recurrent abdominal pain (RAP) is relatively common paediatric problem occurring

mainly in older children and adolescents. It is worrisome to the parents, as regards

acceptance in the diagnosis as well as for doctor for management. Paediatricians
may have a dismissive attitude towards functional pain and parents find it difficult
to understand whether to deal with the pain being real or not.

RAP is defined as episodes of pain occurring atleast monthly for three consecutive
months with severity that interrupts routine functioning.

Clinicopathological entities of RAP

RAP can be classified as either organic or non organic depending on whether a specific cause of
pain is identified or not. Accordingly three distinct patterns have been identified.

Considering the stormy onset, monophasic course,angiographically demonstrable diffuse

vasculitis with subsequent complete resolution and overall good prognosis clinches the final
diagnosis as BACNS.

• Organic - 5-10%

• Non organic - 90-95%

○ Dysfunctional 80-85%

○ Psychogenic 10%

• Organic pain: More than 80% of abdominal pain from organic cause present as acute
abdominal pain, or as recurrent pain which do not fit in to the pattern of RAP.
Pointers to organic pain (red flag)

Physical examination andLab

History
findings
• Age younger than 5 years • Haematemesis
• Significant weight loss • Bilious vomiting
• Pain disturbs night sleep • Haematochezia
• Pain associated with change in bowel habits, diarrhoea, • Haematuria
constipation, nocturnal bowel movements • Arthritis
• Localized pain particularly away from umbilicus • Organomegaly
• Constitutional symptoms such as recurrent fever, loss • Rashes
of appetite or energy
• Localized abdominal
• Dysuria / altered frequency
• tenderness
• Faecal incontinence
• Occult blood in stool
 • Anaemia
• Jaundice

Causes of organic pain

A. G.I. System

• Elementary system: Malrotation, strangulated hernia, Intussusception, abdominal

migraine, bowel ischemia, helminthiasis (ascariasis), lactose intolerance, post operative
adhesions, chronic constipation, recurrent appendicitis, Meckel's diverticulitis.
• Hepatobiliary causes : Liver abscess, cholecystitis, choledochal cyst, sclerosing
cholangitis, gall stone, hepatitis
• Pancreatic cause: Chronic pancreatitis, pancreatic divisum.
B. Non G.I. System

• Genitourinary: Urinary tract infection, Pelvic inflammatory disease, dysmenorrhoea,

ovarian cyst and tumors, urolithiasis.
• Splenic : Portal hypertension
• Lymphatic : Inflammation, infection
• Peritoneal : Primary peritonitis
• Metabolic : Diabetic ketoacidosis, lead poisoning, porphyria
• CVS : Rheumatic fever, pericarditis
• Nervous system : Abdominal epilepsy
• Lungs : Basal pneumonia, diaphragmatic pleurisy
• Skeletal : Vertebral osteomyelitis, osteomyelitis of hip, spinal tumors
• Sickle cell disease
Non-organic pain

Dysfunctional and psychogenic pain can be considered as the two sides of the same coin, with
one group (dysfunctional) having a definite pattern e.g., IBS and non ulcer dyspepsia and the
other (psychogenic) having no recognizable pattern to their symptoms.

Characteristic features
• Onset > 6 years of age
• Pain is often midline periumbilical, may be localized to the epigastric / suprapubic region
• Non radiating or have bizarre radiations
• Usually no relationship with meals
• Generally does not disturb sleep but can interfere with diurnal variation
 • Pain episodes are short, lasting for 15 minutes to 1 hour with fairly asymptomatic pain
free interval in between
• Improvement of symptoms during school holidays and vacations
• Examination and lab investigation do not disclose any abnormality.
Psychogenic pain

Here purely psychogenic factors with no somatic predisposition are involved in the causation of
pain. Besides abdominal pain, these children also have the behavioral disorders and a close
connection to some precipitating events which make the clinical diagnosis easy. Factors involved
are:
• Complaint modeling - parents with abdominal pain
• School phobia - learning problems, anxious overachievers, teacher incompatibility, fear
of ridicule by peers, dislike of schools.
• Attention seeking - busy parents, sibling jealousy, single child, attention withdrawal after
an illness.
• Forced feeding and toilet training
• Sexual abuse
• Family psychopathology - illness / death in family, parental conflicts and separation, step
parents.
Dysfunctional pain

Unlike psychogenic pain, children with dysfunctional pain have normal behavior pattern and are
quite often intelligent.

Clinical features: John Apley has aptly summarized the features of FRAP as follows -
Physique - slightly underweight
Intelligence - normal
Psyche - emotionally disturbed
Personality - timid and anxious
Family history - parents usually have vague aches and pains and
psychological problem.
Age - it is seen in children between 4-14 years, mean age of
onset being 5-10 years.
Sex - seen more in females
Major paediatric disorders - IBS, functional abdominal pain syndrome, functional
associated with FRAP dyspepsia.
Diagnosis of RAPA good clinical history and thorough examination are mandatory and
sufficient to arrive at a diagnosis in some patients. But in some cases, laboratory and imaging
studies are required for diagnosis of RAP.

Diagnosis of RAP
A good clinical history and thorough examination are mandatory and sufficient to arrive at a
diagnosis in some patients. But in some cases, laboratory and imaging studies are required for
diagnosis of RAP.

A. History Salient points in history

•
• Location, intensity, character and duration of pain, time of day or night that pains.
• Appetite, diet, satiety, nausea, reflux, emesis.
• Stool pattern, consistency, completeness of evacuation.
• Review of systems : weight loss, growth or puberty delay, fever, rash
• Nutritional interventions
• Family history, travel: night pain or pain on awakening suggests a peptic origin, pain that
occurs at evening or during dinner is a feature of constipation, pain with weight loss,
fever, joint complaints or rash suggests an inflammatory or infectious disease.
B. Site of pain
•
• Above the umbilicus : upper GI pain
• Right lower quadrant : distal ileal and appendicular pain
• Lower abdomen : colonic pain
• Right upper quadrant : gall bladder
• Suprapubic UTI
Physical Examination

The examination must be thorough and comprehensive to rule out the organic problems. It also
reassures the child as well as their parents that their problem being evaluated well and their
concerns are taken seriously. Physical examination includes.
• Weight, height, growth, velocity, pubertal stage, blood pressure.
• Completed physical examination
• Objective abdominal findings - location, rebound, mass, psoas and hepatomegaly,
hepatosplenomegaly
• Costovertebral angle tenderness
• Right lower quadrant mass or fullness
• Perianal fistula, fissure or ulceration, perianal faecal staining
• Arthritis
Investigations

Accepting that only 10-15% of cases of RAP are due to organic aetiology, the laboratory,
radiological or endoscopic evaluation of children with RAP should be individualized and
carefully targeted depending on the findings suggested by detailed history and physical
examination.

Laboratory studies may be unnecessary if the history and physical examination clearly suggest
functional pain. However, a complete blood count, ESR, stool test for parasite, urinalysis are
routine screening test, to avoid missing organic problems.

This will help us to decide next line of investigation. For example, if urine shows hematuria or
albuminuria, USG KUB is mandatory.

Other investigations are to be done according to clinical suspicion.

Biochemical test: Enzyme assay are rarely of diagnostic benefit and are done only in suspicion
of hepatobiliary, renal and pancreatic dysfunction - liver enzyme, amylase and lipase.

USG Abdomen: Helpful only in patients suspected of hepatobiliary, pancreatic or renal disease.

USG Pelvis: is indicated to detect - retroperitoneal disease and visualization of ileum of Crohn's
disease, adenopathy, pelvic abscess.

X-ray abdomen: X-ray abdomen may be valuable in diagnosing intestinal obstruction, fecal
loading, and ureteric calculus. Barium studies are helpful to establish Malrotation,
Intussusception etc.

Radio nucleotide scan: is particularly helpful to detect Meckel's diverticulum.

Upper GI Endoscopy: Upper GI endoscopy is helpful to diagnose peptic ulcer disease.

Endoscopic biopsy may be helpful in identifying the aetiology of inflammation. Particularly H
Pylori infection rapid urease test.

Sigmoidoscopy / colonoscopy: indicated IBD are suspected.

Breath hydrogen test: suspected lactose intolerance test.

Urine for porphyrins: for porphyria.

Association of H. Pylori with RAP in children is still controversial.

Management

The first step of the management is to rule out the organic pain. Although, many cases of RAP
may reveal a probable diagnosis on first encounter, diagnostic certainly in others may be
achieved only after several office encounters and completion of salient investigation.

The aim of therapy is to treat the whole child and family and not just the symptoms.
Psychological problems may coexist with organic problems. Therefore, management of RAP in
children demands a much more broad based approach.

Management of psychogenic and dysfunctional RAP

This group is managed by - counseling, plenty of reassurance, involved doctoring and minimal
drugs.

Management of some specific organic conditions

Constipation - managed by regular toilet training, increased dietary fibers, bulking agents and
lactulose. Irritable bowel syndrome - managed by explanation, avoiding / managing psychosocial
trigger and fiber supplementation.

Lactose intolerance - a trail of lactose free diet for 1-2 weeks may be both diagnostic and
therapeutic.

Prognosis

FRAP could be a difficult problem for the child, the parents and the physician, 30-50% of
children with RAP settle within 6 weeks with the rest somewhat taking longer. However, if
properly evaluated and treated, most of the children outgrow the pain by the end of the school
going age. In patients with severe pain, not responding to the usual measures there may be
evidence of major stress and depression in the child and family and psychological opinion
needed. Small number of children with functional abdominal pain are likely to become adult
with functional disorder although the nature of the symptoms may change.

How common is abdominal pain in children?

Chronic (lasting more than 3 months) or recurrent abdominal pain is one of

the most common reasons that parents seek medical attention. The important
point here is that the pain recurs or persists for a prolonged period of time as
opposed to an acute or sudden, one-time episode of the stomach flu, fo
example.

What are the causes of recurrent abdominal pain?

Although there can be a lot of possible causes, in most cases, a medical cause of abdominal pain is not found.
Surprisingly, when a cause is found, the most common cause is constipation. Other possible causes include:

 Lactose intolerance
 Gastro-esophageal reflux and rarely ulcers
 Urinary tract or bladder infection
 Any abdominal organ problem(such as tumor or inflammation)

When does one worry about abdominal pain?

Usually children with recurrent abdominal pain have no other associated symptoms and continue to grow and
develop normally. Possible alarm or warning signs that there is a serious underlying problem include:

 Weight loss
 Fever
 Diarrhea
 Blood in the stools
 Black or white colored stools
 Urinary symptoms
 Decreased appetite
 Any other associated symptoms such as pallor and fatigue
Fortunately in most cases there is no underlying serious medical problem.

What tests are needed when evaluating children with recurrent abdominal pain?

When a physician evaluates a child for abdominal pain there are a variety of tests including x-rays, and blood tests
that may be done. Which specific tests and how many are performed, if any, depends on the overall individual
situation. Generally if a child is well otherwise with normal growth and there are no alarm symptoms or signs
present, there may be no or minimal testing.

What about appendicitis?

As opposed to recurrent or functional abdominal pain of childhood, appendicitis usually doesn't linger on for
months. Acute appendicitis, usually begins suddenly with pain in the center of the abdomen (belly button area)
which then slowly, works its way down to the right side. There are also some specific signs that a doctor can find
during a physical examination. If you suspect your child has appendicitis, seek immediate medical attention.
For more information on appendicitis in children click here

What can be done for constipation?

Parents are often shocked to find out that the most common identifiable cause of recurrent abdominal pain in
children is constipation. In many cases, parents do not even realize that their child is constipated. Abdominal pain
due to constipation results from "overloaded intestines" that do not empty out completely. The retained stool puts
pressure on the intestines resulting in abdominal pain. This is why in some instances the pain is relieved if the child
goes to the bathroom. Once the diagnosis of constipation has been confirmed, the treatment is usually simple.
For more information on constipation click here.

Can milk allergy or lactose intolerance cause abdominal pain?

Abdominal pain is not the most common symptom of milk allergy although it can rarely be. On the other hand,
lactose intolerance can cause recurrent abdominal pain. In most cases there is also associated diarrhea or bloating.
However, lactose intolerance can present just with symptoms of abdominal pain. Lactose intolerance means that a
child or an adult cannot digest the milk sugar: lactose. For more on milk protein allergy click here.

What if a cause of the abdominal pain is not found?

When no obvious medical cause is found it is referred to as idiopathic or functional abdominal pain of childhood.
Once a medical/physical cause has been ruled out, social stressors such as school or family problems (ie: recent
family problems such as divorce separation etc) need to be identified as these may be causing the pain. The pattern
of pain may be helpful: For example, if a child's pain is worse during weekdays and absent during weekends and the
summer, this is suggestive of school related stress as the cause. If after a complete assessment, social stressors are
identified as the cause of a child's recurrent abdominal pain the treatment approach focuses on helping and
supporting the child deal with the stress. Depending on the circumstances, this may require the help of other
professionals such as psychologists, guidance counsellors, teachers and/or social workers.

The human abdomen

The abdominal cavity in humans is subdivided into the abdomen proper and the pelvic cavity.
The abdomen proper is bounded above by the diaphragm; below it is continuous with the pelvic
cavity; posteriorly it is bounded by the spinal column, and the back muscles; and on each side it
is bounded by muscles and the lower portion of the ribs. In front, the abdominal wall is made up
of layers of fascia and muscles.

The abdomen is divided into nine regions whose boundaries may be shown by lines drawn on
the surface. The mid-section above the naval between the angle of the ribs is known as the
epigastric region; that portion around the navel, as the umbilical; below the navel and above the
pubic bone, as the hypogastric region. It is further divided into right and upper left quadrants on
each side above the navel, and right and left lower quadrants on each side below the navel. The
lumbar region extends on either side of the navel posteriorly and laterally.

The principal organs of the abdominal cavity are the stomach, duodenum, jejunum, ileum, part
of the large intestine, liver, gall bladder and biliary system, spleen, pancreas and their blood and
lymphatic vessels, lymph glands, and nerves, kidneys and ureter. The pelvic portion of the
abdomen contains the sigmoid colon and rectum, part of the small intestine, the urinary bladder,
in the male the prostate gland and seminal vesicles, in the female the uterus, Fallopian tubes,
and ovaries.

The human abdomen (from the Latin word meaning "belly") is the part of the body between the
pelvis and the thorax. Anatomically, the abdomen stretches from the thorax at the thoracic
diaphragm to the pelvis at the pelvic brim. The pelvic brim stretches from the lumbosacral angle
(the intervertebral disk between L5 and S1) to the pubic symphysis and is the edge of the pelvic
inlet. The space above this inlet and under the thoracic diaphragm is termed the abdominal
cavity. The boundary of the abdominal cavity is the abdominal wall in the front and the
peritoneal surface at the rear.
Functionally, the human abdomen is where most of the alimentary tract is placed and so most of
the absorption and digestion of food occurs here. The alimentary tract in the abdomen consists of
the lower esophagus, the stomach, the duodenum, the jejunum, ileum, the cecum and the
appendix, the ascending, transverse and descending colons, the sigmoid colon and the rectum.
Other vital organs inside the abdomen include the liver, the kidneys, the pancreas and the spleen.
The abdominal wall is split into the posterior (back), lateral (sides) and anterior (front) walls.

Psychogenic pain, also called psychalgia,[1] is physical pain that is caused,

increased, or prolonged by mental, emotional, or behavioral factors.

Psychosomatic:
1. Of or relating to a disorder having physical symptoms but originating from mental or
emotional causes.
2. Relating to or concerned with the influence of the mind on the body, and the body on the
mind, especially with respect to disease: psychosomatic medicine.

3.Somatic nervous system

4. From New World Encyclopedia
5. Jump to: navigation, search
6. Previous (Somalian Revolution (1986–1992))
7. Next (Son House)

8.
9.
10. The human nervous system. Blue is the peripheral nervous system, while red is central
nervous system.
11. The somatic nervous system, or voluntary nervous system, is that part of the peripheral
nervous system that regulates body movement through control of skeletal (voluntary)
muscles and also relates the organism with the environment through the reception of
external stimuli, such as through the senses of vision, hearing, taste, and smell. The
somatic nervous system controls such voluntary actions as walking and smiling through
the use of efferent motor nerves, in contrast with the function of the autonomic nervous
 system, which largely acts independent of conscious control in innervating cardiac
muscle and exocrine and endocrine glands.
12. Every living thing interacts with other organisms and its environment. This continuous
interaction between an organism and its environment is needed for the organism to
survive and grow. It is the somatic nervous system that allows individuals to receive
sensory information and consciously react to environmental changes.