Recurrent Abdominal Pain Syndrome

Aka: Recurrent Abdominal Pain Syndrome, Functional Abdominal Pain in Children

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II. Epidemiology

  1. Ages 5 - 16 years (peaks at age 9 years)
  2. Prevalence
    1. School age children: 10-15%
    2. Pre-teen and teenage children: 20%

III. Pathophysiology

  1. Autonomic Dysfunction with altered intestinal motility
  2. Hyperalgesia and altered sensory pathways

IV. Causes

  1. Functional Abdominal Pain in most cases
    1. Functional Dyspepsia
      1. Postprandial fullness, early satiety, Epigastric Pain on 4 days per month for 2 months
      2. Not associated with Defecation
    2. Abdominal Migraine
      1. Two episodes in 6 months of intense Abdominal Pain lasting >1 hour
      2. Associated with >=2 symptoms: Anorexia, Nausea, Vomiting, Headache, photophobia, pallor
    3. Functional Abdominal Pain NOS
      1. Abdominal Pain 4 times per month for at least 2 months
      2. Not associated with eating or Menses, and not Dyspepsia, irritable bowel, abdominal Migraine
    4. Irritable Bowel Syndrome
    5. Functional Constipation
    6. Cyclical Vomiting
    7. Adolescent Rumination Syndrome
  2. Organic cause in 3-8% of cases (see differential diagnosis as below)
    1. See Abdominal Pain Causes

V. Diagnosis

  1. Pain occurs at 3 bouts of pain for at least 3 months
  2. Severe enough to affect daily activity and school attendance

VI. Risk Factors

  1. School Phobia (and related stresses) closely associated
  2. Parents (especially mothers) often have Anxiety Disorder or Major Depression

VII. Associated Conditions

  1. Anorexia Nervosa

VIII. Symptoms

  1. Nonspecific recurrent Abdominal Pain
    1. Typically periumbilical or epigastric, ill-defined pain
    2. Not related to meals
    3. Not related to movement or activity
  2. Nausea or Vomiting may be present depending on type
  3. No Dysuria

IX. Signs

  1. Normal growth curves (or Body Mass Index for age)
  2. Well appearing child
  3. Exam is often normal or mild abdominal tenderness
    1. Exam should include pelvic and scrotal exam in adolescents

X. Signs: Red flags

  1. Pain location distant from Umbilicus (esp. RUQ, lower quadrants)
  2. Pain that awakens child at night
  3. Erythrocyte Sedimentation Rate (ESR) or C-Reactive Protein (C-RP) elevated
  4. Family History of Inflammatory Bowel Disease or Celiac Sprue
  5. Unintentional Weight Loss
  6. Dysphagia
  7. Decreased linear growth
  8. Delayed Puberty
  9. Chronic, severe or nocturnal Diarrhea
  10. Blood in stool
  11. Significant Vomiting
  12. Unexplained fever

XI. Labs (Limited and focused work-up)

  1. Urinalysis
  2. Urine Pregnancy Test
  3. Complete Blood Count (CBC)
  4. Erythrocyte Sedimentation Rate (ESR)
  5. C-Reactive Protein
  6. Fecal Occult Blood
  7. Stool for Ova and Parasites for 3 samples
    1. Giardia is common cause of recurrent Abdominal Pain
  8. Sexually Transmitted Infection Testing (e.g. Gonorrhea PCR, Chlamydia PCR)
  9. Celiac Sprue Testing (e.g. IgA TTG, Total IgA)
  10. Inflammatory Bowel Disease (e.g. Fecal Calprotectin)

XII. Imaging

  1. Flat and upright abdominal XRay (KUB)
  2. Consider RUQ Ultrasound
  3. Consider pelvic Ultrasound

XIII. Diagnostics: Upper endoscopy (findings in 37% of children with RAP >1 year)

  1. Reflux Esophagitis
  2. Eosinophilic Esophagitis or Gastritis
  3. Helicobacter Pylori
  4. Celiac Sprue
  5. Hiatal Hernia
  6. Erosive Esophagitis
  7. Crohn Disease

XIV. Differential Diagnosis

  1. Crohn's Disease
  2. Peptic Ulcer Disease
  3. Carbohydrate intolerance
  4. Appendiceal colic
  5. Nephrolithiasis (Ureteropelvic junction obstruction)
  6. Giardia
  7. Blastocystis hominis
  8. Hereditary Pancreatitis
  9. Abdominal Migraine
  10. Epilepsy
  11. Gynecologic disorder
  12. Psychiatric disorder or abuse
    1. Major Depression
    2. Generalized Anxiety Disorder
    3. Sexual Abuse
    4. Physical abuse
    5. Conversion reaction

XV. Management: General Measures

  1. Avoid Medications
    1. Peppermint Oil capsule three times daily has been used
    2. Probiotics have mixed results
  2. Emphasize the patient's response to pain
  3. Involve the parents
  4. Reassure that the problem is NOT life threatening
  5. Be realistic and frank
    1. Problem may persist for extended period of time
  6. Promote full activity and a sense of health
  7. Dietary management
    1. Encourage a well balanced diet
    2. Encourage adequate hydration
    3. Encourage adequate fiber intake
      1. See Fiber supplementation
  8. Maintain school attendance
  9. Psychological management
    1. Hypnotherapy
      1. Rutten (2013) Arch Dis Child 98(4): 252-7 [PubMed]
    2. Cognitive Behavioral Therapy
      1. Gro (2013) Int J Behav Med 20(3):434-43 [PubMed]
      2. Lonergan (2016) Ir J psychol Med 33(4):251-64 [PubMed]
  10. References
    1. Rutten (2015) Pediatrics 135(3);522-35 [PubMed]

XVI. Management: Organic cause empiric management

  1. See Irritable Bowel Syndrome
  2. Treat suspected Constipation aggressively
    1. See Pediatric Constipation Management
    2. Magnesium Citrate
    3. Polyethylene Glycol (Miralax)
    4. Fleet Enema
  3. Gastroesophageal Reflux disease or Dyspepsia
    1. Proton Pump Inhibitor or H2 Antagonist trial
  4. Abdominal Migraine
    1. See Migraine Headache Management in Children
    2. Analgesics (e.g. Ibuprofen) and Antiemetics (e.g. Ondansetron)
    3. Triptans
    4. Consider Migraine Prophylaxis (e.g. Propranolol, Cyproheptadine)

XVII. Course

  1. Usually resolves by age 20 years
    1. RAP persists for a median duration of 7.5 months and for 5 years in up to 29%
  2. Irritable Bowel Syndrome may develop
    1. Functional Abdominal Pain is found in 35% of adults who had a history of RAP as a child

XVIII. Prognosis

  1. These children often get lower grades than peers

XIX. References

  1. Claudius in Majoewsky (2012) EM:RAP-C3 2(3): 3
  2. Reust (2018) Am Fam Physician 97(12): 785-93 [PubMed]
  3. Thiessen (2002) Pediatr Rev 23(2):39-46 [PubMed]

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