1. RecuRRent
AbdominAl
PAin
Dr. Ravi Malik
CMD Radix Hospital
IMA Headquaters
DMC medical education
convenor
2. INTRODUCTION
RAP
3 episodes over 3 months
Severe enough to affect activities
Inter periods of well being
No specific cause identified
3. epIDemIOlOgy
10-12% of school aged children.
Peak incidence at 4-6 years and at 7-12
years.
Obesity and RAP.
Fruits consumption and RAP.
4. ClINICal pROfIle
Pain is genuine
Peri-umbilical pain
Nausea, vomiting
Pallor
Headache & limb pains
Family history
5. ClassIfICaTION
• It can be organic or nonorganic.
• Nonorganic(functional) abd pain
• Functional dyspepsia
• Irritable bowel syndrome
• Abdominal migraine
• Functional abdominal pain
6. eTIOlOgy
Organic Pain (10%) Non-organic Pain (90%)
Site Flanks, suprapubic Central and often epigastric
Family History - VE + VE
Psychological History - VE + VE
Headache - VE + VE
Weight Loss +VE - VE
Abnormal Signs +VE - VE
Abnormal Investigations +VE - VE
Alarming Symptoms + VE - VE
7. Functional dyspepsia
Pain or discomfort in the upper abd.
Stomach fullness
Bloating
Nausea
Retching or vomiting.
Irritable bowel syndrome
8. Abdominal migraine
Intense abdominal pain
Mid-abdomen
Anorexia, nausea, vomiting, pallor,
headache, or sensitivity to light
A family history of migraine
Functional abdominal pain syndrome
11. paThOphysIOlOgy
Gastrointestinal motility- High levels of
emotional stress and abnormalities in
autonomic nervous system may contribute.
Visceral hypersensitivity-
Intensity of signals from GIT is exaggerated.
Abnormal bowel sensitivity to physiological,
psychologic or noxious stimuli may be present.
May occur following viral gastroenteritis or
after psychologically traumatic events.
12. Emotional stress
Patients can sometimes date the onset of pain to
a specific stressful event, such as change in school,
birth of a sibling or separation of parents, family
member's illess.
Higher levels of anxiety and depression are found
in patients with RAP than in healthy children.
Starting school may also trigger recurrent
abdominal pain.
13. Psychological factors:-
A child can develop chronic abdominal pain related
to his or her need for attention.
Parental response to child's pain can reinforce the
child's behavior. If parents are worried about child's
pain, the child may become more anxious, and the
pain may worsen.
Parents should pay attention to the child's other
activities, this might satisfy the child's need for
attention & reduce the abdominal pain.
14. alaRm sympTOms
(NeeDINg fURTheR INvesTIgaTIONs)
Features that suggest an organic disorder may include one or
more of the following:
Pain that awakens the child,
Significant vomiting/constipation/bloating
Persistent right upper/lower quadrant pain
Unexplained fever
Dysphagia
Chronic severe diarrhea
G.I. blood loss
Unintentional weight loss or slowed growth
Delayed puberty
Pain/ bleeding with urination
Family H/O inflammatory bowel disease, celiac or peptic ulcer disease
15. alaRm sIgNs
(NeeDINg fURTheR INvesTIgaTIONs)
Localized tenderness in right upper/lower quadrant
Localized fullness or mass
Hepatomegaly/Splenomegaly
Jaundice
Costovertebral angle tenderness
Arthritis
Spinal tenderness
Perianal disease
Unexplained physical findings
Pallor/Rash
Hernia
16. DIagNOsIs
RAP should not require an exhaustive
series of diagnostic tests to rule out organic
causes
History – absence of alarming symptoms
Meticulous examination
Other associated symptoms
Normal investigations
Organic & nonorganic may co-exist
17. INvesTIgaTIONs IN ReCURReNT
abDOmINal paIN
Basic investigations (1st line investigations)
Full blood count
ESR/C-reactive protein
Urine analysis & Urine culture
Stool for ova, cysts and parasites
Second line investigations
Plain X-ray abdomen
LFT & KFT
Celiac panel
Abdominal ultrasound
Breath hydrogen test for lactose intolerance
Tests for Helicobacter pylori
Barium follow through
Esophageal manometry and pH-metry
Upper and lower gastrointestinal endoscopy
Intravenous urogram/micturition cystourethrogram
18. Only basic urine, stool and blood examinations are
recommended to exclude organic causes in the
diagnosis of RAP.
Ultrasound scanning, extensive radiographic
evaluation and invasive investigations like endoscopy
in these children are rarely diagnostic or cost
effective.
Presence of an abnormal test result alone does not
pinpoint to a diagnosis unless it is clinically relevant.
19. abDOmINal paIN
TReaTmeNT
Treat organic cause if present.
For functional abdominal pain variety
of treatments.
Close follow up required.
20. gUIDelINes fOR maNagemeNT
Of ReCURReNT abDOmINal
paIN
Rule out organic cause
Reassurance & education of the family.
Discuss the apprehensions of family.
Explore stressors.
Acknowledge but no undue attention.
Avoid psychological labelling.
21. gUIDelINes fOR maNagemeNT Of
ReCURReNT abDOmINal paIN-(II)
Allow normal activity.
Establish regular follow-up system of return visits to
monitor the symptoms.
Be available Assure parents that you are available to see
the child if changes occur or the parents become anxious.
Allow appropriate time, in an unrushed environment for
them.
Make judicious use of “second opinions”
22. DRUg TheRapIes
Pharmacological treatments are commonly used in an
effort to manage symptoms despite the lack of data
supporting their efficacy.
Usually a part of the multidisciplinary approach.
Commonly used medications include acid suppressants
for dyspepsia symptoms, antispasmodics & low dose
amitriptyline .
For chronic abdominal pain with IBS symptoms,
antidiarrheals and nonstimulating laxatives are used.
Peppermint oil found to be very effective in the treatment
of irritable bowel syndrome in children.
PPIs and anticholinergics are often unhelpful.
23. DIeTaRy mODIfICaTIONs
There is no evidence that lactose-restricted diet and
fiber supplements decrease the frequency of attacks
in chronic abd. pain.
In some children, there are foods, drinks, and
medicines that make symptoms worse.
Common triggers include: High-fat foods, Caffeine &
foods that increase gas (beans, onions, raisins,
bananas, apricots, prunes, cabbage, cauliflower,
broccoli etc.)
Medicines that can cause upset stomach include
aspirin and ibuprofen etc.
24. behavIORal TheRapIes
Recommended for children or adolescents with functional
abdominal pain that has severely impacted activities of
daily living.
Cognitive-behavioral therapy is help full in short term for
managing pain and functional disability.
Relaxation techniques, hypnosis, biofeedback, and
psychotherapy help to reduce a child's anxiety levels, help
them to participate in normal activities and to better
tolerate the pain.
A significant improvement of symptoms and fewer school
absences in children with RAP following a short period of
cognitive behavioral family treatment is reported.
25. pROgNOsIs
With this approach, approximately 30% to 60% of
children have resolution of their pain.
Remainder continue to exhibit symptoms and go
on to be adults with abdominal pain, anxiety, or
other somatic disorders.
Other studies have reported development of irritable
bowel syndrome in 25-29% of them in later life.
