Abdominal pain in children

Departament of Paediatric Allergology,Gastroenterology and Nutrition

Medical University of Łódź
 Plan of lecture

► Pathophysiology of abdominal pain

► Basic terminology and definitions
► Acute and chronic abdominal pain in children
► Diffrenation functional from organic causes of
abdominal pain
► Evaluation and management/treatment of
abdominal pain in children
► Causes of organic abdominal pain in children
► Functional gastrointestinal disorders connected
with chronic abdominal pain
 Abdominal pain

► Abdominal pain is one of the most common symptom

in children

► Its prevalence ranges from 10%–45% in school-going

children, and it accounts for 2%–4% of visits to
primary care physician and up to 50% of visits to
paediatric gastroenterologists

► Problem for whole family and primary care physician

► Costs of diagnosing and therapy in children !!!

 Abdominal pain

► acute
► chronic

► organic
► functional
 Basic terminology and definition
(AAP i NASPGHAN)

► Chronicabdominal pain - long-lasting or recurrent

abdominal pain – organic or functional origin

► Functionalabdominal pain – abdominal pain not

caused by anatomical, metabolic, infectious,
inflammatory or neoplastic disease

[JPGN 2005]
 Kinds of pain
► Somatic pain
▪ Sharp pain, sudden onset
▪ Persistent
▪ Localized, not referred
▪ Intensified by cough, movement, deep breath
▪ Without associated autonomic symptoms
► Visceral pain
▪ Dull pain, transitory, growing gradually
▪ Not localized, reffered
▪ Felt in median line
▪ With autonomic symptoms
► Reffered pain
▪ Felt in distant place from viscera’s damage
Causes of acute organic abdominal pain

► Abdominal cavity diseases

► Diseases of organs localized outside abdominal

cavity

► Metabolic and endocrine disorders

► Exogenous intoxication
 Causes of acute abdominal pain
Visceral cavity diseases
► Inflammation ► Mechanical ileus
- acute appendicitis - incarcerated hernia
- peritonitis - intestinal torsion
- acute pancreatitis - obstruction of biliary tract
- acute cholecystitis - nephrolithiasis
- diverticulitis - bowel obstruction
- IBD
- infectious bowel disease ► Rupture of organs
- Schőnlein-Henoch disease
- urinary tract infection - rupture / splenic infarction
- extrauterine pregnancy
- aortic aneurysm
► Perfusion disorders ► Other
- acute haemostasis in liver
- spleen vein trombosis - tumor of ovarium, uterus
- acute portal hypertension - hemolytic crisis
- splenic infarction
- mesenteric infarction
 Acute abdominal pain
► Surgical diseases
✓ ileus
✓ intussusception
✓ torsion
of the testis
✓ appendicitis
 Causes of acute abdominal pain
Diseases of organs localized outside
abdominal cavity

► Organs in thorax
- onset of infectious diseases
- angina
- pneumonia
- esophagitis
- achalasia cardiae
- heart problem

► Torsion of testis
► Toxic, metabolic causes
 Causes of acute abdominal pain

Metabolic and endocrine disorders

► Endocrine disorders
- diabetic acidosis
- adrenal crisis
- pheochromocytoma
► Uraemia

Exogenous intoxication of caustic substances

Chronic abdominal pain
 Chronic abdominal pain in children
► Approximately 2% to 4% of all pediatric outpatient visit are
due to chronic or recurrent abdominal pain
Galler J.R., Neustein S., Walker W.A. Clinical aspects of recurrent abdominal pain in children. Adv. Pediatr. 1980;27:31-
53

► It effects about 10- 40% of children

Faull C., Nicol A.R.: Abdominal pain in six-year-olds: An epidemiological study in a new town. J. Clin. Psychol.
Psychiatry Allied Dis., 1986, 27, 251

► In only small number of children (33%) chronic abdominal

pain is caused by an organic disease. In most children
(67%) the pain is functional.
Hyams J.S., Burke G., Davis P.M., Rzepski B., Andrulonis P.A.: Abdominal pain and irritable bowel syndrome in
adolescents: a community-based study. J. Pediatr., 1996; 129(2):220-226.
 Chronic abdominal pain
Definition:

► At least three episodes over at least 3 months

interfering with function
Apley J.: The child with recurrent abdominal pain. Pediatric Clinics of North
America, 1967

► Required duration of symptoms:

- it allows 4 weeks to establish acute disease
- it allows next 4 weeks to establish chronicity

Rasquin A., Di Lorenzo C., Forbes D., Guiraldes E. Hyams J.S., Staiano A., Walker
L.S.:
Childhood functional gastrointestinal disorders: child/adolescent. Gastroenterology,
2006
Chronic abdominal pain - pathogenesis
► 0rganic origin

causes: anatomic
metabolic
infectious
inflammatory
neoplastic

Cooke HJ., FASEB J., 1989

Drossman DA., Gastroenterology, 2002
Van Ginkel R.,Gastroenterology, 2001
Di Lorenzo C., J. Pediatr., 2001
Differential diagnosis of recurrent abdominal pain
in children aged 4-10 years
OFTEN, PREVALENCE > 1/100 RARE, PREVALENCE <
► Functional abdominal pain 1/100
► Sickle cell anaemia
► Constipation
► Malposition of gut
► Irritable bowel syndrome
► Bile cyst
► Colitis due to infection
► Eosinophilic esophagitis
► Infection of urinary system ► Postoperative adhesions
► Parasitosis ► Urolithiasis
► Celiac disease ► Schonlein disease
Differential diagnosis of recurrent abdominal pain
in children aged 10-18 years

OFTEN, PREVALENCE > 1/100 RARE, PREVALENCE < 1/100

► Chronic appendicitis
► Irritable bowel syndrome
► Sickle cell anaemia
► Functional abdominal pain
► Cysts of bile ducts
► Abdominal migraine
► Chronic pancreatitis
► Lactose intolerance
► Postoperative adhesions
► Gastritis
► Cholelithiasis
► Colitis due to
infection/Inflammatory bowel ► Eosinophilic esophagitis
disease ► Dyskinesia of biliary tract
► Painful menses ► Urolithiasis
► Parasitosis ► Polyarteritis nodosa
► Chronic hepatitis ► Systemic lupus
erythematosus
► Superior mesenteric artery
syndrome
► Mesenteric vein obstruction
 Organic causes of abdominal pain
► Chronic gastritis, duodenitis
► Gastric ulcer disease, duodenum ulcer disease
► Gastro-esophageal reflux
► Pancreatitis
► Ileus
► Chronic inflammatory bowel disease
► Lactose intolerance
► Food allergy
► Urinary tract infection
► Nephrolithiasis
► Parasitosis
► Ovaritis and salpingitis
► Metabolic disorders (eg. porphyria, acetonemic vomitus)
► Respiratory tract diseases (eg: infectious of upper respiratory tract –
pharyngitis; pneumonia)
 Methodology
CHRONIC
ABDOMINAL PAIN

PATIENT’S HISTORY
+PHYSICAL EXAMINATION

ALARM SYMPTOMS (+) ALARM SYMPTOMS (-)

DIAGNOSTICS BASIC DIAGNOSTICS

INVESTIGATION
INVESTIGATIONS

POSITIVE RESULTS (+) NEGATIVE RESULTS(-)

POSITIVE RSEULTS
ORYGINAL
QUESTIONARE

ORGANIC CLASSIFICATION OF FUNCTIONAL

ABDOMINAL PAIN ABDOMINAL DISORDERS CONNECTED
WITH ABDOMINAL PAIN
 Abdominal pain
► Localization
► Character (ie, dull, colicky, burning, gnawing)
► Frequency
► Time of duration
► Time of day when pain occurs
► Radiation
► Factors that aggravate or resolve symptoms
► Other symptoms (vomiting, bleeding, weight loss,
diarrhea, constipation)
Alarm symptoms, signs and features in children and
adolescents with noncyclic abdominal Pain-Related FGID

► Persisten right upper or right lower quadrant pain

► Dysphagia
► Persistent vomiting
► Gastrointestinal blood loss
► Nocturnal diarrhea
► Family history of inflammatory bowel disease, celiac disease, or peptic
ulcer disease
► Pain that wakes the child from sleep
► Arthritis
► Perirectal disease
► Involuntary weight loss
► Deceleration of linear growth
► Delayed puberty
► Unexplained fever
Differentiation functional from
organic causes of abdominal
pain
 Medical history
► When did it start? ► What makes the pain better?
▪ F – Concurrent stressful event in life ▪ F – No relationship to interventions
▪ O – Trauma or travel ▪ O – medications or re-positioning
► Where is it located? ► Is the pain intermittent or constant
▪ F – Peri-umbilical or epigastric ▪ F – Constant
▪ O – Well localized away from umbilicus ▪ O – Intermittent
► How long does it last? ► Association with other signs or
▪ F – Prolonged duration with no clear signs symptoms?
▪ O – Variable ▪ F – Signs of anxiety, family history
► What does the pain feel like? ▪ O – Association with red flags
▪ F – Vague, gradual onset, variable severity
▪ O – Isolated, sudden onset

F- functional
O- organic
Alarm symptoms indicating organic cause of reccurent
abdominal pain (1)

► Pain- localized in extraumbilical area, radiating to shoulders

- duodenal ulcer, gastric ulcer, gastroduodenitis
- cholelithiasis
- pancreatitis
► Loss of weight, deceleration of linear growth, delayed puberty
- celiac disease
- inflammatory bowel disease
► Change in frequency and form of stools, gastrointestinal blood
loss, presence of occult blood in stool
- inflammatory bowel disease
- celiac disease
- enterocolitis, gastroduodenitis
Alarm symptoms indicating organic cause of reccurent
abdominal pain (2)
► Extraintestinal symptoms- fever, rash, uvenitis, arthritis,
jaundice, problems with passing water
- inflammatory bowel disease
- systemic lupus erythematosus

► Foreign travel, exposure to contaminated water or milk

- hepatitis
- lambliosis
- yersiniosis

► Positive family history for inflammatory bowel disease, celiac

disease, stomach or duodenal ulcer
- inflammatory bowel disease
- celiac disease
- stomach or duodenal ulcer
Alarm symptoms indicating organic cause of reccurent
abdominal pain (3)

► Immune deficiency- acquired, inherent, after transplantation

- infection of opportunistic pathogen
- very early onset IBD

► Drugs- nonsteroidal anti-inflammatory drugs

- gastroduodenitis, gastric or duodenal ulcer

► Laboratory tests- anaemia, elevated erythrocyte

sedimentation rate, parasites in stool
- inflammatory bowel disease
- celiac disease
- parasitosis

► Age under 4 years

 Abdominal pain
► Periumbilical area- functional abdominal pain
► Pain localized in right lower abdominal quadrant +
Blumberg syndrome + muscle guarding- chronic
appendicitis, Crohn’s disease, Yersinia infection
► Pain localized in epigastric area radiating to the
shoulders- pancreatitis
► Pain localized in right upper abdominal quadrant,
radiating to right shoulder + enlarged, tender liver-
cholecystolithiasis, hepatitis
► Murphy syndrome + fever- cholecystitis
 Change of frequency and form of stool
► Steatorrhoea- malabsorption (ie, due to pancreatitis, celiac disease)

► Melaena- bleeding from gastrointestinal tract proximally to Treitz

ligament (ie, esophagitis, Mallory-Weiss syndrome, gastroduodenitis,
stomach or duodenal ulcer)

► Red coloured stool (hematochezia)- bleeding from gastrointestinal tract

distally to Treitz ligament (hemorrhoids, fissures, inflammatory bowel
disease- Crohn’s disease, ulcerative colitis, colitis due to infections)

► Hard stools- constipation, irritable bowel syndrome

► Loose stools- viral or bacterial infection, parasitosis, lactose intolerance,

celiac disease, irritable bowel syndrome, inflammatory bowel disease

► Loose/hard stools- irritable bowel syndrome

► Loose, bloody stools- infection of gastrointestinal tract, inflammatory

bowel disease
 Abdominal pain + blood in the vomitus

► Newborn
▪ ingested maternal blood, drug induced, ulcer

► Toddler
▪ ulcers, gastritis, esophagitis

►2 to 6 years
▪ ulcers, gastritis, esophagitis, varices

►6 years and older

▪ ulcers, gastritis, esophagitis, varices
 Abdominal pain and blood in the stool

► Newborn
▪ ingested maternal blood, formula intolerance, necrotizing
enterocolitis, milk allergy

► Toddler
▪ anal fissures, infectious colitis, Meckel’s diverticulitis, milk allergy,
juvenile polyps, intussusception

►2 to 6 years
▪ infectious colitis, juvenile polyps, anal fissures, intussusception,
Meckel’s diverticulitis, IBD

►6 years and older

▪ IBD, infectious colitis, polyps, hemorrhoids, Meckel’s diverticulitis
 Examinations:
► Complete blood count with white blood smear
► ESR, CRP
► Aminotranspherase, lipase level
► Bilirubin, alcalic phosphatase and
gammaalutamylotranspeptidase (GGTP) level
► Protein and albumin level
► H.pylori antigen in stool
► IgE level
► Urine test
► Occult blood in stool
► Stool culture
► Parasites in stool
► Ultrasonographic examination
► Hydrogen brath test for lactose intolerance
 Other diagnostisc examinations

► Food allergy estimation

► Gastroscopy, rectoscopy, colonoscopy with histopathological
examination
► pH-metria of espohagus, pH-impedance
► cystography, urography
► Radiological examinations (with or without contrast) of GI
tract
► Jejunum biopsy
► Gynecological examination
► Neurological examination
► Endocrine, metabolic or other examination
 IV rome criteria
Functional gastrointestinal disorders (2016)

A. Esophageal disorders
B. Gastroduodenal disoreders
C. Bowel disorders
D. Centally mediated disorders of gastrointestinal pain
E. Gallbladder and sphincter of Oddi disorders
F. Anorectal disorders
G. Childhood functional GI disorders: neonate/toddler
H. Childhood functional GI disorders: child/adolescent
 IV rome criteria
Childhood functional GI disorders: child/adolescent

H1. Functional nausea and vomiting disorders

H1a. Cyclic vomiting syndrome
H1b. Functional nausea and functional vomiting
H1c. Rumination syndrome
H1d. Aerophagia
H2. Functional abdominal pain dysorders
H2a. Functional dyspepsia
H2b. Irritable bowel syndroem
H2c. Abdominal migraine
H2d. Functional abdominal pain
H3. Functional defecation disorders
H3a. Functional constipation
H3b. Nonretentive fecal incontinence
 Functional abdominal pain disorders

• variable combination of chronic or recurrent

gastrointestinal symptoms (abdominal pain-
related) without evidence of pathologic condition
such as:
- anatomic
- metabolic
- inflammatory
- infectious
- neoplastic disease
 Patophysiology of FGIDs

► Genetic predispositions
► Early family environment
► Psychosocial factors
► Abnormal motility
► Visceral hypersensitivity
► Inflammation
► Altered bacterial flora
Chronic abdominal pain - pathogenesis

Enteral nervous system disorders

Disturbance of communication between CNS and intestine (ENS – digestive
system brain)
- motoric disorders ???
- emotional problems
- unproper intestine reaction on physiological stimulation (meal,
hormonal changes) and pathological stimulation (inflammatory process)
or stress (parents separtion, school)
- visceral hypersensitivity on pain – lower level of feeling pain as a
consequence of changes in preassure in the lumen of intestine
 Functional abdominal pain and
visceral hypersensitivity
Inflammation of mucosa

Infection Allergy IBD

Sensitization of ascending neurofibres

Visceral hypersensitivity

Talley NJ., Lancet, 2002

H2. Functional Abdominal Pain
Disorders
H2. Functional abdominal pain disorders

H2a. Functional dyspepsia

H2a1. Postprandial distress syndrome
H2a2. Epigastric pain syndrome

H2b. Irritable bowel syndrome

H2c. Abdominal migraine
H2d. Unspecific childhood functional abdominal pain
 H2a. Functional Dyspepsia
Diagnostic criteria:

► Must include 1 or more of the following bothersome symptoms at least 4

days per month:

1. Postprandial fullness
2. Early satiation
3. Epigastric pain or burning not associated with
defecation
4. After appropriate evaluation, the symptoms cannot be
fully explained by another medical condition.

* Criteria fulfilled at least 4 days per month for at least 2 months before diagnosis
 H2a. Functional Dyspepsia
The following subtypes are now adopted:

1. Postprandial distress syndrome:

-includes bothersome postprandial fullness or early
satiation that prevents finishing a regular meal

-supportive features include upper abdominal bloating,

postprandial nausea, or excessive belching
 H2a. Functional Dyspepsia

2. Epigastric pain syndrome

- includes all of the following: bothersome (severe enough
to interfere with normal activities) pain or burning
localized to the epigastrium
- the pain is not generalized or localized to other
abdominal or chest regions and is not relieved by
defecation or passage of flatus
- supportive criteria can include:
(a) burning quality of the pain but without a retrosternal component
(b) the pain commonly induced or relieved by ingestion of a meal
but may occur while fasting.
 H2a. Functional dyspepsia

► Physiological features:
- disordered gastric myoelectrical activity
(electrogastrography)
- delayed gastric emptying (radionuclide
imaging/ultrasound examination)
- altered antroduodenal motility (antroduodenal
manometry)
- reduced gastric volume response to feeding
- visceral hypersensitivity
 H2a. Functional dyspepsia

► Treatment:
- avoidance of nonsteroidal antinflammatory agents and
foods that aggravate symptoms (eg, caffeine, spicy and
fatty food)

- antisecretory agents (H2-blockers, proton pump

inhibitors) – for pain predominant symptoms

- prokinetics (metoclopramide, erythromycin, cisapride)

to reduce nausea, bloating and early satiety
 H2b. Irritable bowel syndrome
Diagnostic criteria:
Must include all of the following:
1. Abdominal pain at least 4 days per month associated with one or more
of the following:
a. related to defecation
b. a change in frequency of stool
c. a change in form (appearance) of stool
2. In children with constipation, the pain does not resolve with resolution
of the constipation (children in whom the pain resolves have functional
constipation, not irritable bowel syndrome)
3. After appropriate evaluation, the symptoms cannot be fully explained
by another medical condition

Criteria fulfilled for at least 2 months before diagnosis.

 H2b. Irritable bowel syndrome

► Symptoms that support diagnosis:

1. abnormal stool frequency (4 or more stools per day and 2 or less

stools per week)

2. abnormal stool form (lump/hard or loose/watery stool)

3. abnormal stool passage (straining, urgency, or feeling of

incomplete evacuation)

4. bloating or feeling of abdominal distention

 H2b. Irritable bowel syndrome

► Subtypes:

1. IBS with constipation

2. IBS with diarrhea

3. IBS with constipation and diarrhea

4. unspecified IBS
 H2b. Irritable bowel syndrome
clinical evaluation

Treatment:
► Dietary interventions alter motility or stool form
(supplementation with dietary fiber)

► A trial of lactose restriction (especially when lactose

intolerance is confirmed by hydrogen breath test)

► Anticholinergic drugs, enteric-coated peppermint oil

capsules (calcium channel blockade in smooth muscles)
 H2b. Irritable bowel syndrome
clinical evaluation
➢ IBS with diarrhea → exclude infection, celiac disease,
carbohydrate malabsorption, and inflammatory bowel
disease

► The greater the number of alarm symptoms present, the

greater the likelihood of an organic disease

► Determination of fecal calprotectin is increasingly being

utilized as a noninvasive screen for intestinal mucosal
inflammation and appears to be superior to standard
testing such as C-reactive protein.
 H2c. Abdominal migraine
Diagnostic criteria:
Must include all of the following occuring at least twice:
1. Paroxysmal episodes of intense, acute periumbilical, middline or
diffuse abdominal pain that lasts for 1 hour or more
2. Episodes are separated by weeks to months
3. The pain interferes with normal activities
4. Stereotypical pattern and symptoms in the indyvidual patient
5. The pain is associated with 2 or more of the following:
a. Anorexia
b. Nausea
c. Vomiting
d. Headache
e. Photophobia
f. Pallor
6. After appropriate evaluation, the symptoms cannot be fully explained
by another medical condition
Criteria fulfilled for at least 6 months before diagnosis
 H2c. Abdominal migraine
► Supportive criteria include a family history of migraine
and a history of motion sickness
► Obstructive process in the urologic or digestive tracts,
biliary tract disease, recurrent pancreatitis, familial
Mediterranean fever, and metabolic disorders should be
excluded
► A favorable response to medications used to prophylaxis
of migraine headache supports the diagnosis
► Treatment:
- potential triggers should be avoided: caffeine-
containing foods, prolonged fasting, altered sleep
pattern, exposure to flickering or glaring lights
- prophylactic drug therapy: pizotifen, propranolol,
cyproheptadine, or sumatriptan
 H2d. Unspecific Functional Abdominal Pain

Diagnostic criteria:
Must include all of the following:
1. Episodic or continuous abdominal pain that does not occur
solely during physiologic events (eating, menses)

2. Insufficient criteria for other FGIDs

3. After appropriate evaluation, the symptoms cannot be fully

explained by another medical condition

Criteria fulfilled at least 4 days for at least 2 months before diagnosis

 H2d. Chilhood Functional Abdominal Pain
H2d1. Chilhood Functional Abdominal Pain
Syndrome
► Limited and reasonable screening
includes:
- complete blood cell count
- erythrocyte sedimentation rate
- C-reactive protein
- urianlisis
- urine culture
- chemical profiles (liver, kidney, pancreas)
- stool culture, occult blood test
- examination for ova and parasites
- breath hydrogen testing
- ultrasonographic examination
 Lactose intolerance

► Lactose is main carbohydrate of human and other

mammals milk → „milk sugar”

► In healthy children lactose is digested (hydrolysed) in small

intestine by lactase (ß- lactosidase – enzyme of
enterocytes brush) into glucose and galactose

► Monosaccharides are absorbed via mucosa of small

intestne by active transport
 Lactose intolerance

Clinical symptoms:
► dyscomfort in abdomen
► flatulence
► abdominal pain
► diarrhoea
► vomitus
 Lactose intolerance
Diagnosis:
► Hydrogen breath test- is higly specific and sensitive test to
identify lactose malabsorption

► Detecable increases in hydrogen and methane arising from

bacterial fermentation of undigested lactose show up in
breath within one or two hours after exposure
 Hydrogen breath test
► Prior to test individuals fast for at least 12 hours

► At the start of the test, the concentration of hydrogen is

measured in sample of breath

► Then the individual ingests a small amount of test sugar and

concentration of hydrogen is measured in additional samples of
breath, which are collected every 15 minutes for three and up to
five hours
 Hydrogen breath test
► If the carbohydrates are completely absorbed in the small bowel,
there is no change of the level of expired hydrogen

► An increase of 20pmm of hydrogen throughout the test indicates

the significant malabsorption of lactose

► If there is small bowel bacterial overgrowth, the carbohydrate load

will be fermented in the small intestines giving rise to:
- an elevated baseline hydrogen level
- a double peak configuration to the hydrogen line
 Treatment:
► Diet:
- elimination of lactose
- lower lactose dosage in diet (cheeses, fermented
milk)
► Farmacotherapy:
- Lactase enzyme 15-30 min before milk meal
 Lambliosis
► Giardia lamblia is parasite – localized in upper part of GI
► Source of invasion – ill people, animals – dogs, cats
► Clinical symptoms: abdominal pain in epigastrium, lack of apetite,
nausea, vomitus, diarrhoea, lost of weight, pyrexia
► diagnosis: antigens of Giardia lamblia in stool (ELISA)
► treatment: metronidazol 15 mg/kg 7 days, tinidazol 50md.kg 1 dosage
7days ornitazoksamid 3 days
 Yersiniosis
► Gram (-) bacillus, family Enterobacteriaceae

► Reservoir: animals; infection after eating infected food as milk, meat (usually
pork), vegetables and fruits

► Clinical symptoms: intestine type, pseudoappendicitis, general infection,

abdominal type- fever, diarrhoea, bloody diarrhoea

► Diagnosis:
- immunoensymatic reaction (ELISA) – antibodies in classes IgA, IgG, IgM for
Yersinia antigens
- bacteriological culture of stool

► Treatment: III gen. cefalosporine, piperacylin, aminoglicoside, tetracyclin,

fluorochinolon, trimetoprim-sulfametoksazol