Abdominal Pain

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SUPPLEMENT 955

Abdominal

Pain

Michael K.

Farrell,

MD

From the Division of Gastroenterology, Children’s Hospital Research Foundation, Cincinnati

ABSTRACT. Chronic abdominal pain affects 10% to 12% of school-aged children. In 90% to 95% of such patients,

no organic cause can be elicited. Certain behavioral and personality characteristics are frequently evident in these

children. Significant stress is usually present in the

fan-iies. The goal of the evaluation is education of the child

and family about the abdominal pain. The reality of the pain is acknowledged, but the stress is dealt with as the

primary issue. Pediatrics 1984;74(suppl):955-957, abdom-inalpain, parent education, functionalcomplaints, anxiety.

Chronic abdominal pain is one of the most frus-trating problems encountered by the pediatrician. Whereas many illnesses include abdominal pain as a symptom, virtually all pediatricians recognize that most abdominal pain is benign and self-limit-ing. However, many parents have heard tales of ignored or misdiagnosed abdominal pain that later evolved into a catastrophic illness such as cancer

or

a ruptured appendix. The pediatrician may feel compelled to leave no stone unturned in evaluating each complaint. In addition, parents are no longer satisfied with simplistic answers; they expect de-tailed explanations and assurances. The pediatri-cian must also contend with a prevalent attitude that instant relief is available for all illnesses, no matter how trivial. Finally, while besieged by these factors, the pediatrician must respond appropri-ately and compassionately to the child with recur-rent abdominal pain.

This paper briefly reviews the clinical features and management of chronic abdominal pain. The focus is on the counseling and education of the child and family.

Read before the Symposium on Pediatric Patient Education:

Challenge for the SOs, Dallas, Nov 29-30, 1983.

Reprint requests to (M.K.F.) Division of Gastroenterology and

Nutrition, Children’s Hospital Medical Center, Elland and Be-thesda Ayes, Cincinnati, OH 45229.

PEDIATRICS (ISSN 0031 4005). Copyright © 1984 by the

American Academy of Pediatrics.

Chronic abdominal pain is a common pediatric complaint, affecting 10% to 12% of school-aged children at some time in their childhood. Apley’ provides a useful defmition in his classic mono-graph (which should be read and reread by all who care for children). Apley defmes chronic abdominal

pain as three or more episodes severe enough to affect the child’s activities, occurring over a period longer than 3 months. The abdominal pain usually begins between ages 5 and 10 years; the incidence is slightly higher among girls.

A family history of “functional” gastrointestinal symptoms, such as abdominal pain, diarrhea, and the irritable bowel syndrome, can frequently be elicited. Certain emotional disturbances and per-sonality traits occur more frequently in affected children than in control subjects2 (Table 1). Af-fected children often appear worried and “uptight” and do not express their feelings well.

Little about the pain itself is diagnostically help-ful. The pain is usually periumbilical and/or epi-gastric and described in vague terms. Frequently, the parents appear more concerned than the child.

No consistent relationship can be demonstrated

between the pain and specific foods, meals, position, activity, or time of day, except that the pain is rarely nocturnal. Headaches, vomiting, and pallor are frequently part of the symptom complex.’

EVALUATION

Most authors agree as to how chronic abdominal pain should be evaluated.3’4 The initial evaluation includes a detailed interview with the child and the parents, a thorough physical examination, and spe-cific screening laboratory studies. The child is usu-ally symptom-free when initially examined; it is useful to reexamine the child during an episode. After all data have been evaluated, a meeting should be held with the family and child to explain the situation and discuss therapeutic plans.

Adequate time for the initial evaluation must be

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956 PEDIATRIC PATIENT EDUCATION

TABLE 1. Frequent Traits in Children with Abdominal Pain

Emotional Disturb- Personality Traits

ances

Undue fears High-strung, excitable

Enuresis Anxious

Sleep disorders Apprehensive

Appetite difficulties Perfectionistic * Modified from Apley.

allocated; chronic abdominal pain cannot be treated

in the “flying coattails” manner that, unfortunately,

is so characteristic of the modern harried pediatric practice.5

During the interview, the pediatrician should es-tablish a mutually trusting relationship with the child and family. It is important to acknowledge that the pain is real and is located in the abdomen,

not “in the head.” The child is suffering, recognizing this helps build the foundation for future discussion and intervention. The goal should be to “listen to the child talking with his body.”’ The clinician must recognize that there may be a hidden agenda.6’7 The abdominal pain may be viewed as a “ticket of ad-mission” for the discussion of other concerns. Com-mon sources of anxiety include fear of a specific illness, such as cancer or appendicitis, or fear of death. Another member of the family, such as a grandparent, may be exerting pressure on the par-ents to “fmd out what’s really wrong.”

The physical examination should be thorough and meticulous. The laying on of hands may be therapeutic in itself. Careful scrutiny of the abdo-men and a rectal examination should be included.

Factors that suggest organic disease are listed in Table 2. The child’s growth record is particularly helpful. Normal growth is reassuring, growth failure and/or weight loss should heighten suspicion of an organic lesion. Numerous studies3’4 have docu-mented that no organic lesion will be found in 95% of children with chronic abdominal pain if the

symptoms listed in Table 2 are absent The most

commonly identified organic problems are related to the urinary tract. Routine screening laboratory studies most likely to be helpful are the complete blood count, sedimentation rate, urinalysis, urine culture, and stool guaiac. If these studies have neg-ative findings, more extensive and invasive inves-tigations, such as upper gastrointestinal study, bar-ium enema, and endoscopy, are unnecessary and unrewarding.

Following the evaluation, the physician will usu-ally tell the child and family that no organic disease has been found and that there is no physical danger to the child. Rather, the symptoms appear related to stress and tension. Ample time for questions should be allowed and particular concerns

dis-cussed. A useful analogy of abdominal pain is head-ache; most adults have experienced stress-related headache without an underlying brain tumor. Many adults also recognize gastrointestinal responses to stress, eg, the queasy stomach or loose stools.

In-quiries into sources of stress should be continued.

commonly determined sources are listed in Table

31.8 The possibility of secondary gain for the child

should be explored. Is the child directly benefiting from the pain by increased family attention, or avoidance of school or gym class?

Most families accept the explanation and are grateful that no serious illness is present. However, a vicious cycle may begin and it must be promptly broken. The onset of pain will provoke parental anxiety, which may result in exaggerated attention being focused on the child. This may lead to more abdominal pain, thus perpetuating the cycle. The physician must avoid becoming an unwitting cata-lyst in perpetuating the cycle by well-meaning, but

never-ending, efforts to find “the” cause. The effect is to increase everyone’s anxiety by implying that “there must be something seriously wrong or they would not keep looking so hard.”

Parents invariably request an explanation of the cause of the pain. Because the pathogenesis is not completely understood, the physician may answer

superficially or ignore the question, thus

heighten-ing anxiety. The fact that many common diseases are of unknown cause, yet can be satisfactorily managed, should be discussed. Again, headache is a useful example because many adults suffer stress-related headache. It is useful to mention the fact that pain perception may be increased or decreased by environmental and emotional factors. Useful examples include the nocturnal worsening of a toothache and the ability of an athlete to continue

TABLE 2. Symptoms Suggesting Organic Disease

Persistent fever Growth failure Weight loss Anemia Hematemesis Hematochezia Melena Perianal disease

Pain away from midline

TABLE 3. Potential Emotional Issues in Children with

Chronic Abdominal Pain*

Marital discord (parents) School problems

Detached father

Physically ill or depressed mother Excessively rigid parenting styles Child’s perfectionistic personality

* Adapted from Apley’ and Berger et al.8

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SUPPLEMENT 957 competition despite injuries that will later severely

limit activity.

Current understanding of the abdominal pain may be reviewed. Visceral receptors are most sen-sitive to mechanical stimuli such as stretching and distension. Considerable evidence suggests that the irritable bowel syndrome in adults is associated with alterations in gastrointestinal motility.9”#{176} Un-fortunately, such data are limited in children, but changes in gastrointestinal rectosigmoid motility and transit time have been documented.”2 Re-cently, increases in circulating neurotransmitter such as fi-endorphin and norepinephrine have been documented.’3 These neurotransmitters may affect pain perception as well as gastrointestinal motility. Perhaps stress and anxiety increase perception to the point that variations in normal intestinal phys-iologic events are perceived as painful.

THERAPY

The therapy for the chronic abdominal pain of

childhood is reassurance, support, and education.

Pharmacologic therapy is rarely helpful and is

po-tentially harmful. Antimotility agents are not

effec-tive, have a low therapeutic-toxicity ratio, and may aggravate symptoms. Sedatives and hypnotic med-ications are not appropriate therapy. Over-the-counter remedies have not been shown to be effec-tive and may contain potentially harmful ingredi-ents such as salicylates.

Dietary manipulations are rarely necessary. The child and family should consume well-balanced meals. Elimination diets are not necessary. Any specific food that aggravates symptoms in the in-dividual patient should be avoided. A high-fiber diet may be helpful not only to the child but to the whole family.

The goal is to treat the whole child and the family, not the symptoms. Apley’ has commented that “the more time the doctor spends on the his-tory, the less time he is likely to spend on treat-ment.” Doctors who treat the symptom tend to give a prescription. Doctors who treat the patient are more likely to offer guidance. A goal is to reduce the stress on the child because he or she must return to school. Understanding and briefoffice counseling are effective in the majority of cases; some patients and families may require psychiatric referral.

PREVENTION AND EDUCATION

Prevention is at the foundation of pediatrics. Prevention of chronic abdominal pain, which in-cludes prevention of stress-related symptoms and behavior, should begin in infancy. The pediatrician

must be alert to excessive parental anxiety about minor injuries and illnesses; this may be indicative of underlying parental worries.7 Excessive parental expectations or rigid parenting styles may portend future psychosocial problems. Families in which someone is always ill, in which members “talk with their bodies,” or have a history of functional disease are at particular risk. Early, friendly, and support-ive intervention by the pediatrician may alleviate some of the causes of stress. Encouraging family members and the child to discuss their feelings freely may decrease future problems. Functional gastrointestinal complaints occur frequently in adults’4 Children with chronic abdominal pain con-tinue to have functional complaints as adults”5: early intervention reduces these sequelae.

ACKNOWLEDGMENT

This work was supported, in part, by United States Public Health Service grant no. RR-00123 from the Gen-eral Clinical Research Centers Branch, Division of Re-search Resources, National Institutes of Health.

REFERENCES

1. Apley J: The Child withAMominal Pains. Oxford, Blackweil

Scientific Publications, 1975

2. Apley J, Naish N: Recurrent abdominal pains: Afield survey

of 1,000 school children. Arch Dis Child 1958;33:165 3. Stone RT, Barbero GJ: Recurrent abdominal pain in

child-hood. Pediatrics 1970;45:732

4. Green M: Diagnosis and treatment: Psychogenic, recurrent abdominal pain. Pediatrics 1967;40:84

5. Austin G: Pediatricians will speak up for themselves! Pedi-atrics 1981;68:893

6. Barsky AJ: Hidden reasons some patients visit doctors. Ann Intern Med 1981;94:492

7. Hickson GB, Altemeier WA, O’Connor 5: Concerns of

moth-era seeking care in private pediatric office. Pediatrics 1983;72:619

8. Berger HG, Honig PJ, Liebman R Recurrent abdominal

pain: Gaining control of the symptom. Am J Dis Child

1977;131:1340

9. McRae 5, Younger K, Thompson DG, et al: Sustained

mental stress alters human jejunal motor activity. Gut 1982;23:404

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bowel motility demonstrated in a patient with irritable colon. Lancet 1979;2:1321

11. Kopel FE, Kim IC, Barbero GJ: Comparison ofrectosigmoid motility in normal children, children with recurrent abdom-inal pain, and children with ulcerative colitis. Pediatrics 1967;39:539

12. Dimson SB: Transit time related to clinical fmdings in

children with recurrent abdominal pain. Pediatrics 1974; 47:666

13. Stangheffini V, Malagelada JR, Zinsmeister AR, et al:

Stress-induced gastroduodenal motor disturbances in hu-mans: Possible humoral mechanisms. Gastroenterology 1983;85:83

14. Lennard-Jones JE: Functional gastrointestinal disorders. N EnglJ Med 1983;308:431

15. Christensen MF, Mortensen 0: Long-term prognosis in

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1984;74;955

Pediatrics

Michael K. Farrell

Abdominal Pain

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1984;74;955

Pediatrics

Michael K. Farrell

Abdominal Pain

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