Abdominal pain, recurrent in children

Probability diagnosis

Non-organic recurrent abdominal pain (RAP)

Constipation

Recurrent viral illness (mesenteric adenitis)

Serious disorders not to be missed

Infection:

• recurrent urinary infection/ureteric reflux

• parasitic infection of gut (e.g. pinworm, strongyloides, whipworm)

• tuberculosis

Cancer:

• colon cancer (rare)

Other:

• hydronephrosis

Pitfalls (often missed)

Inflammatory bowel disease (IBD)

Childhood migraine equivalent (periodic syndrome)

Food allergy (incl. lactose intolerance)

Gastritis/oesophageal reflux

Rarities:

• Meckel’s diverticulum

• Temporal lobe epilepsy

• Sickle cell disease

  • Henoch-Schönlein purpura

  • irritable bowel syndrome (IBS)

Masquerades checklist

Depression

Diabetes

Drugs

Spinal dysfunction

UTI

Is the patient trying to tell me something?

Highly likely as non-organic (functional) RAP is common. Consider anxiety and depression.

Key history

RAP, which is three distinct episodes of abdominal pain over 3 or more months, occurs in 10% of school-aged children. In only 5–10% will an organic cause be found. A very careful history includes the site, radiation, onset, duration and periodicity of the pain, and aggravating, relieving and associated factors. Ask if the pain wakes the child at night, interferes with activities and is associated with anorexia, vomiting, diarrhoea, dysuria or weight loss, or is related to food. Family history of abdominal pain, migraine, IBD or IBS. Enquire about social history, school difficulties, stressors and anxiety.

Key examination

• Usual systematic examination including rectal examination

• Growth chart is important

Key investigations

• Urine analysis and M&C

• FBE/ESR/CRP

• Plain abdominal X-ray to assess any faecal retention

• Ultrasound for suspected kidney tract or ovarian pathology

Diagnostic tips

• Avoid the trap of excessive investigations.

• In approximately 90% of RAP patients referred to hospital no underlying cause is found, but take the problem seriously.

• Talk to the child alone, if possible.

• Organic disease is indicated by pain distant from the umbilicus and/or waking with pain at night, associated with vomiting, loss of appetite or weight, change in bowel habit, failure to thrive and inability to undertake normal activities.