Chronic Abdominal Pain Done by Mohammad Amjad UQU

Chronic Abdominal Pain Classified into Organic Functional 90-95% 5-10%

Chronic Abdominal Pain at least 3 pain episodes over at least 3 months that severe enough to affect daily activity (1,3,4)

months, can be considered chronic (1) Evaluation (dilemma) Individual children differ in their perception & tolerance to abdominal pain In Clinical Practice A pain that exceeds 1 or 2 months, can be considered chronic (1)

chronic abdominal pain in children is usually a functional disorder rather than organic disease (1)

Recurrent Abdominal pain?? An episodes of pain occurring at least monthly for 3 consecutive months with a severity that interrupt a routine functioning (3) Recommend not to use this term in any literature

Organic Abdominal Pain

Organic Abdominal Pain (3,4) Causes of must be considered : Chronic constipation GERD, peptic ulcer & H. pylori Parasitic infection Inflammatory bowel disease Lactase deficiency Less common : Pancreatitis Cholelithiasis Porphyrias Abdominal epilepsy

Organic Abdominal Pain (3,4) Symptoms that suggest an organic causes: Age <6 yr Pain awake the patient from sleep Vomiting & diarrhea Relation to meals Fever Weight loose Joint symptoms family history of inflammatory bowel disease

Organic Abdominal Pain Signs that suggest an organic causes: Pain localized away from umbilicus (apley’s rule) Abdominal tenderness rectal fissures Occult blood in the stool Abnormal growth (serial growth points should be plotted) Hepatomegaly & splenomegaly Message: Specific pain suggest organic rather than functional (2)

Functional Abdominal Pain

Functional Abdominal Pain (FAP) Irritable bowel syndrome Abdominal migraine Non-ulcer dyspepsia

Functional Abdominal Pain Refers to pain that can not be explained on a structural, physiologic, or biochemical basis. (3) Important to look for possible sources of stress (i.e. school, friend & family) (5)

Functional Abdominal Pain Refers to pain that can not be explained on a structural, physiologic, or biochemical basis. (3) Important to look for possible sources of stress (i.e. school, friend & family) (5) Majority of functional abdominal pain will diagnosed as IBS (3)

Functional Abdominal Pain There is evidence that anxiety may lead to altered motility which may perceived by the child as pain??? (5) Pain typically central, around amblicus & the children are otherwise entirely well (5)

It just hurts (4) Clues: Pain that occurs in every school morning . doesn’t occurs in weekend or holiday or awaken him/her during night ??? Presence of stressor (like exam or school), Relocating or death of relative

Functional Abdominal pain In children 4 to 18 years of age with chronic abdominal pain when there are no alarm symptoms or signs, the physical examination is normal, and the stool sample tests are negative for occult blood, without the requirement of additional diagnostic evaluation (1) How to diagnose ???

Cont. (3) Clues: Most common location is periumbilical. Other location : If epigastric associated with nausea that not respond to acid-blocking medication think (nonulcer dyspepsia) If below umbilicus it usually accompanied by abdominal cramp, bloatining & distention with an altered bowel pattern think IBS

Match The Color Irritable Bowel Syndrome Dyspepsia Abdominal Maigrain abdominal pain or discomfort in the upper abdomen & not respond to acid blocking medicaton abdominal pain associated with alteration in bowel movements abdominal pain associated with anorexia, nausea, vomiting, or pallor

Match The Color Irritable Bowel Syndrome Dyspepsia Abdominal Maigrain abdominal pain or discomfort in the upper abdomen abdominal pain associated with alteration in bowel movements abdominal pain associated with anorexia, nausea, vomiting, or pallor

Match The Color Irritable Bowel Syndrome Dyspepsia Abdominal Maigrain abdominal pain or discomfort in the upper abdomen abdominal pain associated with alteration in bowel movements abdominal pain associated with anorexia, nausea, vomiting, or pallor

Match The Color Irritable Bowel Syndrome Dyspepsia Abdominal Maigrain abdominal pain or discomfort in the upper abdomen abdominal pain associated with alteration in bowel movements abdominal pain associated with anorexia, nausea, vomiting, or facial pallor + Family H/x of maigrain

If still Non-Specific?? Functional abdominal pain syndrome

No single best test (‘’the history is the best tool”) Lab Work Lab testing & procedures should be minimal & guided by clinical evaluation (3) No single best test (‘’the history is the best tool”)

Lab Work In absence of symptoms & signs it is mandatory to request urine analysis & culture (5)

Management Very important that a full history & examination are not only done, but seen to be done Examination will establish that, the child is growing normally & there are no abnormalities on examination (5)

& chronic abdominal pain is a common symptom in children. Management Explain in simple language that although the pain is real, most likely no underlying serious disease & chronic abdominal pain is a common symptom in children. like a headache, which experienced at some time by most adults, which very rarely is associated with serious disease (1) Reassure the family regarding the absence of organic disease

Management Main aim being the return to normal function (1) , (e.g. return to school) AND avoidance of causes that encourage pain behaviors (e.g. by providing attention, rest, special treatment, distraction, or medication) is equally important Relief of symptoms is a secondary goal (2)

Management Avoid overmedication Maintain an open mind in term of reassessing the diagnosis if the clinical presintation changed (3) benefit of treatment with H2 receptor agonists, supplemental fiber, or a lactose-free diet is inconclusive (2)

Prognosis (5) 50% of affected children rapidly become free of symptoms In 25%, the symptoms take some months to resolve In 25%, symptoms continue or return in adulthood

Poor prognosis Factors that have been suggested to be associated with : painful family male gender Age < 6 years at diagnosis > 6 months duration of pain before seeking treatment high levels of depression and anxiety symptoms and negative life-events

Ευχαριστώ Thank You! Dankie WAD MAHAD SAN TAHAY GADDA GUEY

Reference (1)http://www.pediatrics.org/cgi/content/full/115/3/812 (2) Up To Date, Management of the child and adolescent with chronic abdominal pain literature review for version 16.3 (3) Nelson Text Book of Pediatrics 18th edition (4) Kaplan pediatric 2008 (5)Illustrate text book of pediatrics