Recurrent abdominal pains are a common presentation to general practitioners, paediatricians, and emergency departments.  Empathy with the parents and dealing with their concerns is an important part of management of these sometimes challenging consultations.

A careful history and examination will:

• lessen the need for unnecessary investigations
• Rule out significant organic causes
• Provide a framework of management.

Introduction

Recurrent abdominal pains is defined as pains which occur regularly which impact on the day to day life of the child. These pains will very from frequent complaining without other features, to doubling over and retiring to bed. These pains are central, come and go and are frequent in the mornings and late in the day. They usually occur in the 5-10 year olds

Symptoms suggesting Functional cause

• Several times per week, well between episodes
• Sleep and activity not effected by abdominal pains
• Appetite normal
• Present for many months/years without any concerning symptoms.

Functional causes

• Sensitivity to the ‘moans and groans’ of the GIT tract
• Constipation
• Part of anxiety
• Irritable bowel

Red flags indicating Organic cause

• Pains quickly increasing over time with other symptoms
• Documented weight loss, or lessening of growth velocity
• Other GIT symptoms, including diarrhoea, constipation, vomiting, anorexia
• Other symptoms, such as fevers, rashes,
• Findings on abdominal examination – palpable liver, spleen or impression of a mass, faecal impaction

Organic causes 

• Infection – persistent parasite infection such as giardia
• Inflammation – Inflammatory bowel disease
• Hypersensitivity reactions to food
• Coeliac disease
• Surgical causes – intermittent volvulus, meckels diverticulum
• Adolescent gynaecological causes
• Upper GI causes – oesophagitis, gastritis
• Hepatosplenomegaly

Assessment

Practice Tip –

• careful empathetic history and examination will avoid unnecessary investigations and (hopefully) lots of alternative opinions.
• Ask what the parent’s think is the the cause. After Hx and Ex directly discuss their specific concerns. Many parents are concerned about
  • Possible tumour
  • Gut anomaly
  • Food allergies/intolerances

History – ask about 

• Pain – onset, frequency, site, what does a usual episode look like. Non organic causes are vague and central and have been present for months/years
• Any associated symptoms to suggest organic cause – weight loss, fevers, diarrhoea, vomiting, night waking with pain.
• School and activity – how are these pains affecting day to day life
• Bowels –  symptoms to suggest bowel function as a cause, particularly if considering constipation, irritable bowel.
• Treatments tried including dietary restrictions, medications, alternative treatments.
• General demeanor, relaxed, anxious, school avoidance behaviour.
• Voiding issues – (constipation can be a cause of enuresis)

Examination

• Measure ht/wt, and check/print percentiles – this is essential as part of the therapeutic relationship
• Perform abdominal and general examination. Check conjunctiva for pallor, jaundice, ensure no hepatosplenomegaly, faecal impaction.
• Check for atopy.

Targeted Investigations

• Faeces MCS – Consider giardia infection.
• Blood tests if considering Coeliac or IBD.  These should be limited to FBC/ESR/Coeliac serology.  Extensive shotgun blood tests in otherwise healthy children may result in anomalies actioning further unnecessary tests or referrals adding to parental anxiety
• AXR is not contributory and results in unnecessary radiation exposure
• Abdominal US – This will be normal in functional and some organic causes. It’s role is to rule out parental causes.
• helicobacter breath tests are rarely indicated in recurrent abdominal pains unless concerned about dyspepsia

Management

Organic causes – Investigate and refer as per current guidelines

Non – Organic or functional.

Education

• Start by addressing parent’s specific concerns, and then deciding with the parent what the next step involves. Discuss recurrent abdominal pains in children. Use headaches as an analogy, they are sometimes frequent, can be significant, but there is often not a simple explanation or cure. A significant cause will result in associated other symptoms – particularly in growth. Advise that extensive investigations are unnecessary.

Further Management

• If the parent is particularly anxious, an abdominal US is a reasonable investigation.
• If the parent or  GP is still keen for tests consider a FBC/ESR/ Coeliac serology +/- Fe Studies.
• Encourage regular toilet sitting, school attendance, a healthy diet and active lifestyle.
• Review in a month with a diary to assess episodes and also recheck weight is an appropriate first line management
• If concerned about anxiety as a cause consider assessment and referral to child psychologist

When to refer Non organic causes

• If it is clear the parent is unhappy and feels more needs to be done – consider general paediatrician
• If the child has comorbid anxiety – refer to child psychologist