Recurrent abdominal pain Quak Seng Hock Department of Paediatrics KTP- University Children’s Medical Institute National University Hospital NUHS June 2015; GI teaching
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 June 2015; GI teaching
June 2015; GI teaching
outline • The pain • Epidemiology • Long term outcome • Some interesting cases • management June 2015; GI teaching
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 June 2015; GI teaching
Pain characteristics • Location • Severity • Frequency • Personality • Timing of pain • Associated features June 2015; GI teaching
outline • The pain • Epidemiology • Long term outcome • Some interesting cases • management June 2015; GI teaching
Age distribution Quak &Wong; IMJ 1997 Age 30 25 20 15 Age 10 5 0 <1 1+ 2+ 3+ 4+ 5+ 6+ 7+ 8+ 9+ 10+ 11+ 12+ June 2015; GI teaching
June 2015; GI teaching
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 June 2015; GI teaching
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 June 2015; GI teaching
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 June 2015; GI teaching
outline • The pain • Epidemiology • Long term outcome • Some interesting cases • management June 2015; GI teaching
RAP in children: a long term follow-up Maqni 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 June 2015; GI teaching
June 2015; GI teaching
June 2015; GI teaching
outline • The pain • Epidemiology • Long term outcome • Some interesting cases • management June 2015; GI teaching
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 June 2015; GI teaching
ML June 2015; GI teaching
XC • 5 year old boy • Recurrent bouts of severe abdominal pain • Usually improved after vomiting • In between episodes of pain, he is well June 2015; GI teaching
XC June 2015; GI teaching
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 June 2015; GI teaching
June 2015; GI teaching
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 June 2015; GI teaching
June 2015; GI teaching
outline • The pain • Epidemiology • Long term outcome • Some interesting cases • management June 2015; GI teaching
Clinical approach • What are the three important investigations: June 2015; GI teaching
Clinical approach • Three important investigations: – 1) good history and physical examination June 2015; GI teaching
Clinical approach • Three important investigations: – 1) good history and physical examination – 2) good history and physical examination June 2015; GI teaching
Clinical approach • Three important investigations: – 1) good history and physical examination – 2) good history and physical examination – 3) good history and physical examination June 2015; GI teaching
Understanding the scenario patient Pain parents environment June 2015; GI teaching
Initial screening tests • Anthropometrics • Urinalysis • ESR • Stool occult blood June 2015; GI teaching
Initial screening tests • Anthropometrics • Urinalysis • ESR • Stool occult blood • Next steps – Ultrasound – Food diary – Only when indicated: • Invasive procedures June 2015; GI teaching
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 June 2015; GI teaching
Ann Nutr Metab 2012;61-95-101 June 2015; GI teaching
Cochrane review 2009, issue 1 June 2015; GI teaching
Clinical Psychology review 2011;31:1192-7 • Meta-analysis of 10 interventional studies June 2015; GI teaching
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 June 2015; GI teaching
• 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 June 2015; GI teaching
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 June 2015; GI teaching
Thank you Terima Kaseh June 2015; GI teaching
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