TRANSIT TIME RELATED TO CLINICAL FINDINGS IN CHILDREN WITH RECURRENT ABDOMINAL PAIN

(1)

(Received July 16; revision accepted for publication October 1, 1970.)

ADDRESS: (S.B.D.) 34 Sheldon Avenue, Highgate, London, N.6, England.

PEDIATRIcS, Vol. 47, No. 4, April 1971 666

TRANSIT

TIME

TO

CLINICAL

FINDINGS

IN

CHILDREN

WITH

RECURRENT

ABDOMINAL

PAIN

Samuel B. Dimson, M.D. (London), M.R.C.P.

From Sydenham Children’s Hospital, London, and the Departments of Paediatrics of East Ham Memorial Hospital, London Jewish Hospital, and Queen Mary’s Hospital, Stratford

ABSTRACT. Carmine was used as a marker to

es-timate the transit time through the gut of 306

chil-dren with recurrent abdominal pain (RAP) of

whom 96 had migraine as well. They were

com-pared with a further 160 children with migraine alone.

Clinical examination revealed that having rectal

constipation was present in 66 (22%) of children

with RAP and transit was delayed in 91% of them.

They presented distinctive features which suggest that rectal constipation alone may be a cause of

RAP. In the remaining 240 children (78%)

co-lonic spasm was thought to be responsible for

at-tacks of abdominal pain. Transit time was prolonged

in 44% and the colon was tender in 45% of cases.

Colonic tenderness was associated more often with

migraine and with a greater incidence and severity

of intestinal delay than when colonic tenderness

was absent. However in neither subgroup did the

coexistence of migraine further delay intestinal transit. Children with migraine alone showed a

de-lay in transit in 27% of cases, possibly accounted

for mostly by colonic constipation, but delay is

al-most doubled in incidence and severity if abdomi-nal pain supervenes with colonic tenderness.

It is suggested that when rectal constipation has been excluded, children with RAP should be classi-fied as cases of colonic spasm in view of the strong similarity with spastic colon of adults. Pediatrics,

47:666, 1971, RECURRENT ABDOMINAL PAIN, CO-LONIC SPASM, CONSTIPATION, TRANSIT TIME, CAR-MINE, MIGRAINE.

A

TTACKS of recurrent abdominal pain

(RAP) without demonstrable cause

are said to occur in 14.0% of boys and

15.7% of girls who are 7 years old,’ while in

1,000 school children of all ages the

respec-tive figures are 9.5% and 12.3%.2

These attacks are universally regarded

as psychosomatic reactions to emotional

stress.2’ Although the operative mechanism

is still obscure, some progress was made

when it was shown experimentally that

anx-iety greatly enhances rectosigmoid activity6

which unduly retards the onward

move-ment of faeces and may cause abdominal

pain. Nevertheless it is commonly held that

constipation hardly ever occurs in children

with RAP, amounting to only 5%,2 4%,3

10%, and 12%8 of all cases. However since

this paper was prepared, a figure of 30%

has been given.4 Since constipation was

un-defined in these series, it is not clear

whether its diagnosis was based upon the

history given or upon the clinical findings;

Sibinga8 and Stone and Barbero alone

refer specifically to rectal examination.

Because of this uncertainty and the

con-flict of ideas relating constipation to

ab-dominal pain, it was decided to estimate

the transit time of carmine through the gut

of every child seen with RAP who fulfilled

certain criteria. This test had objectively

demonstrated delay in 92% of constipated

children as against 6% in normal control

children and moreover broadly assessed the

degree of constipation present.9

Accord-ingly, immediately after a careful clinical

examination, which

did

not however

in-clude proctoscopy, the carmine test was

ap-plied and the results read a week or two

later.

METHOD

Children were given carmine 0.3 gm as

described by Dimson.#{176} Mothers were asked

not to give laxatives during the test. They

were given a form to fill out stating the date

and time the stools first changed colour (R)

(2)

TABLE I

CLINICAL FEATURK OF RECURRENT ABDOMINAL PAIN

DIFFERENTIATING BETWEEN CASES OF RECTAL ORIGIN FROM THOSE OF CoIoNIc ORIGIN

667

The results were interpreted as follows

ac-cording to criteria which were tentatively

evolved; a color change on the first, second,

or third day after ingestion

(

R 1, 2, or 3)

which disappeared on the fourth day

(

N4)

was taken to be normal, but if the stools did

not look normal until the fifth day

(

N5)

de-lay in transit was considered mild, N6 or

over as moderate, and R4 plus as

consider-able. “Nil” returns were made in 5% of

cases, sometimes even after repetition, and

these were excluded from this series.

PATIENTS

Over the past 10 years a total of 306

chil-dren with RAP were seen who gave positive

readings to the carmine test. The great

ma-jority were seen in outpatient clinics and

the

test was usually carried out in a

quies-cent phase between attacks. The site of the

pain was most often periumbiical and the

selection of cases conformed to the criteria

laid down by Apley’ for his hospitalised

Se-ries. They included the absence of any

or-ganic cause supported by negative blood,

urine, stool and radiological examinations,

the onset of attacks at least 3 months

previ-ously, and the exclusion of children under

the age of 3 years. The children in this

se-ries also had to satisfy the following

addi-tional criteria: (1) no child had at any time

suffered from enuresis, soiling, or

encopre-sis, (2) none had a recent history

sugges-tive of an anal fissure, (3) none was

men-tally subnormal, (4) none had chronic

diar-rhoea, and (5) all had been examined

per-sonally.

Of these 306 children 210 were cases of

RAP alone without any history of headache,

but 96 had “migraine” as well. They were

compared with a separate group of 160

children with “migraine” alone who never

had abdominal pain and who were seen

over the same period of time. The

“mi-graine” in both these latter groups was

identical in type; the attacks were

paroxys-mal, often bilateral and frontal,

accompa-nied by nausea or vomiting and a desire to

lie down. The absence of an aura or family

history of migraine did not exclude these

DataRectal Origin Colonic Ongin

Number of cases 66 (5) 4O (78) history of bowel irregularity + + + +

past analfissure + + + (43) + (4)

Descending colon palpable + + + + +

tender + (II) + + + (4)

seybalae felt + + +

Rectum capacious + + + +

loaded +++

faeces bard + + + + + + (scanty)

empty - ++

Analtags +

-Emotional trigger factors + + + + +

Associated migraine + (17) ++ (35)

children so that undoubtedly some with

tension headache have been classified as

migraine. The proportion of all children

with RAP who have paroxysmal headaches

is thus 31% compared with 23%,2 49%,4

and over 50%. Correspondingly the

inci-dence of abdominal pain in migrainous

children is 37.5% which compares with

61%10 and 20.5%.”

Clinical Findings

Physical examination was negative except

for clinical evidence of constipation in some

and in many a palpable portion of the

co-lon, usually the sigmoid, which was often

tender.

Of the two types of constipation

de-scribed by Hurst12-rectal (dyschezia) in

which defaecation is inefficient, and “colic”

(spastic colon) in which delay occurs in

the sigmoid and the rectum may be

empty-rectal constipation was relatively easy to

di-agnose clinically. This was not so with

co-lonic constipation. In only few children

could this diagnosis be made and then only

when scybalae could be felt in the

descend-ing colon with at most a few fecal pellets in

the rectum; commonly constipation was not

even suspected as a daily bowel action was

not unusual. Furthermore,

misinterpreta-tion of signs was easy; the descending colon

is often palpable in normal children

(3)

TABLE II

AGE AND SEX DISTRIBUTION OF ChILDREN WITH RE-CURRENT ABDOMINAL PAIN OF RECTAL ORIGIN, OF

COLOXIC ORIGIN WITh AND WITHOUT MIGRAINE, ANI) ChILDREN WITH MIGRAINE ALONE

Boys 31 73

Girls 35 82

45 76 225

40 84 241

Age RAP of Rectal #{149} Origin RAPof Colonic Origin Alone RAPoJ Colonic Origin with Migraine Migraine Alone Total 3 4 5 6 7 8 9 10 II 12 13 14 15 Total 9 5 4 10 10 6 6 2 8 2 2 2 -66 4 9 14 14 12 24 22 20 14. 12 7 3 -155 -2 2 6 9 11 20 11 9 9 3 3 -85 -4 5 5 11 18 18 26 54 15 11 9 4 160 IS 20 25 35 42 59 66 59 65 38 25 17 4 468 Mean Age

(years) 7.35 8.43 9.25 9.93

tenderness could be due to a heavy hand or

to hypersensitivity, or the lack of it to

stoi-cism; and the quantity and hardness of

feces and rectal capacity could be difficult

to assess objectively. Nevertheless, since all

cases were examined personally, a certain

measure of conformity can be assumed.

It is believed, for reasons to be discussed

later, that abdominal pain in the presence

of rectal constipation is probably rectal in

origin but that in the remainder its origin is

probably colonic without necessarily being

associated with colonic constipation. The

site, character, intensity, and duration of

the pain showed no distinguishing features

by which its origin could be determined

but the points of differentiation are

summa-rized in Table I.

Following on this differential diagnosis,

the 306 cases fall into two main groups: (1)

those with rectal constipation-66 cases (11

of whom had migraine), and (2) those

with a colonic origin-240 cases (with

mi-graine in 85) who can be subdivided into

those with (a) tender colons-107 cases,

and (h) nontender colons-133 cases. In

the control group of 160 children with

mi-graine alone, rectal constipation was found in only 5%.

Age and Sex Distribution

These 466 children comprised 241 girls

and 225 boys (Table II) but neither sex

predominated in any one group.

However the age distribution when these

children were first examined, on average 1%

years after the onset of symptoms, is

signifi-cantly different in each group. Their mean

ages reflect a chronological sequence-RAP

alone; RAP with migraine; migraine alone.

This fits the concept of the periodic

syn-drome and also the tendency for children

with RAP to develop classical migraine in

later childhood or in adult life.”

RESULTS

Table III shows that a great difference

exists between the transit times of the

groups of children studied depending on

whether RAP is of rectal or colonic origin

or is absent altogether. In the 66 cases

with rectal constipation, 91% showed a

de-lay in transit which was considerable in

27%. This is significantly more common (P

<0.001) than in children with RAP of

colonic origin in whom the respective

fig-ures were 44% and 10%, with no significant

difference between those with and those

without migraine (P = 0.24). However in

migraine without abdominal pain delayed

transit was found in only 27% of cases, a

difference which is highly significant (P

<0.001).

Colonic Tenderness

Although constipation has been defined

basically as a delay in transit through the

gut,9” it does not follow that the converse

is true. Spasm could equally be the cause

and the presence of colonic tenderness in

many children with

RAP

points to spasm

rather than constipation as the cause of

de-lay.

It can be seen from Figure 1 that an

im-portant distinction emerges when children

with RAP of colonic origin are subdivided

(4)

ARTICLES

TABLE III

* H= indicates when a color change of the stools was first noticed. t N = indicates when the stools reverted to their normal color.

tenderness on gentle palpation. Tenderness

was mainly over the descending colon but

sometimes over the transverse colon and/or

cecum. It was present in 45% of cases, 55%

of whom showed delay in transit which was

considerable in 18%. In the remaining

cases in which the descending colon was

ei-ther only palpable or not felt at all, the

cor-responding figures were 35% and 4%. This

669

difference is highly significant (p <0.002).

This latter subgroup is very similar as

re-gards transit time to the control group of

children with migraine alone (P = 0.2),

who in their turn show intestinal delay

much more frequently (P <0.001) than a

group of 102 normal children of all ages in

10% of whom delay was found. This group

of normal children is comparable with the

RESULTS OF THE CARMINE TEST IN RECURRENT ABDOMINAL PAIN COMPARED WITH MIGRAINE ALONE

Initial Reading Final Reading in Days

()?) (N)

Data Days Number of Normal Transit Delayed

First

-Second 21

Third 27

Rectal Fourth 11

Constipation Fifth 4

Sixth 2

>Sixth 1

Total 66

Second Third Fourth

2 2

2

2 4

Fifth Sixth Seventh >Seventh

10 4 1 2

17 6 1 1

5 3 3

1 2 1

1 1

1

32 14 8 6

First .5

Second 96

Recurrent Third 40

Abdominal Pain Fourth 9

Alone (Colonic) Fifth 2

Sixth 2

>Sixth 1

Total 155

1 2

3 37 39

10

4 39 49

1 1

11 5 1

19 7 4

4 4 1

1 1

1

35 18 8 2

First 4

Second 40

Recurrent Third 31

Abdominal Pain Fourth 6

(Colonic) with Fifth 1

Migraine Sixth 2

>Sixth 1

Total 85

4

1 15 13

10

1 19 23

5 5 1

17 2 2

2 2 1 1

1

1 1

1

24 10 5 3

First 2

Second 95

Migraine Third 48

Alone Fourth 12

Fifth 1

Sixth 2

Total 160

2

51 34

2 28

55 62

4 5 1

14 3 1

4 6 2

1

2

(5)

ABDOMINAL PAIN NO ABDOMINAL PAIN

Cases 66 107 133 160 65 102

COLON IC

I

RECTAL

100

90

80

70

60

Yo

50

40

20

10

0

Rectal Normals

Constipation

FIG. 1. Comparison between the clinical findings in children with and

with-out recurrent abdominal pain related to transit time.

Colon

Tender

Colon

Not

Tender

Migraine Simple Alone Constipation

EJ

Transit time normal

mildly delayed

moderately delayed

severely delayed

migrainous control subjects in that both

groups included some with a history of

bowel irregularity, whereas in the normal

children in the previous series with daily

bowel actions, delay was present in only

6%.’

In cases of colonic RAP with migraine, it

was found (Fig. 2) that migraine is more

often (P < 0.04) associated with tender

co-lons (43%) than with nontender colons

(30%). Nevertheless the incidence and

se-verity of intestinal delay is not enhanced by

the coexistence of migraine, a finding which

is also reflected in Table III.

Despite the delay found in almost all

children with rectal constipation associated

with RAP, colonic tenderness was found in

only 8 (12%). Moreover tenderness was

elicited in only 5 of the 160 children with

migraine alone. It would therefore appear

that in general when there is no history of

abdominal pain there is no tenderness

ei-ther, but that the converse is not true.

DISCUSSION

It may seem anomalous that whereas

gas-troenterologists believe that constipation is

a frequent cause of abdominal pain arid

dis-comfort, most pediatricians are inclined to

doubt this’4 and, apart from Stone and

Barbero, are moreover in general united in

thinking that in RAP constipation is rare.

Apley and Naish’ reported it in only 5% of

their cases against 3% in the control

sub-jects; nevertheless this difference is

(6)

00

90

80

70

60

Numbers 50

40

30

20

10

0

ARTICLES 671

found constipation in only 10% of his 200

cases and yet in 38% pain was relieved by

defecation suggesting a colonic origin for

the pain.” Rectal examination was

obvi-ously impracticable in the large series of

Pringle, et al.’ and of Apley and Naish.’ It is

therefore suggested that the presence of

rectal constipation was sometimes

over-looked and the history of bowel regularity

perhaps accepted uncritically.

In this series, 22% of cases of RAP were

associated with the clinical diagnosis of

rec-tal constipation and this figure may

there-fore legitimately indicate the minimum

in-cidence of constipation in RAP approaching

that of Stone and Barbero.

Rectal Constipation

That rectal constipation can produce

ab-dominal pain has been demonstrated

exper-imentally in megarectum by increasing

in-trarectal pressures in childrenbn and also in

young adults because of colonic dilatation’7 through reflux from voluntarily withholding

defecation.18 Such reilux may possibly act

as a stimulus to the colon and heighten

co-Ionic overactivity which Connell’#{176} found to

be present in severely constipated young

adults. He2#{176}believed that pain is due not so

much to the colonic high pressure waves

themselves as to the damming back of gas

and feces thereby producing proximal

dila-tation of the colon.

Colonic tenderness was usually absent in

rectal constipation and emotional factors

were correspondingly rare. If tenderness

can be equated with spasm, which has yet

to be proved experimentally, then secondary

spasm is also likely to be uncommon.

Furthermore the additional points of

clini-cal differentiation tabulated in Table I, in

conjunction with the experimental work

done by others, suggest that rectal

constipa-tion may alone be the cause of about 20%

of cases of RAP and should therefore be

si-phoned off from the main body of cases

which are solely of colonic origin and

emo-tionally determined. Nevertheless

confirma-tion of this hypothesis is required since

Stone and Barbero,4 who alone claim that

constipation is present in a high proportion

With MigrQine Without Migraine

Colon Colon Colon Colon

Tender NotTender Tender Not Tender

FIG. 2. Relationship between migraine and

tender-ness of the colon in children with colonic RAP.

of cases of RAP, regard it as only an

associ-ated sign.

It is not suggested that rectal

constipa-tion is usually accompanied by abdominal

pain. During the same period as the present

survey, an equal number of children were

seen with predominantly rectal constipation

but without abdominal pain.9 Apart from

the possibility of secondary colonic spasm

and also of reflux, which has not yet been

investigated in children, it is not clear why

abdominal pain should be present in some

of these cases but absent in others.

Colonic Spasm, Constipation,

and Tenderness

After excluding these children with rectal

constipation, who will not be discussed

fur-ther, there remained the majority, 107 with

colonic tenderness who showed an

inci-dence and severity of intestinal delay much

greater than the remaining 133 cases in

which no tenderness was found. Such delay

could be the result of either colonic

consti-pation, colonic spasm, or both. In view of

the difficulty in diagnosis, the incidence of

colonic constipation cannot be ascertained.

Neither can it be decided whether, if

pres-ent, it is primary or secondary to spasm.

However intermittent spasm seems more

likely to be the cause of abdominal pain

(7)

normal transit times were commonly found

between attacks presumably after spasm

had largely subsided. On the other hand

when children were seen during attacks,

co-Ionic tenderness was almost the rule,

in-cluding those referred by surgical

col-leagues when cecal tenderness raised the

suspicion of appendicitis.

If this hypothesis that spasm is reflected

clinically by tenderness is accepted, then its

persistence between attacks might explain

the increased delay often encountered, but

if spasm is mild or unsustained, normal

transit times could be expected. At such

symptom-free periods, normal resting

pat-terns during intraluminal studies have been

found in adults with spastic #{232}olon2’and in

children with RAP.” It therefore seems

rea-sonable to assume that the discovery of

tenderness should not be dismissed as

merely due to hypersusceptibility to pain in

“little bellyachers,” for if this were true in

all cases transit times would be the same

whether tenderness is present or not.

Autonomic Imbalance

Although some children in this study

un-doubtedly showed hypersusceptibility to

pain, a concept which regards it as the

cause of every case of RAP’ is too

sweep-ing. It is nonetheless accepted that

individ-ual variation in sensitivity to abdominal

pain exists; this has been demonstrated

ex-perimentally in adults with spastic colon23

and is likely to be true also in children with

RAP. Moreover the threshold to cutaneous

pressure pain has been shown to increase

with age in children24 who also normally

show 50% greater colonic activity than

adults.6 However this may account only

for the high incidence of RAP in childhood

without necessarily indicating general

hy-persensitivity to visceral pain. Autonomic

imbalance provides a more acceptable

expla-nation for most cases of RAP. Kopel, et al.22

found that rectosigmoid hypermotility

in-duced by prostigmine in normal children

was greatly increased in patients with RAP,

thus replicating the findings of Chaudhary

and Truelove” in adults with spastic colon.

Pupillometric experiments provided further

evidence of autonomic dysfunction in

RAP.’5”6

Nevertheless it remains possible that

“bellyachers” are those who are endowed

with an unusual degree of autonomic

im-balance and readily respond with mild

spasm to emotional stress. They would then

be more likely to be found among those

who show transit times which are normal or

only mildly delayed.

Migraine

Autonomic imbalance may also underlie

migraine as well as colonic RAP and may

thus account for the frequent association of

these conditions. Colonic tenderness was

virtually absent in children with migraine

alone but when they developed RAP

intes-tinal delay was greatly increased,

presum-ably as a result of secondary spasm, and

the colon then was often tender.

Children with migraine alone showed

de-lay more often than normal children and

since only few had rectal constipation it is

tempting to speculate that delay was chiefly

due to colonic constipation. Since

intralumi-nal studies have never been carried out on

migrainous subjects as a group, this

hypoth-esis must remain unverified. It is

notewor-thy that adults with migraine too are

“usu-ally” constipated;’7 the proportion is 40%,28

but the type is unspecffied. The relationship

is not one of cause and effect’7 and this may

apply equally to children for the

coexis-tence of migraine did not influence the

transit times of children with RAP.

The Spastic Colon of Childhood

Features shared between adults with

spastic colon and children with RAP

in-dude the frequency with which they occur,

the common finding of colonic tenderness

and hypermotility, and the evidence in both

of autonomic imbalance and emotional

stress. Some differences remain to be

stud-ied further. Any association in adults

(8)

ARTICLES 673

yet been investigated and diarrhea is a

prominent symptom in adults in contrast to

children.

While adults with spastic colon have

claimed to have suffered from constipation

or RAP in childhood,’ documentation has

been poor. There is therefore urgent need

for longitudinal studies before the identity

of adult spastic colon and RAP4” can be

substantiated, and for further work on the

colonic physiology of children with and

without RAP in order to replace conjecture

by fact and thereby possibly forestall

gas-trointestinal disease in later life.

SPECULATION

When transit is delayed in children with

recurrent abdominal pain, the site is most

likely to be either in the descending colon

or in the rectum. Clinical examination

showed that either site may be involved but

rarely both. Rectal constipation alone

ac-counted for some cases of RAP. Colonic

spasm seemed to be the cause in the

major-ity who were probably affected by

auto-nomic imbalance; in this respect RAP

re-sembles adult spastic colon. Even though

their identity has not yet been firmly

estab-lished, it may be legitimate to substitute the

term “colonic spasm” for “recurrent

abdom-inal pain,” once rectal constipation has been

excluded. This more restrictive delineation

should lead to more rational therapy and

remove from most children the stigma that

their pain is merely due to hypersensitivity,

a theory which is challenged by the finding

that in many of them colonic delay exists

which may, on occasion, be considerable.

SUMMARY

The transit time of carmine through the

gut was determined in 306 children with

re-current abdominal pain (RAP) of whom 96

had migraine as well. A further 160

chil-dren with migraine alone were used for

comparison.

Rectal constipation was considered to be

solely responsible for 66 (22%) cases of

RAP presenting features which distinguish

it from the remaining 240 cases thought to

be colonic in origin. Transit times were

de-layed in 91% and 44%, respectively,

com-pared with 27% in migraine alone.

In RAP of colonic origin the colon was

tender in 45% of cases and this was

signifi-cantly more often associated with delayed

transit and migraine than when the colon

was not found to be tender. Nevertheless

the coexistence of migraine

did

not further

increase intestinal delay although children

with migraine were more prone to

constipa-tion than normal children.

It is suggested that RAP of childhood is

due most frequently to colonic spasm in

children affected by autonomic imbalance.

Although similar in many respects to adult

spastic colon, these two conditions cannot

on present evidence be regarded as

identi-cal.

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Acknowledgment

(10)

1971;47;666

Pediatrics

Samuel B. Dimson

RECURRENT ABDOMINAL PAIN