2. Chronic Abdominal Pain
Done by
Mohammad Amjad
UQU

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

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

5. 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)

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

7. 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

9. Organic Abdominal Pain

10. 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

11. 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

12. 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)

14. Functional Abdominal Pain

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

16. 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)

19. 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)

20. 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)

21. 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

22. 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 ???

23. 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

24. 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

25. 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

26. 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

27. 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

28. If still Non-Specific?? Functional abdominal pain syndrome

29. 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”)

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

31. 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)

32. & 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

33. 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)

34. 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)

35. 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

36. 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

38. Ευχαριστώ
Thank You!
Dankie
WAD MAHAD
SAN TAHAY
GADDA GUEY

39. 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