Abdominal Pain in Children

Abdominal pain is a very common presentation in children. These can be split into non-organic causes, medical causes and surgical causes. Non-organic or functional abdominal pain is very common in children over 5 years. This is where no disease process can be found to explain the pain.

 

Medical Causes of Abdominal Pain

Other causes need to be excluded before diagnosing non-organic pain:

  • Constipation is also very common
  • Urinary tract infection
  • Coeliac disease
  • Inflammatory bowel disease
  • Irritable bowel syndrome
  • Mesenteric adenitis
  • Abdominal migraine
  • Pyelonephritis
  • Henoch-Schonlein purpura
  • Tonsilitis
  • Diabetic ketoacidosis
  • Infantile colic

There are addition causes in adolescent girls:

  • Dysmenorrhea (period pain)
  • Mittelschmerz (ovulation pain)
  • Ectopic pregnancy
  • Pelvic inflammatory disease
  • Ovarian torsion
  • Pregnancy

 

Surgical Causes of Abdominal Pain

  • Appendicitis causes central abdominal pain spreading to the right iliac fossa
  • Intussusception causes colicky non-specific abdominal pain with redcurrant┬ájelly stools
  • Bowel obstruction causes pain, distention, absolute constipation and vomiting
  • Testicular torsion causes sudden onset, unilateral testicular pain, nausea and vomiting

 

Red Flags for Serious Abdominal Pain

  • Persistent or bilious vomiting
  • Severe chronic diarrhoea
  • Fever
  • Rectal bleeding
  • Weight loss or faltering growth
  • Dysphagia (difficulty swallowing)
  • Nighttime pain
  • Abdominal tenderness

Initial investigations that may indicate the pathology pathology:

  • Anaemia can indicate inflammatory bowel disease or coeliac disease
  • Raised inflammatory markers (ESR and CRP) can indicate inflammatory bowel disease
  • Raised anti-TTG or anti-EMA antibodies indicates coeliac disease
  • Raised faecal calprotectin indicates inflammatory bowel disease
  • Positive urine dipstick indicates a urinary tract infection

 

Recurrent Abdominal Pain

A diagnosis of recurrent abdominal pain is made when a child presents with repeated episodes of abdominal pain without an identifiable underlying cause. The pain is described as non-organic or functional. This is common and can lead to psychosocial problems, such as missed days at school and parental anxiety. There is overlap between the diagnoses of recurrent abdominal pain, abdominal migraine, irritable bowel syndrome and functional abdominal pain.

Recurrent abdominal pain often corresponds to stressful life events, such as loss of a relative or bullying. The leading theory for the cause is increased sensitivity and inappropriate pain signals from the visceral nerves (the nerves in the gut) in response to normal stimuli.

Management involves careful explanation and reassurance. Measures that can help manage the pain are:

  • Distracting the child from the pain with other activities or interests
  • Encourage parents not to ask about or focus on the pain
  • Advice about sleep, regular meals, healthy balanced diet, staying hydrated, exercise and reducing stress
  • Probiotic supplements may help symptoms of irritable bowel syndrome
  • Avoid NSAIDs such as ibuprofen
  • Address psychosocial triggers and exacerbating factors
  • Support from a school counsellor or child psychologist

 

Abdominal Migraine

Children are more likely than adults to suffer with a condition called abdominal migraine. This may occur in young children before they develop traditional migraines as they get older. Abdominal migraine presents with episodes of central abdominal pain lasting more than 1 hour. Examination will be normal.

There may be associated:

  • Nausea and vomiting
  • Anorexia
  • Pallor
  • Headache
  • Photophobia
  • Aura

Management of abdominal migraine is similar to migraine in adults. Careful explanation and education is important. It involves treating acute attacks and preventative measures. Preventative medications are initiated by a specialist.

Treating the acute attack:

  • Low stimulus environment (quiet, dark room)
  • Paracetamol
  • Ibuprofen
  • Sumatriptan

Preventative medications:

  • Pizotifen, a serotonin agonist
  • Propranolol, a non-selective beta blocker
  • Cyproheptadine, an antihistamine
  • Flunarazine, a calcium channel blocker

Pizotifen is the main preventative medication to remember for abdominal migraine. It needs to be withdrawn slowly when stopping as it is associated with withdrawal symptoms such as depression, anxiety, poor sleep and tremor.

 

Last updated January 2020
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