1. Abdominal Pain: Hot or Not
Abdulwahab Telmesani MD
College of Medicine
Umm Al-Qura University

2. Abdominal Pain: Hot or Not!

3. Abdominal Pain
Acute
Chronic

4. Acute Abdominal Pain 5% of the unscheduled visits to clinics
Sense of urgency
Gets proper attention

5. Chronic Abdominal Pain
Pathological (Organic abdominal pain).
Functional abdominal pain (Non organic)

6. Chronic Abdominal Pain (Non organic/Functional)?

7. Chronic Abdominal Pain (Non organic/Functional)
No objective evidence of an
Underlying organic disorder.

8. Chronic Abdominal Pain (Pathological)?

9. Chronic Abdominal Pain (Pathological)?
Alarm symptoms or signs
RED FLGS

10. Chronic Abdominal Pain Pathological
Weight loss.

11. Chronic Abdominal Pain Pathological
Weight loss.
Gastrointestinal bleeding.

12. Chronic Abdominal Pain Pathological
Weight loss.
Gastrointestinal bleeding.
Persistent fever.

13. Chronic Abdominal Pain Pathological
Weight loss.
Gastrointestinal bleeding.
Persistent fever.
Chronic severe diarrhea.

14. Chronic Abdominal Pain Pathological
Weight loss.
Gastrointestinal bleeding.
Persistent fever.
Chronic severe diarrhea.
Significant vomiting.

16. Chronic / Functional Abdominal Pain
Why?

17. Chronic / Functional Abdominal Pain
A common problem
Indication of higher prevalence in our society
It is a cry for help

18. Chronic / Functional Abdominal Pain Terms Used

19. Chronic / Abdominal Pain Terms Used
Chronic recurrent abdominal pain RAP
Functional abdominal pain
Nonorganic abdominal pain
Psychogenic abdominal pain
Rome II criteria for abdominal pain

20. Chronic recurrent abdominal pain (RAP)
3 episodes of abdominal pain, over a period of
3 mo, severe enough to affect activities

21. Functional abdominal pain
Abdominal pain that occurs in the absence of
anatomic abnormality, inflammation, or tissue
damage

22. Functional abdominal pain
Used interchangeably with:
Nonorganic abdominal pain
&
Psychogenic abdominal pain

23. Rome II criteria for abdominal pain?

24. Rome II criteria for abdominal pain
In 1999, a group of investigators (Rome II
committee) was charged with identifying
and then developing diagnostic criteria for
childhood functional disorders including
recurrent abdominal pain.

25. Rome II criteria for abdominal pain
Functional dyspepsia.
Irritable Bowel Syndrome (IBS).
Functional abdominal pain.
Abdominal migraine.

26. Rome II criteria for abdominal pain
Functional dyspepsia.
Upper abdominal pain, recurrent or persistent x 12 wks. Non organic.

27. Rome II criteria for abdominal pain
Functional dyspepsia.
Upper abdominal pain, recurrent or persistent x 12 wks. Non organic.
Irritable Bowel Syndrome (IBS).
Abdominal discomfort x 12wks + changed stool frequency and form.

28. Rome II criteria for abdominal pain
Functional dyspepsia.
Upper abdominal pain, recurrent or persistent x 12 wks. Non organic.
Irritable Bowel Syndrome (IBS).
Abdominal discomfort x 12wks + changed stool frequency and form.
Functional abdominal pain.
Abdominal pain more than 12 wks in a school-aged child or adolescent.

29. Rome II criteria for abdominal pain
Functional dyspepsia.
Upper abdominal pain, recurrent or persistent x 12 wks. Non organic.
Irritable Bowel Syndrome (IBS).
Abdominal discomfort x 12wks + changed stool frequency and form.
Functional abdominal pain.
Abdominal pain more than 12 wks in a school-aged child or adolescent.
Abdominal migraine
In the preceding 12 mo three or more paroxysmal episodes of intense, acute midline, abdominal pain lasting 2 h to several days, with intervening symptom-free intervals lasting weeks to months. (2 of; headache, one side, photophobia FHx, Aura)

32. Epidemiology

33. 13% of middle-school students and 17%
of high-school students experience weekly
abdominal pain.
Hyams JS et al J Pediatr. 1996

34. Functional Abdominal Pain
Up to 15% of the school age children.
Youssef NN. Clinical Pediatrics 2007

35. IN KSA

36. 27/55(26.2%) middle school students.
RAP was found in 55/314 (17.5%).
27/55(26.2%) middle school students.
28/55(13.3%) secondary school students.
Telmesani A (unpublished)

37. Associated complaints/symptoms

38. Associated complaints/symptoms
Headache,
Joint pain,
Anorexia,
Vomiting,
Nausea,
Excessive gas, and altered bowel symptoms.

40. Our bowl is a mirror for our emotions !

41. The pain is real. The child is not faking

42. RAP & Anxiety children meeting criteria for RAP endorsed
significantly greater trait anxiety, anxiety
sensitivity, pain anxiety, and somatic
symptoms as compared to those not meeting
RAP criteria
Drews, Amanda. Dissertation 2006

43. The impact of recurrent abdominal pain: predictors of outcome in a large population cohort.
Children with recurrent abdominal pain are at
significant and continuing risk of adverse functioning.
Ramchandani, Paul G. et al Acta Paediatrica

44. School stressors, psychological complaints and psychosomatic pain.
School stressors are strongly associated
with psychosomatic pain and psychological
complaints in school children.
Hjern A. et al Acta Paediatrica

45. Recurrent abdominal pain, anxiety, and depression in primary care.
Anxiety disorders were significantly more likely
to precede RAP.
Ramchandani, Paul Child: Care, Health & Development 2004

46. The significance of life-events as contributing factors in childhood RAP
This study strongly suggests that recent stressful
life-events are important risk-factors for RAP.
Boey CC ; Goh KL J Psychosom Res.  2001

47. IN KSA

48. Relation of Anxiety and Depression with Psychosomatic Symptoms in children at a Primary Health Care center at Makkah Al-Mukarama
2003
Halah S. Dahlan
(MOH)

49. Results
The relation of Anxiety and Psychosomatic Symptoms (RAP) represents 53% of the cases.
The relation of Depression and Psychosomatic Symptoms (RAP) represents 57% of the cases.

50. Conclusion
RAP is the most common indicator of psychological problems which can be detected and handled at early stages.

52. RAP and H. pylori?

53. RAP and H. pylori
A causal relationship between H. pylori infection and recurrent abdominal pain of childhood is still not proven.

54. RAP and H. pylori A population-based cross-sectional study among
1221 preschool children aged 5–8 years. A clear
association between recurrent abdominal pain with
social and familial factors, but not with H. pylori
infection
Bode G et al J Psychosom Res 2003

55. RAP and H. pylori
In 65 H. pylori positive children (age: 3–12 years) with recurrent abdominal pain, 83% of the children had complete symptomatic relief after eradication therapy
Das BK Et al J Trop Pediatr 2003

57. IN KSA

58. 27/55(26.2%) middle school students.
RAP was found in 55/314 (17.5%).
27/55(26.2%) middle school students.
28/55(13.3%) secondary school students.
Telmesani A (unpublished)

59. Students with RAP and H. pylori positive, 35/55
(63.6%), compared to 55/314 (27%) overall.
Telmesani A (unpublished)

61. Investigation

62. Investigation A technical review found little or no evidence to
suggest that ultrasonography, endoscopy, or
esophageal pH monitoring increase the yield of
organic disease in the absence of alarm-symptoms.
The 2005 AAP and NASPGHAN guidelines

63. Investigation Rarely limited noninvasive investigations
can be done to reassure very anxious
parents.
The 2005 AAP and NASPGHAN guidelines

64. Treatment

65. Treatment The primary goal is return to normal function
AAP and NASPGHAN 2005

66. Treatment Counseling (Psychologist help) Psychological support
Reverse the Physical and Psychological stress factors
Remove augmentation (lactose intolerance)

67. Treatment
Parents insight and reassurance of no pathology

68. Treatment
Cognitive-behavioral therapy may be useful in improving pain and disability in the short-term
AAP and NASPGHAN 2005

69. Treatment Evidence regarding the benefit of treatment
with H2 receptor agonists, supplemental fiber,
or a lactose-free diet is inconclusive.
AAP and NASPGHAN 2005

70. A Randomized Double-Blind Placebo-Controlled Trial of Lactobacillus GG for Abdominal Pain Disorders in Children.
The LGG appears to moderately increase treatment
success, particularly among children with IBS.
A. GawroŃska et al Aliment Pharmacol Ther. 2007

71. Probiotics and Abdominal Pain.
Modulation of pain perception. Some Lactobacillus
strains appear to induce expression of micro-opioid
and cannabinoid receptors in intestinal epithelial cells
and mediate analgesic functions in the gut in a manner
similar to the effects of Morphine.
Rousseaux, C et al Nat Med 2007

72. Hot or Not?

73. It’s Hot

74. Conclusions RAP is a common problem It is a real pain
Requires no or limited investigations
Pay attention to red flags
Parental engagement and reassurance
Remove psychological stressors.