Abdominal Pain in Children

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Abdominal Pain in Children

• Tina Williams
• FPH

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• Acute
• Infective/Inflammatory
• Obstructive
• Chronic or Recurrent
• Organic
• Functional / Non-organic

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Acute - Inflammatory

• Infections . Viral or bacterial GE
• . Gastritis may be part of systemic
  illness
• . Appendicitis
• . Mesenteric Adenitis
• . UTIs
• . Psoas abscess
• . Pneumonias
• . Pancreatitis

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Obstructive

• Renal calculi

• Constipation
• Malrotations
• Volvolus
• Intussuception
• Biliary calculi, cholecystitis

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Other Acute Causes

• DKA, Shock
• Referred Hip Pain
• Testicular torsion
• Henoch Schonlein Purpura

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Recurrent Abdominal Pain
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Recurrent Abdominal Pain

• Episodes of Abdominal Pain occurring at
• least monthly for 3 consecutive months with
• a severity that interrupts normal functioning
• John Apley, Bristol 1958

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Magnitude of the problem

• Huge percentage of new GP referrals in POPD
• 15 of children over age 6yrs
• About 10 of them seek medical attention
• Majority of teenagers, no organic cause

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• RAP defined by Apley 1958 Bristol
• 8 organic cause found
• 10 15 from some early studies
• Of 103 children referred to a tertiary GI Unit
• 30 organic pathologies
• 50 non-organic pain, half fulfilled criteria for
  IBS (36 of total) El-Matary et al 2004 Bristol
• Not representative

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Functional/Non-Organic RAP

• Usually periumbilical plt0.002-Bristol
• Can be epigastric or suprapubic
• Cramps, IBS symptoms in 30 of these children
• Anxiety related
• Pain alleviated by defaecation plt0.04

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Organic RAP - Red Flags

• lt 6 years
• Growth / Weight affected
• Vomiting
• Fever
• Diarrhoea
• Disturbed sleep plt0.01- Bristol 2004
• Abdominal tenderness plt0.005

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Organic Causes - GIT

• Constipation
• Food intolerance
• Lactose Intolerance/ Sucrase-Isomaltase def.
• Peptic Ulcer Disease/
• H.pylori gastritis Finland J Clin Gastr Sep
  2004
• Oesophagitis
• Coeliac Disease
• Meckels diverticulum
• Recurrent intussuception
• Malrotation

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Gall Bladder / Pancreatic

• Cholelithiasis, cholecystitis
• Choledochal Cyst
• Pancreatitis
• Genitourinary
• UTI
• Urolithiasis
• Wilms
• Pelvic Inflammatory Disease - Chlamydia
• Pregnancy related

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Miscellaneous

• Abd migraine
• Sickle cell crisis
• Pb, Fe poisoning
• HSP
• Familial Mediterranean fever

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Pathophysiology of Abdominal Pain
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Pathophysiology of Abdominal Pain

• Peripheral Nociceptors in GIT
• Cell bodies of afferent fibres in Dorsal Root
  ganglia of spinal cord
• Medulla, Midbrain, Thalami
• Cortical Pain Perception

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Localisation of Pain

• Visceral Pain felt in corresponding dermatome
• Liver, Pancreas, Biliary tree, stomach, upper
  bowel - Epigastrium
• Distal SB, Caecum, Appendix, Prox
  colon - umbilical
• Distal LB, Urinary tract, pelvic
  organs - suprapubic

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Diagnosis

• History Examination
• Dietary
• Family
• Psychosocial
• Red flags of organic disease

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Investigations I

• FBC, ESR, CRP, Amylase
• Coeliac serology
• H.pylori serology/ Urea breath test
• Urine mcs
• Stool mcs, OCP
• Abd USS

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Investigations II - Specific

• Stool for occult blood
• Stool Reducing substances
• Upper GI contrast studies
• ?? Empirical PPIs, H2 blockers
• Endoscopy
• Meckels scan
• Wireless capsule

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Management

• Organic Treat cause identified
• Functional
• Multidisciplinary
• Dietician Dietary exclusions for 6-8 wks
• Psychologists
• School
• Play therapists
• Medical Antispasmodics, Bulk forming laxatives,
  TCAs, ? Pizotifen

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Irritable Bowel Syndrome

• El-Matary et al Bristol 2004
• 36 of referred children fulfilled criteria
• 51 of functional abd pain
• ROME Classification
• Diagnostic criteria for functional
  gastrointestinal disorders

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ROME Classifications

• 1989 Working Team Report
• 1995 ROME I
• 2000 ROME II In use
• 2006 ROME III

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ROME II

• At least 12 weeks of abd. Discomfort or pain in
  last 12 months with at least 2 of the following
• Relief with defaecation and/or
• Onset assoc with change in stool freq. and/or
• Onset assoc. with change in form or appearance of
  stools
• In the absence of organic disease

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Other features of IBS

• Not essential but supportive of diagnosis
• Abnormal stool freq
• Abnormal stool form
• Abnormal stool passage
• Passage of mucous
• Bloating
• Lower abdominal cramps
• Family history/ somatisation

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Management

• MDT approach
• Rehabilitation school physiotherapy
• Drugs as adjunct
• Antispasmodics Mebeverine
• Laxatives bulk forming - if required
• Amytryptiline, Imipramine - dampen afferent
  neurones
• Probiotics

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Summary

• Recurrent abdominal pain over the age of 6 yrs
  more often than not is functional
• Remember Red flags of organic disease
• Basic investigations required
• Multidisciplinary approach to management

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Questions?