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MOCA Minute - Chronic Abdominal Pain

Solomon Behar, MD and Parul Bhatia, MD
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25:31

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Parul and Sol discuss the red flags for chronic abdominal pain and categories of functional abdominal pain for those kids with chronic abdominal pain and no red flags for serious organic pathology.

Pearls:

  • The further away from the umbilicus the pain is, the more likely it is to be organic.

  • No additional testing is necessary in patient with chronic abdominal pain that have a reassuring history and physical exam in addition to a negative guaiac test.

  • The Rome IV Diagnostic Criteria categorizes functional abdominal pain into five main causes:  functional dyspepsia, irritable bowel syndrome, abdominal migraine, functional abdominal pain - not otherwise specified and  functional constipation.

  • Patients should be referred to a specialist if there is concern for inflammatory bowel disease or if the patient has persistent alarm symptoms without a clear diagnosis.

 

  • What is chronic abdominal pain? The term defines abdominal that has occurred on three or more occasions throughout a period of three months or more.

  • It is important to ask about and look for alarm findings on history and physical. These findings help distinguish organic from functional pain in addition to helping the clinician evaluate for serious pathology.

    • Alarm findings on history include:

      • Fever or involuntary weight loss.

      • Difficulty feeding or pain with feeding

      • Severe and/or chronic abdominal pain (three or more watery stools per day)

      • Bloody or tarry stool

      • Vomiting that is bilious or protracted

      • Urinary symptoms (e.g. flank pain or hematuria)

      • Back pain

      • Skin changes

      • Family history - specifically asking about family history of inflammatory bowel disease (IBD), peptic ulcer or celiac disease

    • Alarm findings on physical exam include:

      • Deceleration in height velocity

      • Evidence of oral ulcerations

      • Localized abdominal pain or costovertebral angle tenderness (typically functional abdominal pain is poorly localized or periumbilical)

Editor’s Note:  The further the pain is from the umbilicus, the more likely an organic process is responsible as an underlying cause,  an axiom known as Apley’s Law

    • Hepatosplenomegaly

    • Perianal tags, fissures or any abnormalities

    • Guaiac positive stool - of note, even if the patient has a normal history and exam, a guaiac test should be obtained as it can reveal hidden organic pathology

  • If a patient has alarm findings, what initial testing should be done? The patient’s history and physical will help you tailor which test should be obtained. Initial evaluation can include a CBC, a comprehensive metabolic panel, inflammatory markers (i.e. CRP and ESR), a pregnancy test if the patient is of childbearing age, a lipase if there is vomiting and nausea, a urinalysis, a celiac panel (tissue transglutaminase antibody) and thyroid function test. Additional tests to consider based on history are stool studies and STI testing.

  • When should H. pylori testing be done? Testing for H. pylori, using either the stool antigen or urea breath test, can be helpful if the prevalence of H. pylori is high. However, in the US the prevalence is low, most tests will be falsely positive and treatment may not help.

    • If the patient has a positive guaiac tests or a report of melena along with symptoms consistent with peptic ulcer disease, H. pylori testing could be helpful.

  • Testing for lactose intolerance using the hydrogen breath test is usually not necessary. Instead giving the patient a two-week trial on lactose-free products is typically enough to see if there is a difference in symptoms.

  • When should imaging be obtained? In children with chronic abdominal pain that have no red flags on history or physical and have a negative guaiac test, plain films of the abdomen are not recommended. However, an x-ray may be warranted in patients with a history of chronic abdominal pain that have an acute change in symptoms (e.g. development of vomiting). Ultrasounds are helpful if the patient has gynecologic complaints like dysmenorrhea or pelvic pain. This imaging modality can also help evaluate the size and texture of the kidney and for gallstones and some kidney stones.

  • What does an upper GI help detect? This imaging technique helps to evaluate for bowel obstruction (e.g. from malrotation with volvulus). Remember that malrotation is a small bowel obstruction that happens intermittently. Patients will usually have significant vomiting, oftentimes bilious emesis, that accompanies the abdominal pain.  

  • How does the Rome IV Diagnostic Criteria categorize functional abdominal pain? There are five main functional causes of abdominal pain - functional dyspepsia, irritable bowel syndrome, abdominal migraine, functional abdominal pain - not otherwise specified and  functional constipation.

    • In functional dyspepsia, patients have 2 or more months of abdominal pain with 1 or more of the following symptoms occurring at least 4 days per month: postprandial fullness, early satiation, epigastric pain or burning that is not associated with stooling. Some studies have shown some inconclusive evidence for the role of H2 blockers to treat this. Anecdotally, some practitioners choose to give a trial of an antacid to see if that helps.

    • Irritable bowel syndrome is characterized by 2 or more months of abdominal pain associated with changes related to defecation – this can be a change in frequency of stool or change in the form or appearance of stool. Peppermint oil for about two weeks has been shown to improve symptoms in patients with irritable bowel syndrome.

    • Abdominal migraines are paroxysmal episodes of intense, acute periumbilical,
      midline or diffuse abdominal pain lasting 1 hour or more. Episodes are separated by weeks to months. These patient will often  have other symptomatology typically associated with migraines like loss of appetite, nausea, headache, photophobia, vomiting and maybe even some pallor. To meet criteria, the symptoms have to occur twice within a 6 months period.

    • In functional abdominal pain - not otherwise specified,  patients have episodic or continuous abdominal pain that occurs at least  4 times per month for two months. The abdominal pain does not criteria for irritable bowel syndrome, functional dyspepsia, or abdominal migraine.

    • In functional constipation, patients have 2 or more of the following occurring at
      least once per week for a minimum of 1 month with insufficient criteria for a diagnosis of irritable bowel syndrome:  2 or fewer defecations in the toilet per week in a child of a developmental age of at least 4 years, 1 or more episode of fecal incontinence per week, history of posturing when stooling, presence of a large fecal mass in the rectum, or history of large diameter stools that can obstruct the toilet. These patients are treated as having constipation with close follow-up.

  • In what situation is a referral warranted? If you are suspicious for IBD or a patient has persistent alarm symptoms without a clear diagnosis after you have evaluated them, you need to get them to the specialist. Some people would want to  refer to GI to confirm lactose intolerance - this depends on your comfort level with making the diagnosis and what specialist you have available to you. Another reason to refer is if you feel like there is a need for an upper or lower endoscopy (e.g. you are worried that the patient might have chronic abdominal bleeding). Lastly, if you are managing patients and you are not getting anywhere, referral to a GI specialists may be beneficial for the family and they can also help find something you may have missed.

A copy of the Rome IV criteria referenced above is available here.

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Dude, Where's My Milk? Full episode audio for MD edition 191:36 min - 90 MB - M4APeds RAP December 2018 Written Summary 300 KB - PDF

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