Ultrasonographic Studies in the Management of Recurrent Abdominal Pain

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Ultrasonographic

Studies

in the Management

of Recurrent

Abdominal

Pain

Amir Shanon,

MD; David

John

Martin,

MB, FRCP(C);

and

William

Feldman,

MD, FRCP(C)

From the Children’s Hospital of Eastern Ontario, Ottawa, Ontario, Canada

ABSTRACT. The medical records of 65 children and

adolescents who had abdominal ultrasonography for the evaluation of recurrent abdominal pain were reviewed.

Fifty-three subjects (81%) had normal results; in 12 cases

(19%) an abnormality was detected. In no case could the pain be attributed to the abnormal finding. Furthermore,

in 3 subjects, disclosure of the abnormal findings could

have caused more harm than good. The role of the

ab-dominal ultrasonographic study in the management of

recurrent abdominal pain in children and adolescents is

discussed. Pediatrics 1990;86:35-38; ultrasonography,

re-current abdominal pain.

Recurrent abdominal pain is a common com-plaint of school-aged children. Although underlying organic pathologic conditions cannot be found in more than 90% of these children, laboratory tests are often ordered as part of their management. The most commonly ordered tests include urinalysis, urine culture, blood cell count, sedimentation rate,

stools for analysis of parasites, and occult blood. In recent years, more sophisticated techniques, including endoscopy, sigmoidoscopy, ultnasonog-raphy, and computed tomographic scanning, have been used in the evaluation of recurrent abdominal pain in children. In some institutions, the abdomi-nal ultrasonogram has gained a prominent role in the evaluation of recurrent abdominal pain in chil-then mainly because it is painless and noninvasive and involves no radiation.

A review of the literature revealed no studies on the importance and contribution of the abdominal ultrasonogram in the management of recurrent ab-dominal pain in children and adolescents. The

pun-Received for publication Apr 18, 1989; accepted Jul 12, 1989. Reprint requests to (W.F.) Children’s Hospital of Eastern On-tario, 401 Smyth Rd, Ottawa, Ontario, Canada K1H 8L1. PEDIATRICS (ISSN 0031 4005). Copyright © 1990 by the American Academy of Pediatrics.

pose of our study was to clarify the role of this

imaging technique in the management of this con-dition.

METHODS

The ultrasonography logbook of the Children’s Hospital of Eastern Ontario was reviewed for all abdominal ultrasonographic studies performed for children and adolescents, 3 to 17 years of age, during the period between January 1987 and June

1988 inclusive. All patients referred from the ne-phrology, urology, cystic fibrosis, and oncology out-patient clinics were excluded. As the indication for referral was usually not stated in the logbook, the requisition forms of all patients were reviewed. Those who had the abdominal ultrasonographic study for any indication other than abdominal pain (eg, recurrent urinary tract infections, precocious puberty, abdominal trauma, hepatosplenomegaly) were excluded as well.

The ambulatory medical records of the remaining patients, both clinic patients and those from private offices, were reviewed. Patients who, according to these records, suffered from recurrent abdominal pain were included in the study. The diagnosis of recurrent abdominal pain was based on Apley’s criteria,’ namely, at least three attacks of pain that interfere with the patient’s daily routines, occurring over a period of time longer than 3 months. A total of 65 children and adolescents who fulfilled these criteria and had no other chronic illness were stud-ied. The findings on physical examination and the questions addressed to the radiologist by the refer-ring physicians were recorded.

Three radiologists took part in the initial ultra-sonographic interpretations. All studies with ab-normal results were reviewed blindly by one of the authors (D.J.M.). A random sample of 40% of the

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intraob-36 ULTRASONOGRAPHY AND ABDOMINAL PAIN server and interobserver reliability. Uncomplicated

duplex kidneys, extrarenal pelvis, penitoneal fluid collections of less than 10 mL, ovarian cysts less than 6 cm in diameter, and lymph nodes less than

2 cm long were considered normal.

All information and results were then comput-enized and analyzed.

RESULTS

All 65 patients who fulfilled the inclusion criteria for this study were referred by primary-care

pedia-tnicians to the radiology department. For 30 of these patients who also consulted one of the hospital’s

outpatient clinics, medical information was avail-able from their hospital charts. Pediatrician’s

of-fices were visited on contacted by telephone to

review the charts of the other 35 patients. Patient’s ages ranged from 4 to 17 years; females outnum-bered males 45:20. Physical examination results were normal in all cases.

Physicians inquired about a specific pathologic

condition (pelvic tumor, ovarian cysts, urinary cal-culi, mesenteric lymphadenitis, cholelithiasis, renal

anomaly, cholecystitis, Cnohn’s disease) in 10 (15%)

of the patients.

Results of the ultrasonographic study were nor-mal in 53 patients (81%). The abnormal results were classified into three groups (Table): abnormal

findings that might cause recurrent abdominal pain

(4 patients); abnormal findings not expected to cause recurrent abdominal pain (5 patients); and abnormal or questionable findings with no bearing

on the child’s abdominal pain, the reporting of

which to the patient or parent could cause more harm than good (3 patients).

Intraobserver and interobserver reliability was

100%.

DISCUSSION

Recurrent abdominal pain, a common complaint affecting 10% of schoolchildren,’ is diagnosed when

there are at least three attacks ofpain that interfere with the child’s daily routines, occurring over a period of time longer than 3 months. Underlying organic disease is found in fewer than 10% of these children and many are not psychologically different from normal control subjects.2 Some children ben-efit from additional dietary fiber, probably because

of the shortening of intestinal transit time.3

Typi-cally the pain is peniumbilical in location and the patient is 5 to 14 years old, growing well, and generally in good health.

Many physicians add laboratory tests to the rou-tine history taking and physical examination, the

most common being white and red blood cell counts,

sedimentation rate, urinalysis, urine culture, stools for analysis of parasites, and occult blood. Negative results supposedly reassure the patient and physi-cian that a major organic disease does not exist. The cost of these basic tests alone amounts to approximately $40. In the last few years, with ad-vances in technology, other studies, including gas-troscopy and abdominal ultrasonography, have been added to the management of recurrent abdom-ma! pain in children. Abdominal ultrasonographic studies are considered innocuous and have a special appeal to physicians and parents alike. The ultra-sonographic study is of relatively short duration, is noninvasive, is painless, and involves no radiation. The cost of the study is approximately $75.

Apley, in his classic work,’ Stone and Barbero,4 and later Liebman5 have all shown that organic

disease is found in less than 10% of children with

recurrent abdominal pain. Organic disease should be suspected when uncommon findings (weight loss, persistent pallor and fever, diarrhea, blood in stools) are encountered. Follow-up studies6 have shown that organic disease had developed in only 2% of children over a period of 6 to 7 years, whereas approximately half of the children with this disor-der continued to suffer from abdominal symptoms

as adults.7 The results of our study should,

there-fore, come as no surprise. Results of 81% of the abdominal ultrasonographic studies were normal.

TABLE. Abdominal Ultrasonogra phic Studies: Abnormal Findings

Abnormalities That Could Have Caused Recurrent Abdominal Pain

Abnormalities Not Ex-pected to Cause Recurrent

Abdominal Pain

Findings That Could Cause More Harm

Than Good

Ureteropelvic junction

obstruc-tion (incomplete)

Bilateral mild dilation of renal

pelvis and major calyces Dilation of the pelvicalyceal

system with some loss of

pa-renchymal thickness

Cysts in both kidneys

Hepatosplenomegaly

Head of pancreas larger than normal and irregular Suspected cystitis Accessory uterine horn Suspected imper-fonated hymen Only one ovary

seen and

uterus small for age

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In none of the studies with abnormal results did the findings change the case management.

The abnormal results were classified into three

groups. The first group included abnormal findings

that might cause recurrent abdominal pain but did not in our cases.

Ureteropelvic obstruction of the kidney can cause abdominal pain. Fluid overload during intravenous urographic study will usually elicit the pain. This did not occur in our case. A diuretic renal scan showed an incomplete uretropelvic junction ob-struction. The child did not complain ofpain during the renal scan either. No treatment was necessary.

Mild dilation of the kidney’s major calyces, which

was found in two patients, could represent a normal variant but could also result from vesicouretenal neflux or obstruction. When not associated with urinary tract infection, it is not expected to cause recurrent abdominal pain. Such dilation, which at

times may indicate vesicoureteral reflux, is not an

uncommon finding in abdominal ultrasonographic studies. Cystography is usually recommended to verify positive results. Because of the ultrasono-gram, one of our patients had an intravenous uro-gram and a retrograde cystography; results of both were normal. The other patient was followed up with urine cultures only; all cultures were negative. Another patient had unilateral dilation of the pel-vicalyceal system with 1 cm loss of the panenchymal tissue overlying the upper pole. She was 13 years old at that time and had no history of urinary tract infections, no urinary complaints, and normal re-sults of urine studies. In retrospect, the sequence of tests and follow-up visits generated by the results of the ultrasonographic studies, by generating anx-iety and exposing the patient to x-radiation, may have done more harm than good.

The second group of abnormalities, those not expected to cause recurrent abdominal pain, in-cluded cysts of the kidneys, two cases of spleno-megaly/hepatosplenomegaly (spleens 2 to 3 cm be-low the costal margin, liver 3.5 cm below the costal margin), irregular large head of the pancreas, and suspected cystitis.

The patient with cysts in her kidneys was 15

years old. Both kidneys were of normal size. Two

cysts were present in the left kidney, one in the upper pole (0.8 cm in diameter) and the other in the lower pole (1.2 cm in diameter). Another cyst

(1.5 cm in diameter) was found in the lower pole of the right kidney. No cysts were seen in the liven. There was no history of kidney disease in the family.

An unusual amount of echogenic material and a thickened bladder wall found in another child were compatible with cystitis. The diagnosis was not

confirmed clinically; results of urinalysis and urine cultures were normal.

The third group included abnormal or question-able findings that had no bearing on the patient’s abdominal pain. One patient, studied twice in an-other institution, was suspected of having hemato-colpos. She was referred to a gynecologist who clinically ruled out this diagnosis. Results of a subsequent ultrasonogram performed in our hospi-tal were normal; results of the previous two studies, when reviewed, were also considered normal.

Two other studies revealed an accessory uterine horn in one case and a uterus small for age with a

missing ovary in another. Disclosure of these

find-ings to the patients could cause nothing but anxiety and more unnecessary consultation.

In Apley’s original study,’ an organic cause was found in 8% of the children with recurrent abdom-inal pain. The pathologic conditions included vul-vovaginitis, duodenal ulcer, urinary tract infection, hydronephrosis, urethral cyst, Meckel’s diverticu-lum, colon displacement, and calcification of the pancreas.

In theory, if Apley’s patients had been studied by using ultrasonography, only three abnormalities would have been diagnosed (calcification of the pancreas, hydronephrosis, and urethral cyst). The

calcifications were not treated; the child with

hy-dronephrosis had a urinary tract infection, and his urinary tract would likely have been studied be-cause of symptoms. Thus the management of only 1 of the 100 children with recurrent abdominal pain

in Apley’s study’ could have been changed by using

ultrasonography. Many physicians order the ultra-sonographic study to reassure the parents and themselves that a serious pathologic condition is not missed. In a well-growing child with the classic complaint of recurrent abdominal pain and an

oth-erwise normal history and physical examination, the chances of missing a significant pathologic con-dition in a careful clinical assessment are slim. When there are clinical grounds to suspect an ab-dominal mass or any other organic disease, an abdominal ultrasonographic study is warranted. A good follow-up is always indicated.

The issue of reassurance is not easy to solve. To the best of our knowledge, no one has proved that normal ultrasonographic results do more than a careful history and physical examination to

reas-sure the parents and/or patients or to reduce the

number of visits to physicians.

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38 ULTRASONOGRAPHY

AND ABDOMINAL PAIN are expected to influence the treatment.

Unneces-sary tests are not only expensive but, by identifying

“abnormalities” of minimal clinical significance,

may generate more unnecessary tests and more anxiety.

REFERENCES

1. Apley J. The Child With Abdominal Pains. 2nd ed. Oxford, England: Blackwell Scientific Publications; 1964

2. McGrath PJ, Goodman JF, Firestone P, et al. Recurrent

abdominal pain: a psychogenic disorder? Arch Dis Child. 1983;58:888-890

3. Feldman W, McGrath P, Hodgson MA, et al. The use of dietary fiber in the management of simple, childhood, idi-opathic recurrent abdominal pain. Am J Dis Child. 1985;139:1216-1218

4. Stone RS, Barbero GJ. Recurrent abdominal pain in child-hood. Pediatrics. 1970;45:732-738

5. Liebman W. Recurrent abdominal pain in children. Clin Pediatr (Phiki). 1978;17:149-153

6. Stickler GB, Murphy DB. Recurrent abdominal pain. Am J Dis Child. 1979;133:486-489

7. Christensen MF, Mortensen 0. Long-term prognosis in chil-dren with recurrent abdominal pain. Arch Dis Child. 1975;50:11O-114

HOW

TO WASTE

200 MILLION

DOLLARS

A YEAR!

Ginkgo Biloba Extract: Over 5 Million Prescriptions a Year

For at least 2 years in West Germany more prescriptions have been written for preparations of Ginkgo biloba extract (GBE) than for any other drug. In

1988 doctors. . .wrote 5.24 million prescriptions for ‘Tebonin’. . .The cost to the

Knankenkassen (national health insurance) was DM 370 million. The drug is promoted for use in peripheral arterial disease and organic brain syndromes in the elderly. There is little proof that GBE is effective. The drug was licensed under the new drug law in 1986 because this does not, as in many countries,

require scientific evidence from controlled trials but merely positive therapeutic

“experiences” in even a few cases. Approval of a drug is thus often based on uncontrolled and uncontrollable positive therapeutic experiences reported by physicians who believe in the drug because it fits in with their personal views

of healing, which may include, for example, anthroposophic on naturopathic

concepts. A manufacturer’s submission may consist entirely of such testimony.

The German drug law does not distinguish between drugs of this kind and those that meet high standards of quality and efficacy. As a result, the administrative standards for proof of efficacy have crumbled in recent years.

. . .The manufacturers have also made every effort to suppress critical

evalu-ation of the drug by threatening legal action against anyone publishing negative information.’

. . .The degeneration of the drug approval process in the Federal Republic will

also endanger other countries in the European Community if mutual recognition of drug approvals becomes a reality.

REFERENCES

1. Schwabe U, Paffrath D. Arzneiverordnungs-Report ‘89. Stuttgart: Gustave Fischer, 1989.

Ginkgo Biloba extract: over 5 million prescriptions a year. Lancet. 1989;2:1513-1514. Round the World.

Noted by J.F.L., MD

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1990;86;35

Pediatrics

Amir Shanon, David John Martin and William Feldman