersistent vomitingDysphagiaHaematemesisBleeding PRFeverRashe.g. erythema nodosumDiarrhoeapersistent and/or nocturnal

Faecal incontinenceArthritis

Table 3 Manning criteria for irritable boweldisease.

Abdominal pain+two or more of the followingcriteria: Abdominal pain relieved by defecation More frequent stools at the onset of pain Looser stools at the onset of pain Feeling of bloating/visible abdominal distention

Passage of mucous Sensation of incomplete evacuation

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the most common cause of RAP in children. Thethird study was retrospective and identified 35% ofchildren withno organic disease as having IBS basedon symptoms.7 The latter study used an alternativeclassification of IBS and may explain the differencein percentage identified with IBS. This highlightsthe need for a single definition of FGID so that

studies can be compared accurately. A clinicaldiagnosis of childhood IBS can be made based onsymptoms in the presence of normal physicalexamination and growth. Dietary history is impor-tant, particularly to evaluate dietary fibre and fluidintake in children with predominant-constipationIBS. In children with predominant-diarrhoea andbloating IBS, intake of poorly absorbable carbohy-drates such as sorbital and fructose (fruit, juicesand sweets) need to be considered. Psychosocialconcerns also need to be considered.

Functional dyspepsia

Dyspepsia is defined as recurrent or persistent painor discomfort in the upper abdomen. It is fre-quently accompanied by nausea but not vomiting.Dyspepsia may be functional or caused by disease.There appear to be three subtypes: ulcer-likedyspepsia; dysmotility-like dyspepsia and non-spe-cific dyspepsia.

In ulcer-like dyspepsia, pain is mostly in theupper abdomen (epigastrium) and is often relieved

by food, antacids or antisecretory drugs. It occursbefore meals or when hungry and can waken thechild from sleep. Dysmotility-like dyspepsia is oftendescribed as an unpleasant sensation rather thanpain, and is associated with feeling of early satiety,upper abdominal fullness, bloating and nausea.Non-specific dyspepsia is dyspepsia with neither ofthe above features.

Functional dyspepsia may be difficult to differ-entiate on clinical grounds. It is not an uncommoncomplaint in children presenting to a paediatricgastoenterology unit, but not all children need to

undergo upper gastrointestinal endoscopy. In onestudy from North America, less than 20% of childrenpresenting with dyspepsia had organic disease.8

The presence of an ulcer, either gastric orduodenal, is extremely rare in children, especiallyin isolation, in whom no risk factors have beenidentified. Careful history and examination needsto be taken to highlight any red flag signals thatmight increase suspicion of organic disease. Dys-pepsia can be a symptom of Crohns disease orcoeliac disease. Precipitating factors, such asmedication [e.g. frequent non-steroidal anti-in-

flammatory drugs (NSAIDs)] and dietary foods thatmay aggravate symptoms (e.g. caffeine and fizzydrinks, acidic drinks such as fresh apple juice, spicyand fatty foods), need to be considered. Therelationship between infection with H. pylori andRAP remains an area of controversy. Geographicalarea and poor living conditions and overcrowding

increase the risk of infection. There is no disputethat infection with H. pylori causes ulcer diseaseand gastritis. However, studies in children with RAPcomparing those who were H. pylori positive andthose whowere not demonstrated no difference insymptoms.9,10 Equally, studies have reported vari-able outcomes of resolution of RAP followingtreatment and eradication of H. pylori.11 At thepresent time, there are no data to support routinescreening of H. pylori infection in children withRAP,12 but some clinicians use it as a guide toperform upper gastrointestinal endoscopy for sus-pected ulcer disease. Guidelines for treatment ofH. pylori were published in 2000.13

Abdominal migraine

Abdominal migraine has been described in 13% ofschool-aged children, being most prevalent in 57year olds and more common in girls. It is char-acterized by episodes of abdominal pain lasting forhours or days, often accompanied by pallor andanorexia. Most importantly, these children are well

in between these episodes with symptom-freeintervals lasting weeks to months. Episodes oftenstart at night or early morning. Frequently, head-ache, photophobia and aura accompany theseepisodes. A positive family history is present in lessthan half the cases. Vomiting is unusual but ifpresent may be considered as cyclical vomitingsyndrome. Many clinicians consider the two dis-orders as different phenotypic expressions of asingle problem with pain predominating in theformer and vomiting in the latter. There is noevidence of metabolic, biochemical, gastrointest-inal or central nervous system abnormalities.

Anatomical abnormalities such as ureteropelvicjunction obstruction and intestinal malrotation,recurrent pancreatitis and hepatobiliary obstruc-tion and, rarely, acute intermittent porphyria needto be considered.

Aerophagia (air swallowing)

This is an underappreciated but well-documentedcause of abdominal distention and pain.14 Gum

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chewing and fizzy drinks can exacerbate theproblem and stress may aggravate the condition.

Functional abdominal pain syndrome

Many children and adolescents that do not fulfil the

criteria of the above functional disorders sufferwith RAP. The pain is not related to specific eventsor defecation but is continuous or recurrent andfrequently affects daily activities. Most childrendescribe the pain as peri-umbilical, and difficulty insleeping is not uncommon. They frequently com-plain of other non-specific symptoms such asheadache, fatigue, dizziness, nausea and muscleaches. Physical examination is normal. Thesechildren are often difficult to deal with becausethere is significant paradox between the childssevere complaints and significant impairment of

their daily activities and the lack of objectivefindings on physical examination. Psychosocialhistory may reveal obvious triggers but this is notalways the case.

Investigation of patients with RAP

Following a full history and examination, investiga-tions should be symptom directed. It is possible tocome to a diagnosis of a FGID without performingany investigations. However, there will be times

when the clinician is uncertain and wants toperform baseline biochemical and haematologicalstudies. Also, in practice, clinicians may wantbaseline investigations in order to reassure thechild and the family. The latter is something thatcould be debated extensively but falls under theart of medicine. It is, however, important toidentify what the child and their family fear andwhat they desire from the consultation.15 Fre-quently, reassurance is all that is needed.

Aetiology of FGIDThe pathophysiology of FGID is not known orunderstood. It is thought that symptoms may arisefrom changes in the braingut axis, which links thecentral and enteric nervous system (CNS/ENS).16

The ENS controls motor and secretory functions ofthe gastrointestinal tract. It is influenced by theparasympathetic and sympathetic nervous systemsand involves various neurotransmitters such asserotonin (5HT), which has recently emerged asone of the most important. Approximately 95% of

5HT in the body is found in the gastrointestinaltract. The ENS is able to function autonomously,but is also modified by the CNS, the most commonexample being accelerated colonic transit timeleading to diarrhoea at times of stress andimportant events. The gut is also a sensory organ.An attractive pathophysiological theory for func-

tional pain in adults is one in which visceralhypersensitivity (hyperalgesia) is the final commonpathway precipitated by different sensitizingevents such as inflammation, infection, diet,allergy, trauma and motility abnormalities thatmay be further modulated by psychosocial factorsand genetic environment. How much geneticinfluence is nurture rather than nature continuesto be of debate.

Treatment of patients with RAP

Where an underlying gastrointestinal disease isidentified as the cause of RAP, treatment can beclearly directed. Classifying non-organic diseaseinto the appropriate functional types such as IBS ornon-ulcer dyspepsia helps to direct treatmentappropriately. Most importantly, it is necessary tolet the child know that the symptoms they arefeeling are very real but are not dangerous or life-threatening. Reassurance and simple explanation ofthe condition is necessary. It is important toaddress readily identifiable psychosocial factors

that might trigger or exacerbate symptoms withoutsuggesting that psychological factors are the solecause. Psychological counselling may be effective ifthe child and family are willing to participate.Some children may need referral to a multidisci-plinary pain team, particularly those with func-tional abdominal pain syndrome. Simple dietarymanipulation such as adequate dietary fibre andfluid intake should be considered in children withconstipation-predominant IBS. In children with IBSwith diarrhoea and bloating symptoms, stopping orreducing the intake of poorly absorbable carbohy-

drate such as sorbital and fructose (fruit, juices,fizzy drinks and sweets) may be helpful. Otherfoods like caffeine, fizzy drinks and acidic drinkssuch as fresh apple juice, spicy and fatty foods mayexacerbate dyspeptic symptoms. There are limitedcontrolled trials of different treatment modalitiesof functional gastrointestinal disease in childrenand adolescents. Since the pathophysiology of func-tional gastrointestinal pain is unknown and clearlymultifactorial, most treatments are non-specificand only help to control symptoms, e.g. metoclo-pramide, antacids and H2-receptor antagonists for

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dyspeptic symptoms. Good success has beenachieved with tricyclic antidepressants (TCAs) inthis group. Current medications in IBS includeanticholinergics (antispasmodics), TCAs and selec-tive serotonin re-uptake inhibitors. Diarrhoea maybe controlled with loperamide. TCAs such asimipramine or amitryptilline in low doses have

been shown to improve symptoms in adults withIBS17 but there are no similar studies in children.Child cases of improvement in RAP with TCAs areonly anecdotal. Alosterone, a selective 5HT3receptor antagonist, was briefly approved fordiarrhoea-predominant IBS symptoms in womenbut was withdrawn from the market followingconcerns of ischaemic colitis.18 Tegaserode, a5HT4 receptor agonist, is currently being evaluatedfor constipation-predominant IBS in adults. Treat-ment of abdominal migraine is similar to that usedfor migraine prophylaxis. Pizotifen, a 5HT receptorantagonist, is an effective prophylactic,19 butpropanolol and TCAs can also be effective. In allcases of FGID, the child and family need to decidewhether they want to embark on regular medica-tion, taking into consideration the possible side-effects of the medications vs. the impact on qualityof life of the condition.

In summary, RAP is common in children andadolescents. In the absence of evidence for organicdisease, a diagnosis of FGID can be made andclassified according to Rome II criteria. This enablesa positive diagnosis of FGID to be made rather thanone of exclusion, reducing the need for extensive

investigation prior to appropriate treatment.

References

1. Drossman DA. The functional gastrointestinal disorders andthe Rome II process. Gut 1999;45(Suppl. II):II15.

2. Appley J, Naish N. Recurrent abdominal pains: a field surveyof 1000 school children. Arch Dis Child1958;22:16570.

3. El Matary W, Spray C, Sandhu BK. Irritable bowel syndrome:the commonest cause of recurrent abdominal pain inchildren.Eur J Paediatr, 2004 in press.

4. Rasquin-Weber A, Hyman PE, Cucchiara S, et al. Childhoodfunctional gastrointestinal disorders. Gut 1999;45(Suppl.

II):II60

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5. Manning AP, Thompson WG, Heaton KW, Morris AF. Towards apositive diagnosis of irritable bowel.Br Med J1978;2:6534.

6. Hyams JS, Burke G, Davis PM, Treem WR, Shoup M.Characterisation of symptoms in children with recurrentabdominal pain: resemblance to irritable bowel syndrome.

J Pediatr Gastroenterol Nutr1995;20:20914.7. Croffi JM, Fitzgerald JF, Chong SK. Recurrent abdominal pain

in children. A retrospective study of outcome in a groupreferred to a paediatric gastroenterology practice. ClinPediatr2000;39:26774.

8. Hyams JS, Davis P, Sylvestor FA, Zeiter DK, Justinich CJ,Lerer T. Dyspepsia in children and adolescents: a prospectivestudy.J Pediatr Gastroenterol Nutr2000;30:4138.

9. Reifen R, Rasooly J, Drumm B, Millson ME, Murphy K,Sherman PM. Symptomatology and demographic features ofHelicobacter pylori infection in children. Irish J Med Sci1992;161(Suppl. 10):259.

10. Glassman MS, Scwartz SM, Halata M, Berezin S, Newman LJ.

Campylobacter pylori-related gastrointestinal disease inchildren. Incidence and clinical findings. Dig Dis Sci1989;34:15014.

11. Oderda G, Dellolio D, Morra I, Ansaldi N. Campylobacterpylori gastritis: long term results of treatment with

amoxycillin.Arch Dis Child1989;64:326

9.12. Macarthur C, Saunders N, Feldman W, et al. Helicobacterpylori and childhood recurrent abdominal pain: communitybased casecontrol study. BMJ1999;319:8223.

13. Drumm B, Koletzko S, Oderda G. Helicobacter pylori inchildren: a consensus statement. J Pediatr GastroenterolNutr2000;30:20712.

14. Loening-Baucke V. Aeropahgia as cause of gaseous abdom-inal distention in a toddler. J Pediatr Gastroenterol Nutr2000;31:2047.

15. Britten N. Patientsexpectations of consultations.Br Med J2004;328:4167.

16. Zighelboim J, Talley NJ. What are functional boweldisorders? Gastroenterology1993;104:196201.

17. Greenbaum DS, Mayle JE, et al. Effects of desipramine on

irritable bowel syndrome compared with atropine andplacebo. Dig Dis Sci 1987;32:25766.18. Camilleri M, Northcutt AR, Kong S, Dukes GE, McSorley D,

Mangel AW. Efficacy and safety of alosetron in women withirritable bowel syndrome: a randomised, placebo-controlledtrial. Lancet2000;355:103540.

19. Symon DNK, Russell G. Double blind placebo controlled trialof pizotifen syrup in the treatment of abdominal migraine.

Arch Dis Child1995;72:4850.

Further reading

1. Rome II. A multinational consensus document on functional

gastrointestinal disorders. Gut 1999; 45 (Suppl. II).

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