June 2015; GI teaching
Recurrent abdominal pain
Quak Seng HockDepartment of Paediatrics
KTP-University Children’s Medical InstituteNational University Hospital
NUHS
June 2015; GI teaching
Case history
• LJR
• 12 old boy seen at CE repeatedly for severe abdominal colic at right upper quadrant
• Physical examination: mild tenderness RHC and epigastrium
• Symptomatic treatment and referred to specialist clinic for further management
• Noted weight loss
• Seen by various doctors: gastritis
June 2015; GI teaching
June 2015; GI teaching
outline
• The pain
• Epidemiology
• Long term outcome
• Some interesting cases
• management
June 2015; GI teaching
Definition
• At least 3 bouts of abdominal pain, severe enough to interfere with daily activities, over a period of at least 3 months– J Apley 1958
• In practice, RAP includes children
and adolescents in which parents
seek advice though the duration
may not be 3 months
• Exclude acute abdominal pain
June 2015; GI teaching
Pain characteristics
• Location
• Severity
• Frequency
• Personality
• Timing of pain
• Associated features
June 2015; GI teaching
outline
• The pain
• Epidemiology
• Long term outcome
• Some interesting cases
• management
June 2015; GI teaching
Age distributionQuak &Wong; IMJ 1997
0
5
10
15
20
25
30
<1 1+ 2+ 3+ 4+ 5+ 6+ 7+ 8+ 9+ 10+ 11+ 12+
Age
Age
June 2015; GI teaching
June 2015; GI teaching
Helicobacter pylori, gastroduodenal disease and recurrent abdominal pain in children
– Macarthur C, et al. JAMA 1995;273:729-34
• 45 studies from Jan 1983-July 1994
• Prevalence of HP infection in children with DU was high
• Prevalence rate of infection in children with RAP inconsistent
June 2015; GI teaching
Red Flag symptoms
• Localization of pain away from the umbilicus• Pain associated with changes in bowel habits,
particularly diarrhea, constipation, or nocturnal bowel movements
• Pain associated with night wakening• Repetitive emesis, especially if bilious• Constitutional symptoms, such as recurrent fever,
loss of appetite or energy• RAP in children < 4 years of age• Weight loss
June 2015; GI teaching
Red Flag signs
• Loss of weight or decline in height velocity
• Organomegaly
• Localized abdominal tenderness, particularly away from umbilicus
• Peri-anal abnormalities (fissures, ulceration of skin tags)
• Joint swelling, redness or warm
• Ventral hernias of abdominal wall
June 2015; GI teaching
outline
• The pain
• Epidemiology
• Long term outcome
• Some interesting cases
• management
June 2015; GI teaching
RAP in children: a long term follow-upMaqni et al. Eur J Pediatr 1987;146:72-4
• Long term follow up, minimum of 10 years
• Total of 16 children– Completely disappeared: 50%
– Persisted: 25%
– Other painful symptoms : 25%
• Poor outcome– Painful family
– Many surgical procedures
– Low educational level and social class
June 2015; GI teaching
June 2015; GI teaching
June 2015; GI teaching
outline
• The pain
• Epidemiology
• Long term outcome
• Some interesting cases
• management
June 2015; GI teaching
ML
• 3+ year old boy
• Previously well
• Seen various doctors for RAP
• Treated for constipation
• Referred to NUH because pain persistent and progressively more frequent and severe
June 2015; GI teaching
ML
June 2015; GI teaching
XC
• 5 year old boy
• Recurrent bouts of severe
abdominal pain
• Usually improved after
vomiting
• In between episodes of pain,
he is well
June 2015; GI teaching
XC
June 2015; GI teaching
NKL
• 10 year old Chinese boy with RAP
• Associated with vomiting which may last for days (up to 7-10 days)
• Weight loss
• Missed school for > 6 months
• Thin boy with no abnormality found in abdomen
June 2015; GI teaching
June 2015; GI teaching
PF
• 12 year old Chinese girl
• Seen by various doctors for RAP
• Noted to have iron deficiency anaemia
• Treated for gastritis, anaemia without improvement
• Later seen be endocrinologist for delayed puberty
June 2015; GI teaching
June 2015; GI teaching
outline
• The pain
• Epidemiology
• Long term outcome
• Some interesting cases
• management
June 2015; GI teaching
Clinical approach
• What are the three important investigations:
June 2015; GI teaching
Clinical approach
• Three important investigations:
– 1) good history and physical examination
June 2015; GI teaching
Clinical approach
• Three important investigations:
– 1) good history and physical examination
– 2) good history
and physical examination
June 2015; GI teaching
Clinical approach
• Three important investigations:– 1) good history and physical examination
– 2) good history and
physical examination
– 3) good history
and physical
examination
June 2015; GI teaching
Understanding the scenario
Pain
patient
parents environment
June 2015; GI teaching
Initial screening tests
• Anthropometrics
• Urinalysis
• ESR
• Stool occult blood
June 2015; GI teaching
Initial screening tests
• Anthropometrics
• Urinalysis
• ESR
• Stool occult blood
• Next steps
– Ultrasound
– Food diary
– Only when indicated:
• Invasive procedures
June 2015; GI teaching
Food as cause of RAP
• Lactose intolerance– Some 40% of patients with RAP has lactose
intolerance • Quak & Wong IMJ 1997
• Other food– Mainly as food additives: sorbitol, artificial
sweeteners
• Eosinophilic gastroenteritis– Tien FM, et al. Pediatrics & Neonatology 2011
June 2015; GI teaching
Ann Nutr Metab2012;61-95-101
June 2015; GI teaching
Cochrane review 2009, issue 1
June 2015; GI teaching
Clinical Psychology review 2011;31:1192-7
• Meta-analysis of 10 interventional studies
June 2015; GI teaching
Clinical Psychology review 2011;31:1192-7
• Psychological therapies, mainly cognitive-behavioral therapy, have a moderate effect on the reduction of pain in children with RAP
June 2015; GI teaching
• 63 patients (11-18 years) randomly assigned to receive standard medical care (SMC) or written self-disclosure (WSD) + SMC
• WSD + SMC associated with significantly fewer pain experiences and reduced health care utilization
June 2015; GI teaching
summary
• RAP is common
• Significant effect on HRQoL
• Red flags
• Good history and careful physical examination remain the key step toward successful management
• For functional RAP, CBT is successful in reducing the frequency and severity of pain
June 2015; GI teaching
Thank you
Terima Kaseh