Abdominal Pain in Children (Paediatrics)

Abdominal pain (also known as a stomach ache, or a tummy ache) is one of the most common symptoms and reasons for parents to take children to their doctor or the hospital emergency department. However, it is a symptom associated with both non-serious and serious medical issues that might require urgent medical attention. About 10-15% of school-aged children (more often girls) suffer from recurrent abdominal pain and 90-95% of them do not have specific organic diseases.

Among the warning signs that might indicate the origin of the pain and may further lead to a better understanding of the disorder and a precise differential diagnosis are: abdominal pain in children under the age of 4, can be localised everywhere but around the navel, manifestation of pain, it interferes with sleep - causing insomnia, weight loss, noticeable change in development, vomiting, fever etc. 

Types of Abdominal Pain

 * according to the course:
 * acute - severe, persistent abdominal pain of sudden onset (usually develops within a couple of hours or days)
 * acute appendicitis, cholecystitis, intestinal obstruction...
 * chronic - pain that is present for more than 3 months. It may be present all the time or come and go (recurring incidentally or might be linked to a certain activity or irritation by food)
 * celiac disease, gastoesophageal reflux disease, Crohn's disease...
 * according to the origin/cause:
 * organic - lactose intolerance, gastroduodenal ulcers
 * functional – dyspepsia, irritable bowel
 * according to characteristics:
 * visceral (diffuse, blunt, difficult to localize);
 * parietal (sharp, localized pain) when the peritoneal lining is irritated, pain makes breathing difficult; also might be of a vertebrogenic or a metabolic aetiopathogenesis - diabetic ketoacidosis (pseudoperitonitis diabetica), lead intoxication etc.
 * psychogenic (pain that is caused, increased, or prolonged by mental, emotional, or behavioral factors - this diagnosis can be determined only after excluding other causes and evaluating the child by a psychologist)
 * psychogenic (pain that is caused, increased, or prolonged by mental, emotional, or behavioral factors - this diagnosis can be determined only after excluding other causes and evaluating the child by a psychologist)

Health Assessment Questions:
 * intensity of pain (on a scale 1→10, we can also evaluate from indirect signs such as the child's position and the intensity of crying),
 * duration
 * localization (younger children cannot usually point to a specific area, older children locate it in the periumbilical area),
 * possible triggers (food, position of a body, particular part of a day, stress),
 * associated symptoms (fever, nausea, vomiting, constipation, diarrhea, stool abnormalities, dysuria),
 * time context (especially in case of psychogenic pain – for example in the morning of a school day, right before a dentist appointment)

Infantile Colic

 * hardly defined problems in early stages of infancy, affecting about 1 in 10 infants (it is most common around six weeks of age and gets better by six months of age)
 * equally common in both bottle and breast-fed infants

Clinical evidence: episodes of severe irritability and abdominal pain typically alongside with lifting of the legs


 * they are associated with the food consumption, they appear in the second half of the feeding, and stop after the meal
 * gradually worse in the afternoon and in the evening
 * they are accompanied by borborygmi ("tummy rumble") and flatulence

Examination: exclusion of other causes (hunger, thirst, urinary tract infections, otitis)


 * sometimes the cause is solely intolerance to cow's milk or lactose

Therapy: in breastfed children, mothers might be advised to change their diet - avoid dairy products (need to supplement calcium)


 * hospital care - only for prolonged or severe difficulties, physiological development issues - poor weight gain, in case of very persuasive and anxious parents

Differential Diagnostics: severe pain may suggest intussusception (invagination) -


 * intussusception linked trias: 1. colic-like pain, 2. intussusception tumor in the abdomen, 3. stool in the form of mucus usually coloured by blood (in only about 20% of diagnosed children)

Recurrent Functional Abdominal Pain
definition: at least 3 cases of abdominal pain in a period of 3 months - it is a functional disease that has a paroxysmal character
 * it is a functional disorder with episodes of incidental pain
 * pain limits child's physiological activities
 * observed in 10-15% of children, more likely girls
 * often affect children aged 4-16 with the usual onset at around the age of 5
 * it might develop due to mental and physical stress, genetic predisposition, anxiety (such as social anxiety from meeting new people in different environment), low self-confidence, etc.

Clinical Evidence

 * children locate pain in the periumbilical area, or the mid-epigastric area
 * the pain does not project anywhere, it has a paroxysmal character
 * it is not associated with food, defecation and child's activity
 * does not occur at night

Diagnosis

 * diagnosis is primarily based on precise personal and family health history assessment, clinical evidence, physical examination (including per rectum examination), laboratory test results and additional examinations - need to distinguish whether it is an organic or a functional cause
 * lab. tests: blood (CBC, FW, urea, creatinine, bilirubine, aminotransferases, amylase, glycemia, IgA - transglutaminase and endomysium antibodies, lipids, ANCA, ASCA), urine (chemical properties, sedimentation, quantitative bacteriuria, porhyrins screening), stool (occult gastrointestinal bleeding, antigen test for H. pylori, parasitology tests, calprotectin levels)
 * abdominal and renal ultrasound examination
 * further gynecologic examination might be suggested (girls)
 * lactose malabsorption in anamnesis, or additional tests (such as the hydrogen breath test)

Differetinal Diagnosis

 * if following symptoms are present it is more likely a different diagnosis than functional recurrent abdominal pain → well-localised pain (not in the periumbilical area), pain radiates, causes insomnia, weight loss, growth retardation, vomiting, diarrhea, constipation and systematic signs - fever, artralgia, exanthem, anaemia...

Treatment
Prognosis: statistically 50-70% of patients report disappearance of any difficulties in adulthood but in 30–50% pain persists even later in life (headache, menstrual pain, beck pains)
 * treatment takes a long time and demands an intensive cooperation of a doctor and both children and parents
 * the key procedure of the treatment is the interview (and communication overall) with parents - it is neccesary to emphisize that their child suffers of pain that is absolutely real and present - by virtue of motoric activity of the gastrointestanal system as a result of increased sensitivity to normal or stressful stimuli
 * the doctor makes sure that parents fully support their child, not the pain itself
 * a child cannot be deprived of daily activites to some extent
 * regular sessions with a psychologist or a psychiatrist are convenient
 * the positive impact of medication was not fully proven - on the contrary it may further psychologically worsen patient's condition

Recurrent Functional Abdominal Pain Associated with Functional Dyspepsia
Clinical evidence : nausea, bloating, stomach rambles, belching, hiccups, regurgitation - a mixture of gastric juices, and sometimes undigested food, rises back up the esophagus and into the mouth, burning pain in retro-sternal are
 * Functional dyspepsia (also known as nonulcer stomach pain) is a term for recurring signs and symptoms of indigestion that have no obvious cause. Functional dyspepsia is common and can be long lasting — although signs and symptoms are mostly intermittent. These signs and symptoms resemble those of an ulcer, such as pain or discomfort in your upper abdomen, often accompanied by bloating, belching and nausea.

Differential Diagnostics: crucial to eliminate an organic cause (mainly peptic ulcers, oesophageal reflux, gastritis and positive test for Helicobacter pylori)

Recurrent Functional Abdominal Pain Associated with Clinical Signs of Irritable Bowel
Clinical Evidence: repetitive changes in bowel habits - diarrhea, constipation, abdominal pain subsides after defecation, mucus in stool, bloating,s ubjective sensation of incomplete evacuation
 * also known as lower abdomen dyspepsia
 * more frequent in adolescents

Differential Diagnostics: commonly idiopathic bowel inflammation, positive occult gastrointestinal bleeding test leads to further procedures - colonoscopy, contrast CT scan..

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