1. RECURRENT ABDOMINAL PAIN IN CHILDREN
Khaled Hawwas

2. An 11 year old female presented on 15/8/2012 with :
Right sided abdominal pain, right loin pain.
No urinary symptoms-regular bowel habit.
Significant weight loss in the last 6 month.
2 month back, she attend medical care and suspected to have UTI or appendicitis.
U/S done : bilateral mild renal pelvis dilation ,no masses, reviewed by general surgeon and reported free.

3. One month back ,she visited causality because of abdominal pain, mid cycle pain, appendix abscess was suspected and was seen by surgeon ---non specific abdominal pain.
Lactulose was given as? Constipation.
2 weeks back, again , she got lower abdominal pain and renal colic, pelvic inflammatory disease, abdominal migraine were suspected—referred to gynecologist--- free

4. Social history
She lives with her mother 29 year old and father 34 year old.
Recently seeing her friends less than usual.
Frequently sent home from school in the last 6 month as she was feeling tired.
Missed her exam through illness.
Currently in school holiday.

5. Family history
Paternal grandmother underwent bowel resection for Chron s disease .
Grand father is known to have recurrent renal stone.
Mother has migraine.

6. Pysical examination & investigations:
No pallor or jaundice, no fever , hydrated.
GIT: tender right inguinal fossa with fullness.
tender right loin,no masses or guarding.
normal bowel sound.
Other systemic examination was normal.
CBC, liver& kidney functions—normal.
CRP, ESR& electrolytes –normal.
Urine routine was suggestive of uti.
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7. OUTLINE OF PRESEN TATION
1.TERMINOLOGY AND DEFINITION 2.EPIDEMILOGY & ETIOLOGY PATHOPHYSIOLOGY 3.EVALUATION AND DIAGNOSIS 4.MANAGEMENT 5.PROGNOSIS

8. TERMINOLOGY
Chronic and recurrent abdominal pain are common symptoms in children and adolescents .
Chronic abdominal pain can be organic or nonorganic, depending on whether a specific etiology is identified.
Nonorganic or functional abdominal pain refers to pain without evidence of anatomic, inflammatory, metabolic, or neoplastic abnormalities.
Overlap between chronic and recurrent abdominal pain exists.
SOURCE: J.APLEY

9. DEFINITION
Chronic abdominal pain is defined by pain of at least two to three months' duration.
Recurrent abdominal pain is one of the most common recurrent pain syndromes in childhood.
The classic definition is based upon four criteria
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
Chronic abdominal pain can be organic or nonorganic, depending on whether a specific etiology is identified.
Nonorganic abdominal pain or functional abdominal pain refers to pain without evidence of anatomic, inflammatory, metabolic, or neoplastic abnormalities.
In the original case series, recurrent abdominal pain of childhood was considered to be the diagnosis . However, using the term as a description rather than a diagnosis probably is more accurate .
Clinical and laboratory observations suggest that recurrent abdominal pain in childhood is not a single entity, but a symptom complex with organic and functional etiologies that can be exacerbated by psychologic disorders.
Source :Di Lorenzo et al 2001; Dufton L, et al 2009
Source:Hyams et.al 1996.

10. EPIDEMIOLOGY
The exact incidence and prevalence of chronic abdominal pain is not known.
There are reports of chronic abdominal pain affecting 9-15% of children.
13% of middle school and 17% of high school children have weekly complaints of abdominal pain.
It affect 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.
- The overall incidence appears to 10 to 12 years. RAP is rare among children younger than 5 years of age, & an organic cause must be -considered even more carefully in this younger age group.
- Apley observed that males and females are affected equally in early childhood up until the age of 9.
- Between 9 and 12 years of age the female-to-male ratio approaches 1.5 to 1.
- Onset of chronic pain in a child younger than 4 years old requires a more in-depth organic evaluation, particularly for structural abnormalities.

11. Recommended Clinical Definitions
Chronic abdominal pain
Long-lasting intermittent or constant abdominal pain that is functional or organic.
Functional abdominal pain
Abdominal pain without demonstrable evidence of pathologic condition, such as anatomic, metabolic, infectious, inflammatory or neoplastic disorder. Functional abdominal pain can manifest with symptoms typical of functional dyspepsia, irritable bowel syndrome, abdominal migraine or functional abdominal pain syndrome.

12. 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 for functional, psychological, or stress-related abdominal pain .
source: American Academy of Paed.2005

13. CHILDHOOD FUNCTIONAL ABDOMINAL PAIN SYNDROME
Diagnostic criteria satisfy criteria for childhood functional abdominal pain and 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.
Diagnostic criteria satisfy criteria for childhood functional abdominal pain and 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

14. CHILDHOOD FUNCTIONAL GI DISORDERS: CHILD/ADOLESCENT
Irritable bowel syndrome
Abdominal migraine
Childhood functional abdominal pain
Constipation and incontinence
Functional constipation
Vomiting and aerophagia
Cyclic vomiting syndrome
Aerophgia
Functional dyspepsia

15. PATHOPHYSIOLOGY
The traditional concept that motility disorders alone have an important role in functional pain has not been confirmed.
It is believed that visceral hypersensitivity leading to abnormal bowel sensitivity to stimuli (physiologic, psychologic) might have a more dominant role in functional abdominal pain .
Visceral hypersensitivity could be due to abnormal interpretation of normal signals by the brain or aberrant signals sent to the brain or a combination.
Intestinal pain receptors respond to mechanical and/or chemical stimuli.
The visceral receptors can respond to both mechanical and chemical stimuli, but the mucosal receptors are primarily stimulated by chemical stimuli.

16. PATHOGENESIS OF FUNCTIONAL BOWEL DISEASE

17. Clinical Presentations of RAP
Children who have RAP tend to exhibit one of three clinical presentations:
Isolated paroxysmal abdominal pain.
Abdominal pain associated with symptoms of dyspepsia.
Abdominal pain associated with an altered bowel pattern.

18. Common symptoms associated with recurrent abdominal pain

19. EVALUATION
(AAP) and (NASPGHAN) guidelines for the evaluation and treatment of children with chronic abdominal pain recommend history, physical examination, and stool testing for occult blood to identify potential indications of an organic etiology.
The technical review found little or no evidence to suggest that ultrasonography, endoscopy, or esophageal pH monitoring increase the yield of organic disease in the absence of "alarm findings”.

20. Evaluation and Diagnosis ALARM SYMPTOMS USUALLY NEEDING FURTHER INVESTIGATIONS
Pain that wakes up the child from sleep
Persistent right upper or right lower quadrant pain
Significant vomiting (bilious vomiting, projectile vomiting, cyclical vomiting)
Unexplained fever
Genitourinary tract symptoms
Dysphagia
Chronic severe diarrhea or nocturnal diarrhea
Gastrointestinal blood loss
Involuntary weight loss
Deceleration of linear growth
Delayed puberty
Family history of inflammatory bowel disease, celiac disease, and peptic ulcer disease

21. ALARM SIGNS Needing Further Investigations
Localized tenderness in the right upper quadrant
Localized tenderness in the right lower quadrant
Localized fullness or mass
Hepatomegaly
Splenomegaly
Jaundice
Costovertebral angle tenderness
Arthritis
Spinal tenderness
Perianal disease
Abnormal or unexplained physical findings

22. Contd.
Laboratory studies may be unnecessary if the history and physical examination lead to a diagnosis of functional abdominal pain.
Nonetheless, medical tests can reassure the patient and family, and at times the physician, if there is significant functional disability and poor quality of life.

23. Contd.
A complete blood cell count, sedimentation rate, C-reactive protein, basic chemistry, celiac panel, stool culture, stool test for ova and parasites, and urinalysis are reasonable screening studies.
The risk of celiac disease may be 4 times higher in these patients compared with the general population.
Elevated stool calprotectin levels usually suggest an inflammatory etiology.

24. Contd.
If indicated, an ultrasound examination of the abdomen can give information about kidneys, gallbladder, and pancreas; with lower abdominal pain, a pelvic ultra sonogram may be indicated
An upper GI x-ray series is indicated if one suspects a disorder of the stomach or small intestine.
Helicobacter pylori infection does not seem to be associated with chronic abdominal pain, but in patients with symptoms suggesting gastritis or ulcer, an H. pylori test (fecal H. pylori antigen) may be performed.

25. Contd.
Breath hydrogen testing is done for ruling out lactose or sucrose malabsorption.
Lactose intolerance is so common that the finding may be coincidental, and the clinician must be cautious in attributing chronic abdominal pain to this condition.
Esophagogastro-duodenoscopy is indicated with symptoms suggesting persistent upper GI pathology. .

26. Differential Diagnosis
The two broad categories in the differential diagnosis for chronic or recurrent abdominal pain in children and adolescents are
Organic disorders — Conditions in which physiologic, structural, or biochemical abnormalities are present.
Functional disorders — Functional conditions are those for which no specific test exists with which to make the diagnosis.
Most children with chronic abdominal pain have functional disorders, although the organic and functional categories are not mutually exclusive.
The clinician should seek to determine the relative contribution of both organic and functional etiologies when evaluating children and adolescents with chronic or recurrent abdominal pain so that appropriate interventions can be provided.
source:Adams, 1997

27. Organic Disorders
Common organic causes of chronic or recurrent abdominal pain include
Constipation.
carbohydrate malabsorption.
musculoskeletal pain.
parasitic infection.
Dysmenorrhea.
peptic disorders (eg, reflux esophagitis, gastritis, gastric and duodenal ulcers.
H. pylori infection.
Dern M.S 1999

28. Contd. Less common causes include:
Urinary tract infections, inflammatory bowel disease, and pelvic inflammatory disease.
Other, rare causes must also be considered; they include gallstones , kidney stones , late presentation of malrotation or volvulus , heavy metal poisoning , psoas abscess, meconium ileus, imperforate hymen with hematocolpos , ovarian neoplasm , pancreatic injury, familial Mediterranean fever , hypercalciuria , tuberculosis , and hereditary angioedema .

29. Functional Disorders
Functional disorders — Functional disorders are conditions in which the patient has a variable combination of symptoms without any readily identifiable structural or biochemical abnormality.
Several functional gastrointestinal disorders of childhood are recognizable .
Functional dyspepsia
Irritable bowel syndrome (IBS)
Functional abdominal pain
Abdominal migraine
Aerophagia

30. Functional Dyspepsia
Dyspepsia is pain or discomfort that is centered in the upper abdomen(ulcer- like). Discomfort may be characterized by fullness, early satiety, bloating, nausea, or vomiting( dysmotility- like).
Organic causes of dyspepsia symptoms include acid-related disease (esophagitis, gastritis, duodenitis), H. pylori, eosinophilic esophagitis, eosinophilic gastroenteritis, Crohn's disease, and celiac disease.

31. Contd. The pathophysiology of functional dyspepsia is not clear.
Abnormalities in gastric electrical rhythm, delayed gastric emptying, reduced gastric volume response to feeding, and antroduodenal dysmotility have been demonstrated in some children and adolescents .
Abnormal motor function, visceral sensitivity, and psychosocial factors have been studied as possible contributing factors in adults.
source:Cucchiara S,et al, 1992

32. Contd.
No signs or symptoms reliably differentiate functional dyspepsia from upper gastrointestinal inflammatory, structural, or motility disorders.
Symptoms of dyspepsia usually generate a more extensive diagnostic evaluation .

33. Irritable Bowel
IBS is characterized by chronic abdominal pain and altered bowel habits in the absence of any organic cause.
Organic causes that should be considered include Giardia, urinary tract infection, carbohydrate intolerance, inflammatory bowel disease, eosinophilic gastroenteritis, and celiac disease

34. Contd.
IBS occurs infrequently before late adolescence and may be preceded by a long history of constipation or an episode of gastroenteritis.
The diagnosis of IBS can be made on the basis of symptoms; it need not be a diagnosis of exclusion .
source:Thabane M,et al, 2010

35. Contd.
Children who have IBS have a lowered rectal pain threshold and disturbed rectal contractile response to meals .
Adolescents who have IBS-type symptoms have higher anxiety and depression scores than do those without such symptoms .
source:Halac U,et al 2010

36. Functional Abdominal Pain
The symptoms in some children do not meet the diagnostic criteria for IBS or functional dyspepsia, or consistent with organic illness.
Functional abdominal pain may be associated with visceral hyperalgesia, reduced threshold for pain, abnormal pain referral after rectal distension, or impaired gastric relaxation response to meals.
Functional abdominal pain in children 4 to 18 years of age can usually be diagnosed correctly by the primary care provider after a thorough history, physical examination, and stool testing for occult blood, provided that the evaluation does not reveal any signs or symptoms of organic disease

37. Abdominal Migraine
Abdominal migraine is characterized by recurrent episodes of abdominal pain, typically midline or poorly localized, dull and moderate to severe in intensity.
Pain is associated with at least two additional features that may include anorexia, nausea, vomiting, and pallor.

38. Aerophagia Aerophagia is excessive air swallowing that causes:
progressive abdominal distension
may interfere with dietary intake

39. MANAGEMENT
The most important component of the treatment is reassurance and education of the child and family.
The child and family need to be reassured that no evidence of a serious underlying disorder is present.
The family and the child with functional pain might worry about the inability to identify an organic cause and may be resistant to a diagnosis of nonorganic disease.

40. Contd.
Explanation in simple language that although the pain is real, there is no underlying serious disorder usually alleviates the anxiety in the patient and family.
Children of families that do not accept a functional cause of the symptoms are more likely to have persistent somatic complaints and school absences.

41. Contd. Treatment goals should be set for return to
function and minimizing pain.
Cognitive-behavioral therapy is helpful in the short term for managing pain and functional disability.
Relaxation techniques have been useful in some children with functional pain.
Time-limited use of medications .

42. Contd.
The commonly used medications include acid suppressants for dyspepsia symptoms, antispasmodics, and low-dose amitriptyline.
For chronic abdominal pain with IBS symptoms, antidiarrheals and nonstimulating laxatives are used. Peppermint oil for 2 wk improves IBS symptoms in children.
There is no evidence that lactose-restricted diet and fiber supplements decrease the frequency of attacks in chronic abdominal pain in children.
Proton pump inhibitors or visceral muscle relaxants (anticholinergics) have been used empirically but are often unhelpful in the absence of specific indication.

43. DEFINITION OF DISORDER
THERAPY
DEFINITION OF DISORDER
EFFECTIVENESS
Cognitive behavioral (family) therapy
Recurrent abdominal pain
Beneficial
Famotidine
Recurrent abdominal pain and dyspeptic symptoms
Inconclusive
Added dietary fiber
Unlikely to be beneficial
Lactose-free diet
Peppermint oil
Irritable bowel syndrome
Likely to be beneficial
Amitriptyline
Functional GI disorders, Irritable bowel syndrome
Inconsistent results
Lactobacillus B
Irritable bowel

44. Specific Treatment
Patients who have ulcer-like dyspepsia are treated for 4 to 6 weeks with H2-receptor antagonists.
Patients who have dysmotility-like dyspepsia are treated for 4 to 6 weeks with prokinetic agents.
In fact, there are no objective data to support such a treatment.

45. PROGNOSIS of RAP
There are no prospective studies of the outcome of any of the various presentations of functional abdominal pain.
Retrospective studies suggest that organic disease rarely is masked in the context of a functional disorder.
Once functional abdominal pain is diagnosed, subsequent follow-up rarely identifies an occult organic disorder.
Pain resolves completely in 30% to 50% of patients by 2 to 6 weeks after diagnosis.
This suggests that child and parent accept reassurance that the pain is not organic and that environmental modification is effective.
Nevertheless, more long-term studies suggest that 30% to 50% of children who have functional abdominal pain in childhood experience pain as adults.
Thirty percent of patients who have functional abdominal pain develop other chronic complaints as adults.

46. Outcome
After 5 years, approximately one third of children with RAP will have resolution of their pain, one third will continue to complain of the same symptoms, and another one third will have a different recurrent pain complaint.
Factors that seem to be related to worse prognosis are:
positive family history of abdominal symptoms
male sex
age of onset younger than 3 years
a period of more than 6 months before seeking treatment
low educational level and family poverty

47. REFERENCES
Up to date; Evaluation of the child and adolescent with chronic abdominal pain. Last literature review 19.1: January diagnostic criteria for functional gastrointestinal disorders at childhood (ages 4-18 years).
Clinical Report: New recommendations for treating children with chronic abdominal pain. Subcommittee on Chronic Abdominal Pain of the American Academy of Pediatrics. Pediatrics March
Cochrane database of systematic reviews has ongoing reviews of psychosocial, dietary and pharmacological interventions.

48. THANK YOU