Case study: A case of recurrent abdominal pain in an eight-year-old boy

Dr Samar Razaq discusses the key points and when to refer in recurrent abdominal pain in an eight-year-old boy.

An eight-year-old boy presents with his third episode of abdominal pain in three months.

He has griping abdominal pains centred on the umbilicus, flatulence and repeated visits to the toilet with loose stool. Defecation seems to ease the pain for a short period.

You note that he went through a similar phase six months ago. FBC, renal function, LFTs, ESR, serum glucose, coeliac screen, urine and stool microscopy, and faecal calprotectin were normal and he had continued to gain weight satisfactorily.

His mother wants him to have a ‘scan’ as ‘something must be wrong’. These episodes are affecting his school attendance and causing stress at home. Examination reveals a systemically well child with a soft abdomen. What would you do next?

When to investigate
  • Systemically unwell child
  • Faltering growth
  • Urinary symptoms
  • Blood in faeces
  • Family history of organic disease
  • Pain waking child at night
  • Vomiting

Discussion

Recurrent abdominal pain (RAP) was first described in 1958 and the passage of more than half a century has not dulled the importance of this landmark study.1

It found that children who had RAP were more likely to be ‘highly strung, fussy, excitable, anxious, timid and apprehensive’.

The authors also observed that these children were more likely to have undue fears and to experience nocturnal enuresis, sleep disorders and appetite difficulties.

They dealt with all cases of abdominal pain as a single entity. Later studies have attempted to subclassify RAP in children, based on clinical symptoms and underlying causes.

One classification is the Rome II criteria.2 This system sets out to classify the functional GI disorders in infancy, childhood and adolescence. It identifies five entities: functional dyspepsia, irritable bowel syndrome (IBS), functional abdominal pain, abdominal migraine and aerophagia.

To make the diagnosis, these subclassifications require symptoms to be present for at least 12 weeks in the preceding 12 months (for abdominal migraine, at least three episodes in the past 12 months).

More recently, the Rome III criteria have established more subclassifications, presumably to be inclusive of more cases of undiagnosed, chronic paediatric abdominal pain.

The effect of these classifications on management of the problem is unclear and they usually have little bearing on the way cases are dealt with in general practice. They are, however, likely to be useful in specialist paediatric clinics and research.

Key points
  • Pain centred on the umbilicus is less likely to have an organic cause
  • Thorough examination and reassurance is usually sufficient for most patients
  • Faecal calprotectin testing should be carried out where inflammatory bowel disease is suspected, particularly if there is a family history

Investigations

The first step in dealing with RAP is to rule out the presence of an underlying organic problem.2
GPs now have access to a greater number of investigations than the researchers did 50 years ago.

This allows a more complete assessment of the problem, but unfortunately, may identify minor, insignificant problems, which can result in unnecessary anxiety and treatment for the child.

Organic disease is thought to account for 5-10% of cases of RAP in the community.3 However, some studies, particularly those carried out on children referred to secondary care, have found organic pathology much more common.2

This should be expected, because only children with a high suspicion of pathology are usually referred.

The mainstay of management in RAP is reassurance.3 Many parents and children will be reassured by a thorough examination and explanation. Normal initial investigations will reassure most other families. However, some may insist on further investigations, even though the clinician may be convinced all is well.

At this point, an ultrasound scan is not unreasonable if it would further reassure all parties. Others may decide on a paediatric referral instead, again for added reassurance.

Management

Once consensus on diagnosis has been achieved, therapy can be considered. Therapeutic options may be classified as pharmacological, psychosocial and dietary.

Simple analgesics may be used during flare-ups. Prophylactic analgesia in non-migrainous RAP should be avoided, because the condition fluctuates and natural pain-free days should not be attributed to the analgesic drugs.

The serotonin antagonist pizotifen has been shown to be effective in the prophylaxis of abdominal
migraine, while H2 receptor antagonists may have a role in RAP with dyspepsia.

Peppermint oil may be considered where IBS is suspected. Psychological interventions, such as CBT and family therapy, have been tried with some success in RAP. However, access to such interventions is generally limited, making it difficult for them to be routinely used.

Success with a single dietary component is unlikely and management should involve asking the child to keep a food and pain diary.

Suggestions for the addition or avoidance of certain foods can then be based on the information derived from these charts.

Lactose avoidance, increase in fibre intake and probiotics may also be recommended, although the evidence for their effectiveness is currently limited.

  • Dr Razaq is a GP in Berkshire.

References
1. Apley J, Naish N. Arch Dis Child 1958; 33: 165-70.
2. Plunkett A, Beattie RM. J R Soc Med 2005; 98: 101-6.
3. Weydert JA, Ball TM, Davis MF. Pediatr 2003; 111: e1-11.

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