Gut Problems
Recurrent abdominal pain
Chronic or recurrent abdominal pain (RAP) is one of the most commonly encountered events in childhood interfering in the normal lifestyle of up to 10-15 % of all children at some point and described first by Apley who emphasised the role of a thorough history and examination. (Apley 1958) A reasonable definition might be “at least 3 episodes of pain, severe enough to affect normal activity, over a period of greater than 3 months, and continuing in the year prior to investigation”. Apley suggested that less than 10% had organic disease as a cause, especially if the site was peri-umbilical – however this has recently been challenged in light of the increased yield of specific organic diagnoses afforded by modern investigative tools and with the recognition of the potential importance of newly recognised aetiologies in its pathogenesis. (Farrell M 1993)
The pyschogenic origin of the syndrome will be left to the next speaker and this review will concern itself with potential organic causes.
Three clinical patterns have been described: 1) paroxysmal peri-umbilical or epigastric pain; 2) “dyspepsia”, an ill-defined upper abdominal discomfort, frequently associated with bloating, nausea, early satiety, and occasionally vomiting; and 3) lower abdominal pains with alteration in bowel patterns. (Boyle J 1996) The latter may have some similarities with adult irritable bowel syndrome. (Hyams J 1995) Autonomic dysfunction may be an important participant in the path-aetiology of RAP and this may represent a common neural transmission disorder in children with migraine. (Battistella 1992) Abdominal migraine is an entity whose existence is open to debate, however a trial of pizotifen led to an improvement in a group of children diagnosed as having “abdominal migraine”. (Symon N 1995) Altered intestinal motility may exist in the stomach and duodenum in a proportion of patients manifest as morefrequent migrating motor complexes of higher amplitude, shorter duration and slower propagation. (Pineiro-Carrero V 1988)
Controversy also continues regarding the role of upper GI inflammation in the pathogenesis of RAP. Gastro-oesophageal reflux was documented in 14/25 patients with RAP by van de Meer but no endoscopic biopsies were obtained. (van de Meer 1992) The same author had also studied intestinal permeability in 106 children with RAP compared with controls and duodenitis was reported in 28/39 who underwent endoscopy (van de Meer 1990) – however the importance of these findings in relation to pathogenesis is not clear.
The role of helicobacter pylori in the absence of associated duodenal ulceration (DU) remains in doubt, and will be discussed in the light of many recent studies (Fiodorek 1992, Ashorn 1993, Raymond 1994, Chong 1995), but a meta-analysis of 45 studies (including some adult studies) by Macarthur in 1995 concluded that a strong association exists between H pylori and DU, a moderate association with gastritis, and a very weak or zero association with RAP. (Macarthur 1995)
Lactose intolerance may have a role in RAP in some children and was found by Barr et al in 40% of RAP sufferers, 70% of whom experienced resolution of symptoms on a lactose-free diet, however Lebenthal suggested that this was not the direct cause of the pain. (Barr 1979, Lebenthal 1981)
There are no prospective studies of the outcome of RAP, but once a definitive diagnosis of a functional origin of RAP has been made it is unusual for a subsequent organic cause to be found. About 30% of RAP sufferers develop other chronic complaints as adults.
Apley J, Naish N. Recurrent abdominal pains: a field survey of 1000 children. Arch Dis Child 1958;33:165-70.
Ashorn M et al. Upper gastrointestinal endoscopy in recurrent abdominal pain of childhood. J Pediatr Gastroenterol Nutr 1993;16(3):273-77.
Barr R et al. Recurrent abdominal pain in children due tt lactose intolerance: A prospective study. NEJM 1979;300:1449-52.
Boyle J. Chronic abdominal pain. In: Walker A, Durie P, Hamilton J, Walker-Smith J, Watkins J eds. Pediatric Gastrointestinal Disease. St Louis: Mosby-Year Book Inc. 1996.
Chong S et al. Helicobacter pylori infection in recurrent abdominal pain in childhood: comparison of diagnostic tests and therapy. Pediatr 1995;96(2):211-15.
Farrell M. Dr Apley meets Helicobacter pylori. J Pediatr Gastroenterol Nutr 1993;16(2):118-19.
Fioderek S et al. The role of Helicobacter pylori in recurrent functional abdominal pain in children. Am J Gastroenterol 1992;87(3):347-49.
Hyams J et al. Characterisation of symptoms in children with recurrent abdominal pain: resemblance to irritable bowel syndrome. J Pediatr Gastroenterol Nutr 1995;20:209-14.
Lebenthal E et al. Recurrent abdominal pain and lactose malabsorption in children. Pediatr 1981;67:828-32.
Macarthur C et al. Helicobacter pylori, gastroduodenal disease and recurrent abdominal pain in children. JAMA 1995;273(9):729-34.
Pineiro-Carrero V et al. Abnormal gastroduodenal motility in children and adolescents with recurrent functional abdominal pain. J Pediatr 1988;113:820-25.
Symon D and Russell G. Double blind placebo controlled trial of pizotifen syrup in the treatment of abdominal migraine. Arch Dis Child 1995;72:48-50.
Van de Meer et al. Abnormal small bowel permeability and duodenitis in recurrent abdominal pain. Arch Dis Child 1990;65:1311-14.
Van de Meer et al. Gastroesoophageal reflux in children with recurrent abdominal pain. Acta Pediatr 1992;81:137-40.
