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 of
school-aged children and adolescents. It often causes signicant anxiety amongst
parents and child as normal family life is frequently interrupted. Similarly, doctors
often have difculty in knowing who and how much to investigate. Although organic
disease needs to be considered, the majority of these children have functional
gastrointestinal disorders that can be classied according to the symptom-based
Rome II criteria (classication for functional gastrointestinal disorders). At least half
of the children (who have no organic disease) have symptoms compatible with
irritable bowel syndrome. Hence the child and family see the diagnosis of a
functional disturbance as a positive rather than a negative diagnosis resulting from
exclusion 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 recurrent
abdominal pain
FGID can be classied by Rome II symptom-
based criteria
Up to 50% of children with FGID will have
irritable bowel syndrome according to symp-
tom-based criteria
Unnecessary investigations are avoided if
symptoms of recurrent abdominal pain
(RAP) can be classied into one of the FGID
groups
By standardizing the denition of FGID,
study outcomes from different centres can
be compared directly
Research directions
The pathogenesis of FGID needs to be
further elucidated
The role of early childhood risk factors and
family history need further evaluation
Treatment of FGID including specic drug
modalities need to developed
ARTICLE IN PRESS
www.elsevier.com/locate/cupe
KEYWORDS
Recurrent abdominal
pain;
Functional
gastrointestinal
disorders;
Irritable bowel
syndrome
0957-5839/$ - see front matter r 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: christine.spray@ubht.swest.nhs.uk
(C.H. Spray).
The relationship between Helicobacter py-
lori and RAP needs to be further established
Improvement in understanding of psychoso-
cial processes and the role of psychosocial
intervention needs clarication
Introduction
The terms recurrent abdominal pain (RAP) and
chronic abdominal pain are interchangeable. Both
terms are descriptive in nature and do not reect a
specic underlying cause. However, most people
assume the causes to be functional rather than
due to an underlying disease. Functional symp-
toms are dened as those that occur in the
absence of anatomic abnormality, inammation or
tissue damage and are within the range of expected
behaviours for the body.
1
RAP was rst dened by
Apley in the 1950s as intermittent abdominal pain
in children between the ages of 4 and 16 years that
persisted for more than 3 months (not necessarily
consecutive) and affected normal daily activity. He
found that only eight cases out of 100 children who
had been referred to the hospital with RAP had an
organic cause.
2
However, a recent similar study
from the same geographical area found 30% of
children referred to a regional gastrointestinal
department with RAP had underlying organic
pathology.
3
The increase in children identied
with organic disease may be as a result of newly
developed investigations such as endoscopy and
the identication of new diseases, such as
those caused by Helicobacter pylori (H. pylori).
However, the most common cause of RAP is still
functional in the majority of cases. In 1997, a
symptom-based classication for functional gas-
trointestinal disorders (FGID) was developed,
known as the Rome II criteria.
4
A thorough
history and examination is required to identify the
possibility of organic disease (Table 1). In the
absence of any red ag signals (Table 2), a
positive diagnosis of FGID can be made and
classied according to symptoms. Some cases very
clearly t the denition of FGID and no further
investigations are warranted. However, others may
need further investigation, but this needs to be
performed in a systematic way and directed by
clinical suspicion.
Irritable bowel syndrome
The Rome criteria adopted the symptom-based
criteria for irritable bowel syndrome (IBS) used in
adults based on the Manning criteria (Table 3).
5
However, there are only a few studies validating
the Rome II criteria in the diagnosis of IBS in
children.
3,6,7
In those children who did not have
organic disease, a diagnosis of IBS was possible
using the symptom-based classication in 51% and
68% in the two prospective studies,
3,6
making IBS
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Table 1 Common organic diseases associated
with recurrent abdominal pain.
Inammatory bowel disease
Coeliac disease
Infection (e.g. Giardia)
Carbohydrate malabsorption
Pancreatic insufciency
Hepatic disease
Gallbladder disease
Urinary tract disease
Gastro-oesophageal reux
Gastritis
Non-steroidal anti-inammatory drugs
Helicobacter pylori
Crohns disease
Gastric/duodenal ulcer
Table 2 Red ag signals.
Weight loss
Growth delay
Pubertal delay
Perianal diseasetags/ssures/abscess
Positive family history for gastrointestinal disease
Persistent vomiting
Dysphagia
Haematemesis
Bleeding PR
Fever
Rashe.g. erythema nodosum
Diarrhoeapersistent and/or nocturnal
Faecal incontinence
Arthritis
Table 3 Manning criteria for irritable bowel
disease.
Abdominal pain+two or more of the following
criteria:
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
C.H. Spray 594
the most common cause of RAP in children. The
third study was retrospective and identied 35% of
children with no organic disease as having IBS based
on symptoms.
7
The latter study used an alternative
classication of IBS and may explain the difference
in percentage identied with IBS. This highlights
the need for a single denition of FGID so that
studies can be compared accurately. A clinical
diagnosis of childhood IBS can be made based on
symptoms in the presence of normal physical
examination and growth. Dietary history is impor-
tant, particularly to evaluate dietary bre and uid
intake in children with predominant-constipation
IBS. In children with predominant-diarrhoea and
bloating IBS, intake of poorly absorbable carbohy-
drates such as sorbital and fructose (fruit, juices
and sweets) need to be considered. Psychosocial
concerns also need to be considered.
Functional dyspepsia
Dyspepsia is dened as recurrent or persistent pain
or 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-like
dyspepsia; dysmotility-like dyspepsia and non-spe-
cic dyspepsia.
In ulcer-like dyspepsia, pain is mostly in the
upper abdomen (epigastrium) and is often relieved
by food, antacids or antisecretory drugs. It occurs
before meals or when hungry and can waken the
child from sleep. Dysmotility-like dyspepsia is often
described as an unpleasant sensation rather than
pain, and is associated with feeling of early satiety,
upper abdominal fullness, bloating and nausea.
Non-specic dyspepsia is dyspepsia with neither of
the above features.
Functional dyspepsia may be difcult to differ-
entiate on clinical grounds. It is not an uncommon
complaint in children presenting to a paediatric
gastoenterology unit, but not all children need to
undergo upper gastrointestinal endoscopy. In one
study from North America, less than 20% of children
presenting with dyspepsia had organic disease.
8
The presence of an ulcer, either gastric or
duodenal, is extremely rare in children, especially
in isolation, in whom no risk factors have been
identied. Careful history and examination needs
to be taken to highlight any red ag signals that
might increase suspicion of organic disease. Dys-
pepsia can be a symptom of Crohns disease or
coeliac disease. Precipitating factors, such as
medication [e.g. frequent non-steroidal anti-in-
ammatory drugs (NSAIDs)] and dietary foods that
may aggravate symptoms (e.g. caffeine and zzy
drinks, acidic drinks such as fresh apple juice, spicy
and fatty foods), need to be considered. The
relationship between infection with H. pylori and
RAP remains an area of controversy. Geographical
area and poor living conditions and overcrowding
increase the risk of infection. There is no dispute
that infection with H. pylori causes ulcer disease
and gastritis. However, studies in children with RAP
comparing those who were H. pylori positive and
those who were not demonstrated no difference in
symptoms.
9,10
Equally, studies have reported vari-
able outcomes of resolution of RAP following
treatment and eradication of H. pylori.
11
At the
present time, there are no data to support routine
screening of H. pylori infection in children with
RAP,
12
but some clinicians use it as a guide to
perform upper gastrointestinal endoscopy for sus-
pected ulcer disease. Guidelines for treatment of
H. pylori were published in 2000.
13
Abdominal migraine
Abdominal migraine has been described in 13% of
school-aged children, being most prevalent in 57
year olds and more common in girls. It is char-
acterized by episodes of abdominal pain lasting for
hours or days, often accompanied by pallor and
anorexia. Most importantly, these children are well
in between these episodes with symptom-free
intervals lasting weeks to months. Episodes often
start at night or early morning. Frequently, head-
ache, photophobia and aura accompany these
episodes. A positive family history is present in less
than half the cases. Vomiting is unusual but if
present may be considered as cyclical vomiting
syndrome. Many clinicians consider the two dis-
orders as different phenotypic expressions of a
single problem with pain predominating in the
former and vomiting in the latter. There is no
evidence of metabolic, biochemical, gastrointest-
inal or central nervous system abnormalities.
Anatomical abnormalities such as ureteropelvic
junction obstruction and intestinal malrotation,
recurrent pancreatitis and hepatobiliary obstruc-
tion and, rarely, acute intermittent porphyria need
to be considered.
Aerophagia (air swallowing)
This is an underappreciated but well-documented
cause of abdominal distention and pain.
14
Gum
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Recurrent abdominal pain 595
chewing and zzy drinks can exacerbate the
problem and stress may aggravate the condition.
Functional abdominal pain syndrome
Many children and adolescents that do not full the
criteria of the above functional disorders suffer
with RAP. The pain is not related to specic events
or defecation but is continuous or recurrent and
frequently affects daily activities. Most children
describe the pain as peri-umbilical, and difculty in
sleeping is not uncommon. They frequently com-
plain of other non-specic symptoms such as
headache, fatigue, dizziness, nausea and muscle
aches. Physical examination is normal. These
children are often difcult to deal with because
there is signicant paradox between the childs
severe complaints and signicant impairment of
their daily activities and the lack of objective
ndings on physical examination. Psychosocial
history may reveal obvious triggers but this is not
always the case.
Investigation of patients with RAP
Following a full history and examination, investiga-
tions should be symptom directed. It is possible to
come to a diagnosis of a FGID without performing
any investigations. However, there will be times
when the clinician is uncertain and wants to
perform baseline biochemical and haematological
studies. Also, in practice, clinicians may want
baseline investigations in order to reassure the
child and the family. The latter is something that
could be debated extensively but falls under the
art of medicine. It is, however, important to
identify what the child and their family fear and
what they desire from the consultation.
15
Fre-
quently, reassurance is all that is needed.
Aetiology of FGID
The pathophysiology of FGID is not known or
understood. It is thought that symptoms may arise
from changes in the braingut axis, which links the
central and enteric nervous system (CNS/ENS).
16
The ENS controls motor and secretory functions of
the gastrointestinal tract. It is inuenced by the
parasympathetic and sympathetic nervous systems
and involves various neurotransmitters such as
serotonin (5HT), which has recently emerged as
one of the most important. Approximately 95% of
5HT in the body is found in the gastrointestinal
tract. The ENS is able to function autonomously,
but is also modied by the CNS, the most common
example being accelerated colonic transit time
leading to diarrhoea at times of stress and
important events. The gut is also a sensory organ.
An attractive pathophysiological theory for func-
tional pain in adults is one in which visceral
hypersensitivity (hyperalgesia) is the nal common
pathway precipitated by different sensitizing
events such as inammation, infection, diet,
allergy, trauma and motility abnormalities that
may be further modulated by psychosocial factors
and genetic environment. How much genetic
inuence is nurture rather than nature continues
to be of debate.
Treatment of patients with RAP
Where an underlying gastrointestinal disease is
identied as the cause of RAP, treatment can be
clearly directed. Classifying non-organic disease
into the appropriate functional types such as IBS or
non-ulcer dyspepsia helps to direct treatment
appropriately. Most importantly, it is necessary to
let the child know that the symptoms they are
feeling are very real but are not dangerous or life-
threatening. Reassurance and simple explanation of
the condition is necessary. It is important to
address readily identiable psychosocial factors
that might trigger or exacerbate symptoms without
suggesting that psychological factors are the sole
cause. Psychological counselling may be effective if
the 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 dietary
manipulation such as adequate dietary bre and
uid intake should be considered in children with
constipation-predominant IBS. In children with IBS
with diarrhoea and bloating symptoms, stopping or
reducing the intake of poorly absorbable carbohy-
drate such as sorbital and fructose (fruit, juices,
zzy drinks and sweets) may be helpful. Other
foods like caffeine, zzy drinks and acidic drinks
such as fresh apple juice, spicy and fatty foods may
exacerbate dyspeptic symptoms. There are limited
controlled trials of different treatment modalities
of functional gastrointestinal disease in children
and adolescents. Since the pathophysiology of func-
tional gastrointestinal pain is unknown and clearly
multifactorial, most treatments are non-specic
and only help to control symptoms, e.g. metoclo-
pramide, antacids and H2-receptor antagonists for
ARTICLE IN PRESS
C.H. Spray 596
dyspeptic symptoms. Good success has been
achieved with tricyclic antidepressants (TCAs) in
this group. Current medications in IBS include
anticholinergics (antispasmodics), TCAs and selec-
tive serotonin re-uptake inhibitors. Diarrhoea may
be controlled with loperamide. TCAs such as
imipramine or amitryptilline in low doses have
been shown to improve symptoms in adults with
IBS
17
but there are no similar studies in children.
Child cases of improvement in RAP with TCAs are
only anecdotal. Alosterone, a selective 5HT3
receptor antagonist, was briey approved for
diarrhoea-predominant IBS symptoms in women
but was withdrawn from the market following
concerns of ischaemic colitis.
18
Tegaserode, a
5HT4 receptor agonist, is currently being evaluated
for constipation-predominant IBS in adults. Treat-
ment of abdominal migraine is similar to that used
for migraine prophylaxis. Pizotifen, a 5HT receptor
antagonist, is an effective prophylactic,
19
but
propanolol and TCAs can also be effective. In all
cases of FGID, the child and family need to decide
whether they want to embark on regular medica-
tion, taking into consideration the possible side-
effects of the medications vs. the impact on quality
of life of the condition.
In summary, RAP is common in children and
adolescents. In the absence of evidence for organic
disease, a diagnosis of FGID can be made and
classied according to Rome II criteria. This enables
a positive diagnosis of FGID to be made rather than
one of exclusion, reducing the need for extensive
investigation prior to appropriate treatment.
References
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Further reading
1. Rome II. A multinational consensus document on functional
gastrointestinal disorders. Gut 1999; 45 (Suppl. II).
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