Recurrent abdominal pain - NUH

June 2015; GI teaching

Recurrent abdominal pain

Quak Seng HockDepartment of Paediatrics

KTP-University Children’s Medical InstituteNational University Hospital

NUHS


Case history

• LJR

• 12 old boy seen at CE repeatedly for severe abdominal colic at right upper quadrant

• Physical examination: mild tenderness RHC and epigastrium

• Symptomatic treatment and referred to specialist clinic for further management

• Noted weight loss

• Seen by various doctors: gastritis



outline

• The pain

• Epidemiology

• Long term outcome

• Some interesting cases

• management


Definition

• At least 3 bouts of abdominal pain, severe enough to interfere with daily activities, over a period of at least 3 months– J Apley 1958

• In practice, RAP includes children

and adolescents in which parents

seek advice though the duration

may not be 3 months

• Exclude acute abdominal pain


Pain characteristics

• Location

• Severity

• Frequency

• Personality

• Timing of pain

• Associated features


outline

• The pain

• Epidemiology



• management


Age distributionQuak &Wong; IMJ 1997

0

5

10

15

20

25

30

<1 1+ 2+ 3+ 4+ 5+ 6+ 7+ 8+ 9+ 10+ 11+ 12+

Age

Age



Helicobacter pylori, gastroduodenal disease and recurrent abdominal pain in children

– Macarthur C, et al. JAMA 1995;273:729-34

• 45 studies from Jan 1983-July 1994

• Prevalence of HP infection in children with DU was high

• Prevalence rate of infection in children with RAP inconsistent


Red Flag symptoms

• Localization of pain away from the umbilicus• Pain associated with changes in bowel habits,

particularly diarrhea, constipation, or nocturnal bowel movements

• Pain associated with night wakening• Repetitive emesis, especially if bilious• Constitutional symptoms, such as recurrent fever,

loss of appetite or energy• RAP in children < 4 years of age• Weight loss


Red Flag signs

• Loss of weight or decline in height velocity

• Organomegaly

• Localized abdominal tenderness, particularly away from umbilicus

• Peri-anal abnormalities (fissures, ulceration of skin tags)

• Joint swelling, redness or warm

• Ventral hernias of abdominal wall


outline

• The pain

• Epidemiology



• management


RAP in children: a long term follow-upMaqni et al. Eur J Pediatr 1987;146:72-4

• Long term follow up, minimum of 10 years

• Total of 16 children– Completely disappeared: 50%

– Persisted: 25%

– Other painful symptoms : 25%

• Poor outcome– Painful family

– Many surgical procedures

– Low educational level and social class




outline

• The pain

• Epidemiology



• management


ML

• 3+ year old boy

• Previously well

• Seen various doctors for RAP

• Treated for constipation

• Referred to NUH because pain persistent and progressively more frequent and severe


ML


XC

• 5 year old boy

• Recurrent bouts of severe

abdominal pain

• Usually improved after

vomiting

• In between episodes of pain,

he is well


XC


NKL

• 10 year old Chinese boy with RAP

• Associated with vomiting which may last for days (up to 7-10 days)

• Weight loss

• Missed school for > 6 months

• Thin boy with no abnormality found in abdomen



PF

• 12 year old Chinese girl

• Seen by various doctors for RAP

• Noted to have iron deficiency anaemia

• Treated for gastritis, anaemia without improvement

• Later seen be endocrinologist for delayed puberty



outline

• The pain

• Epidemiology



• management


Clinical approach

• What are the three important investigations:


Clinical approach

• Three important investigations:

– 1) good history and physical examination


Clinical approach

• Three important investigations:

– 1) good history and physical examination

– 2) good history

and physical examination


Clinical approach

• Three important investigations:– 1) good history and physical examination

– 2) good history and

physical examination

– 3) good history

and physical

examination


Understanding the scenario

Pain

patient

parents environment


Initial screening tests

• Anthropometrics

• Urinalysis

• ESR

• Stool occult blood


Initial screening tests

• Anthropometrics

• Urinalysis

• ESR

• Stool occult blood

• Next steps

– Ultrasound

– Food diary

– Only when indicated:

• Invasive procedures


Food as cause of RAP

• Lactose intolerance– Some 40% of patients with RAP has lactose

intolerance • Quak & Wong IMJ 1997

• Other food– Mainly as food additives: sorbitol, artificial

sweeteners

• Eosinophilic gastroenteritis– Tien FM, et al. Pediatrics & Neonatology 2011


Ann Nutr Metab2012;61-95-101


Cochrane review 2009, issue 1


Clinical Psychology review 2011;31:1192-7

• Meta-analysis of 10 interventional studies


Clinical Psychology review 2011;31:1192-7

• Psychological therapies, mainly cognitive-behavioral therapy, have a moderate effect on the reduction of pain in children with RAP


• 63 patients (11-18 years) randomly assigned to receive standard medical care (SMC) or written self-disclosure (WSD) + SMC

• WSD + SMC associated with significantly fewer pain experiences and reduced health care utilization


summary

• RAP is common

• Significant effect on HRQoL

• Red flags

• Good history and careful physical examination remain the key step toward successful management

• For functional RAP, CBT is successful in reducing the frequency and severity of pain


Thank you

Terima Kaseh

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Recurrent abdominal pain - NUH

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