Adolescent Health Care: A Practical Guide

Chapter 36

Chronic Abdominal Pain

Paula K. Braverman

Chronic abdominal pain is a common complaint among teenagers and young adults. Efforts to treat chronic abdominal pain can lead to intense frustration among patients, families, and health care providers alike. The approach to this problem is particularly challenging in the adolescent population as there is often no specific organic abnormality found in most cases (~90%–95%).

Definition

Patients with chronic abdominal pain have been commonly diagnosed as having “recurrent abdominal pain (RAP)”. RAP (Apley and Naish, 1958) was defined as three or more separate episodes of pain for at least 3 months, which interfered with normal function and activities. However, RAP was a descriptive term rather than a specific diagnosis, and clinicians commonly used this terminology to refer to patients with chronic abdominal pain that was functional, psychogenic, or nonorganic in nature.

In 2005, the Subcommittee on Chronic Abdominal Pain of the North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition published a report suggesting that chronic abdominal pain can be long lasting, intermittent, or constant. They further suggested that pain exceeding 1 or 2 months in duration can be considered chronic and recommended that the term RAP no longer be used, calling their technical report “Chronic Abdominal Pain” (Di Lorenzo et al., 2005). The differential diagnosis of chronic abdominal pain includes functional gastrointestinal disorders (FGIDs) and organic disorders related to anatomic abnormalities, inflammation, or tissue damage. This chapter will focus on the diagnosis and treatment of chronic abdominal pain highlighting FGID.

Differential Diagnosis and Clinical Manifestations of Chronic Abdominal Pain

Functional Gastrointestinal Disorders

Epidemiology

The epidemiology of FGID is still in its infancy, as definitions of the various FGIDs in children and adolescents have recently been categorized and standardized. Older studies commonly used the previously established terminology of RAP to refer to entities which are now being described as FGIDs. Although the exact prevalence of FGID in adolescents is unknown, the following studies summarize what is known to date.

In a study by Oster (1972), the prevalence of RAP in patients between 6 and 19 years of age was as follows:

  1. Males: 12.1%
  2. Females: 16.7%
  3. Peak prevalence occurred at age 9 (21% male, 30% female)
  4. Prevalence at age 16 to 17 was approximately 5% of all adolescents

A more recent study by Hymans et al. (1996) found similar results in a community-based study of abdominal pain in 7th and 10th graders attending a suburban middle and high school. This study surveyed students on self-reported gastrointestinal (GI) symptoms but did not provide clinical evaluation to rule out organic disorders or specifically identify the cause of pain in a particular adolescent. In this study, there were no significant differences related to gender.

  1. Middle school: Mean age 12.6 years
  2. At least weekly pain: 13%
  3. Pain six or more times in last year: 32%
  4. Pain severe enough to affect activities: 24%
  5. High school: Mean age 15.6 years
  6. At least weekly pain: 17%
  7. Pain six or more times in last year: 37%
  8. Pain severe enough to affect activities: 17%

Etiology of Functional Gastrointestinal Disorders

Proposed etiologies of FGID include:

  1. Visceral hypersensitivity or hyperalgesia with a decreased threshold for pain
  2. Altered GI motility including altered contractile response to a meal
  3. Autonomic dysfunction with abnormal processing of signals at the level of central nervous system and disordered brain–gut communication

Altered bowel reactivity may occur secondary to the following:

  1. Physiological phenomena such as postprandial gastric/intestinal distension, intestinal gas, or GI reflux

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  1. Physical stress factors such as constipation, lactose intolerance, gastritis, mucosal inflammation from infection, or aerophagia
  2. Psychological stress factors such as parental separation, peer relationship problems, school problems, or anxiety

Diagnostic Criteria

During the last decade, FGIDs have been specifically defined by the Rome criteria for adults and subsequently the Rome II criteria for children and adolescents. The Rome II criteria define FGID as abdominal pain lasting for at least 12 weeks (not necessarily consecutive weeks) during the previous 12 months. Categories of FGID in children and adolescents include:

  1. Functional abdominal pain
  2. Functional dyspepsia
  3. Irritable bowel syndrome (IBS)
  4. Abdominal migraine
  5. Aerophagia

Many of the disorders causing chronic abdominal pain are the same for the child/adolescent and the adult classifications. However, the Rome II criteria divide the functional disorders by symptoms or complaints whereas the adult Rome classification is divided by the targeted organ (Table 36.1). A description of the disorders listed in Rome II criteria under the category “abdominal pain” (Rasquin-Weber et al., 1999) follows in subsequent sections.

Functional Abdominal Pain

  1. Epidemiology: Functional abdominal pain is the most common FGID.

TABLE 36.1
Rome Criteria for Functional Gastrointestinal Disorders

Adult Criteria with Selected Subcategories

Child/Adolescent Criteria with Selected Subcategories

Adapted from: Rasquin-Weber A, Hyman PE, Cucchiara S, et al. Childhood functional gastrointestinal disorders. Gut1999:45(Suppl II):II60.

Esophageal disorders

Vomiting

Gastroduodenal disorders

 Cyclic vomiting syndrome

 Functional dyspepsia

Abdominal pain

 Aerophagia

 Functional dyspepsia

 Functional vomiting

 Irritable bowel syndrome

Bowel disorders

 Functional abdominal pain

 Irritable bowel syndrome

 Abdominal migraine

 Functional constipation

 Aerophagia

 Functional diarrhea

Functional diarrhea

Functional abdominal pain

Disorders of defecation

Biliary disorders

 Functional constipation

Anorectal disorders

 Nonretentive fecal soiling

 Functional fecal incontinence

 
  1. Diagnostic criteria
  2. At least 12 weeks of continuous or nearly continuous pain either not related or only occasionally related to physiological events such as eating, menses, and defecation.
  3. The pain is not malingering.
  4. Loss of some daily functioning may occur.
  5. Criteria for other FGIDs not met.
  6. Associated symptoms can include
  7. Nausea without vomiting
  8. Headaches
  9. Dizziness
  10. Fatigue
  11. Lightheadedness
  12. Other factors
  13. The pain is usually periumbilical.
  14. Pain does not usually awaken the patient from sleep but may prevent the patient from falling asleep.
  15. Is associated with individuals who are perfectionistic, have high expectations of achievement, and may have unrecognized learning problems.

Irritable Bowel Syndrome

  1. Epidemiology

IBS occurs in 10% to 20% of adolescents and adults (Lynn and Friedman, 1993; Rasquin-Weber et al., 1999).

  1. In a community-based sample, symptoms consistent with IBS were found in 6% of 7th graders and 14% of 10th graders (Hymans et al., 1996).
  2. Prevalence in females is slightly higher than in males.
  3. Although symptoms increase with stress, an etiological link has not been proved.
  4. Cause of symptoms is probably multifactorial and related to motility and sensory abnormalities.
  5. Symptoms have been found after infective gastroenteritis.
  6. Diagnostic criteria
  7. Abdominal pain/discomfort without metabolic or structural abnormalities associated with disordered defecation and meets two of the following three criteria:
  • Pain relief with defecation

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  • Pain onset with associated changes in stool frequency
  • Pain onset with associated changes in form or appearance of stool
  1. Associated symptoms can include
  2. Abnormal stool passage including straining, urgency, or a feeling of incomplete evacuation
  3. Passage of mucus
  4. Bloating or feeling of abdominal distension
  5. Abnormal stool frequency: Greater than three bowel movements a day or less than three bowel movements a week
  6. Abnormal stool form: Loose/watery or hard/lumpy stools
  7. Other factors
  8. Symptoms do not awaken the patient from sleep

Functional Dyspepsia

  1. Description: Pain or discomfort centered in upper abdomen
  2. Epidemiology: The exact prevalence in adolescents is unknown
  3. Diagnostic criteria
  4. Pain in upper abdomen above the umbilicus
  5. No evidence of organic disease (e.g., normal upper endoscopy)
  6. Pain not relieved by defecation and not associated with change in stool frequency or form
  7. Types of dyspepsia
  8. Ulcer-like dyspepsia—predominant symptom is upper abdominal pain
  9. Dysmotility-like dyspepsia—nonpainful discomfort in upper abdomen with upper abdomen fullness, early satiety, bloating, or nausea
  10. Nonspecific dyspepsia—symptomatic patients not fitting the criteria for ulcer-like or dysmotility type

Abdominal Migraine

  1. Description: Acute incapacitating, noncolicky, midline abdominal pain, lasts for hours to days, associated with pallor and anorexia.
  2. Epidemiology: The exact prevalence in adolescents is unknown.
  3. Diagnostic criteria
  4. Must have at least three episodes in 12 months. Asymptomatic for weeks to months between episodes.
  5. Must have two of the following:
  • Headache during episode
  • Photophobia during episode
  • Family history of migraine
  • Unilateral headache
  • An aura with either visual, sensory, or motor disturbance
  1. No evidence of metabolic, GI, or central nervous system structural or biochemical diseases.
  2. Other factors: Diagnosis in the absence of a history of migraine headaches is presumptive.

Aerophagia

  1. Description: Excessive air swallowing resulting in abdominal distension and sometimes in limited oral intake because of discomfort.
  2. Epidemiology: The exact prevalence in adolescents is unknown.
  3. Diagnostic criteria: At least 12 weeks in the preceding 12 months of at least two of the following:
  4. Air swallowing
  5. Abdominal distension from intraluminal air
  6. Belching and/or flatus
  7. Other factors: Abdominal distension resolves during sleep.

Organic Causes of Chronic Abdominal Pain

Causes of Chronic Pain Commonly Associated with Dyspepsia

  1. Gastroesophageal reflux: Characterized by heartburn and acid regurgitation.
  2. Peptic ulcer disease: Characterized by midepigastric burning pain that can decrease with the ingestion of food or antacids. Peptic ulcers are usually associated with Helicobacter pylorigastritis.
  3. Biliary tract obstruction: Can result in recurrent episodes of epigastric and right upper quadrant (RUQ) abdominal pain, often with nausea and tenderness in the RUQ of the abdomen. Most adolescents with gallbladder stones have one of the following risk factors—use of oral contraceptives, recent pregnancy, family history of gall bladder disease, obesity, hemolysis, and teens receiving parenteral nutrition (Adye and Ryan, 1983; Reif et al., 1991). Approximately 8% of adolescents with gallstones develop pancreatitis (Reif et al., 1991).
  4. Gallbladder dyskinesia: Acalculous biliary colic which is associated with delayed gallbladder emptying.
  5. Chronic pancreatitis: Characterized by midepigastric pain radiating to the back and associated with nausea and vomiting.
  6. Gastroparesis: Can be associated with epigastric pain, nausea, and vomiting and can occur after a viral infection.
  7. Chronic hepatitis

Causes of Chronic Pain Commonly Associated with Altered Bowel Pattern

  1. Lactose intolerance: Caused by a maturational decline in functional lactase activity associated with crampy abdominal pain, diarrhea, flatulence, and belching. It is common in individuals of African-American, Asian, Hispanic, Native American, and Jewish descent.
  2. Inflammatory bowel disease (IBD): IBD can be manifested by the following:
  3. Poor growth
  4. Anemia and elevated erythrocyte sedimentation rate (ESR)
  5. Bloody stools—although stools may be positive for hemoccult without signs of diarrhea
  6. Systemic symptoms—arthritis, iritis, hepatitis, and erythema nodosum
  7. Abnormal findings on radiological contrast studies
  8. Celiac disease: One of the most common genetic diseases occurring in approximately 1 in 250 individuals in the United States and 1 in 18 if a first-degree relative is affected. This disease is often under recognized and under diagnosed by health care providers. Celiac disease can be symptomatic, asymptomatic, or latent. Symptoms include diarrhea, abdominal pain, weight loss, flatulence,

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and nutritional deficiencies. However, 70% to 80% of individuals have silent disease and may only manifest the disease through non-GI symptoms such as dermatitis, osteopenia, short stature, delayed puberty, iron deficiency anemia resistant to oral iron, hepatitis, arthritis, aphthous stomatitis, and epilepsy. Associated conditions include diabetes mellitus, thyroiditis, and Down syndrome. Diagnosis is dependent on suspecting the disease, screening with serological testing, and then small bowel biopsy for confirmation in those with positive serology.

  1. Colitis
  2. Complications of constipation: Encoporesis, megacolon
  3. Infection: Parasites (e.g., Giardia lamblia, Blastocystis hominis) and bacteria (e.g., Clostridium difficile, Yersinia, Campylobacter)
  4. Giardiasis, in particular, may mimic cases of FGID. Individuals with giardiasis may complain of subacute or chronic abdominal pain with bloating, as well as flatulence with or without diarrhea.
  5. Parasitic disease may also present with chronic pain in the absence of an alteration in bowel pattern.
  6. difficilecan be established in the GI tract after the normal flora have been altered by antibiotic use.

Causes of Chronic Pain Commonly Associated with Paroxysmal Abdominal Pain

  1. Musculoskeletal pain: Costochondritis, myositis, or abdominal wall muscle strain may be the cause of abdominal pain. Abdominal wall pain and tenderness are not uncommon in teens who are into athletic training.
  2. Obstructed viscus: Bowel obstruction caused by adhesions or volvulus.
  3. Ureter obstruction: Caused by kidney stones, results in colicky pain, often radiating to the groin.

Gynecological Conditions Associated with Chronic Pain

  1. Pelvic adhesions—sometimes secondary to pelvic inflammatory disease
  2. Mittelschmerz
  3. Dysmenorrhea
  4. Endometriosis
  5. Obstructive müllerian anomalies
  6. Ovarian mass
  7. Hydrosalpinx of fallopian tube
  8. Fibroids

Other Conditions Associated with Recurrent Abdominal Pain

  1. Capsular distension
  2. Hepatomegaly or splenomegaly
  3. Referred pain
  4. May be a result of involvement of the lower lobes of the lung (e.g., pneumonia).
  5. An uncommon source of referred pain is from spinal cord tumors (Neinstein, 1989) or discitis (Leahy et al., 1984).
  6. Systemic conditions
  7. Diabetic ketoacidosis
  8. Sickle cell crisis
  9. Hereditary angioneurotic edema—may occur without cutaneous or oropharyngeal edema
  10. Polyarteritis nodosa
  11. Lead intoxication
  12. Acute intermittent porphyria

Diagnosis

The Subcommittee on Chronic Abdominal Pain in Children reviewed the existing literature and was unable to produce an evidence-based procedural algorithm for the diagnostic evaluation of chronic abdominal pain. Clinicians attempt to distinguish organic causes of abdominal pain from functional disorders on the basis of the history, physical examination, and results of simple screening laboratory tests. The conclusions drawn by the subcommittee regarding the diagnostic value of these components (Di Lorenzo et al., 2005) are detailed in the following sections.

History

  1. Functional abdominal pain disorders have different phenotypic manifestations. There is credible evidence of separate entities that include functional dyspepsia, IBS, and abdominal migraine. Some patients have features of more than one entity.
  2. Functional and organic disorders cannot be distinguished by the pain frequency, severity, location, or impact on lifestyle. Timing of the symptoms including postprandial pain and night-time awakening, were not found to be helpful. Although chronic abdominal pain has been associated with headache, joint pain, anorexia, vomiting, nausea, excessive gas, and altered bowel symptoms, there is insufficient evidence to indicate that these associated symptoms are helpful in distinguishing between functional and organic disorders.
  3. “Alarm symptoms or signs” suggestive of organic disease requiring further diagnostic testing include but are not limited to the following:
  4. Involuntary weight loss
  5. Family history of IBD
  6. Deceleration in linear growth
  7. Unexplained fever
  8. GI blood loss
  9. Significant vomiting—cyclical vomiting, bilious emesis
  10. Chronic severe diarrhea
  11. Persistent RUQ or right lower quadrant pain
  12. Family history
  13. Although parents of patients with FGID have more anxiety, depression, and somatization, such a history is not helpful in distinguishing between functional and organic disorders.
  14. Families of patients with FGID do not differ from families of patients who are healthy or have an acute illness, with respect to overall family functioning (e.g., cohesion, conflict, marital satisfaction).
  15. A family history of metabolic or hematological problems may suggest organic disease, for example, porphyria, diabetes, or sickle cell anemia.
  16. Issues regarding the relationship of pain to current stress and emotional and behavioral concerns include:
  17. Patients with FGID have more anxiety, depression, and negative life event stress. However, the presence of recent negative life events, anxiety, and depression

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do not distinguish functional from organic abdominal pain.

  1. There is a relationship between daily stressors and pain episodes as well as increased negative life events and persistent symptoms.
  2. There is no evidence to support the concept of emotional/behavioral symptoms predicting the severity of pain, course of the pain episode, or response to treatment.
  3. There is evidence to support that adolescents with FGID are at risk for emotional problems and psychiatric disorders (e.g., anxiety and depression) later in life.
  4. Examples of stress areas to investigate in adolescents and young adults include:
  • Home
  • Parental arguments, separation, or divorce Illness or chronic handicap in a family member/loss of family member
  • Move to another location
  • Peers
  • Loss of friends
  • Teasing by friends
  • Pressure by friends
  • School
  • Change of school
  • School failure
  • Pressure in school
  • Teacher–pupil problems

Additional history elements not mentioned in subcommittee report:

  1. Pain diary: It may be helpful to have the teen keep a diary of the pain, describing the pattern, timing, severity, and precipitating factors for 1 to 3 weeks. It is also useful to include documentation of fast foods, fried foods, milk products, carbonated beverages, dietary starches, and sorbitol-containing products and to ask about any foods that may precipitate pain. In addition to helping the clinician work through the differential diagnosis, this type of diary provides a way for the teen to be directly involved in their care plan.

Physical Examination

FGIDs are usually associated with normal findings on physical examination or mild pressure tenderness without rebound commonly located in the upper abdomen. Signs of organic disorders mentioned by the subcommittee include the following:

  1. Lack of growth—evidence of weight loss, decreased growth
  2. Hepatosplenomegaly
  3. Abdominal masses or localized fullness with mass effect
  4. Perianal area—fistulas, fissure, or abscesses
  5. Pelvic examination—ovarian masses, adnexal tenderness
  6. Spine or costovertebral angle tenderness

Additional signs and symptoms suggestive of organic abdominal pain not specifically referred to in the subcommittee report include:

  1. Well-localized pain with location remaining constant
  2. Jaundice
  3. Skin rash
  4. Oral aphthous ulcer lesions
  5. Arthritis
  6. Delayed puberty, short stature—often early signs of organic disease

Laboratory Tests/Radiological Studies/Diagnostic Tests

The Subcommittee on Chronic Abdominal Pain reached the following conclusions regarding laboratory, radiological, and other diagnostic tests:

  1. No studies have been done to specifically evaluate the use of laboratory tests to distinguish between functional and organic abdominal pain even in the face of alarm signals.
  2. There is no evidence that ultrasonography of the abdomen or pelvis, endoscopy, and biopsy, or pH monitoring in the absence of alarm signals significantly detects organic disease.
  3. Ultrasonography of the abdomen and pelvis detects abnormalities without “alarm signals” <1% of the time compared with 10% when atypical symptoms exist.
  4. FGID can be diagnosed by a primary care clinician when there are no alarm symptoms, the physical examination is normal, and there is a negative stool sample for occult blood. Testing is sometimes necessary to reassure the patient and his or her family when the pain is significantly affecting the patient's quality of life.

Testing for Organic Disorders

The following tests should be considered in the evaluation of a possible organic disorders (Boyle,2004; Rasquin-Weber et al., 1999):

  1. Primary screening tests
  2. Complete blood count with differential
  3. ESR
  4. Urinalysis with or without culture
  5. Chemistry profile with liver function tests
  6. Stool samples obtained for evidence of occult blood, ova, and parasites (including stool for Giardia antigen).
  7. If diarrhea is present additional studies to be considered include:
  8. Stool for difficiletoxin
  9. Lactose breath test
  10. Celiac panel
  11. If dyspepsia is present additional studies to be considered include:
  12. Serological testing for H. pyloriantibody (enzyme-linked immunosorbent assay [ELISA])
  13. Serum amylase and lipase
  14. If dyspepsia is associated with recurrent vomiting then an upper GI series with small bowel follow through and abdominal ultrasonography should be considered.
  15. If dyspepsia is associated with RUQ pain then an abdominal ultrasonography may need to be considered. Hepatobiliary scintigraphy with cholecystokinin infusion to evaluate ejection fraction of gallbladder may also be considered.

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  1. Endoscopy—if symptoms are not consistent with functional dyspepsia or are unresponsive to treatment.
  2. If RUQ pain suggesting gall bladder disease or right lower quadrant pain suggesting IBD is present
  3. Abdominal ultrasonography
  4. Upper GI and small bowel follow through
  5. If symptoms suggest obstruction
  6. Upper GI and small bowel follow through
  7. Indications for colonoscopy include the following:
  8. GI bleeding
  9. Profuse diarrhea
  10. Involuntary weight loss
  11. Growth deceleration
  12. Elevated ESR
  13. Iron deficiency
  14. Other signs of IBD including rash, joint pain, fever, and aphthous ulcers

Colonoscopy is considered superior to barium enema in further evaluation for diagnoses of IBD and colitis.

  1. Other tests depending on history and initial laboratory evaluation are as follows:
  2. Renal ultrasonography if renal or urinary abnormalities are detected.
  3. Pelvic ultrasonography for gynecological complaints or findings.
  4. Sickle cell screening for African-American patients.
  5. Urine porphyrins if unusual, recurrent, severe abdominal pain exists.

Approach to the Evaluation of Functional Gastrointestinal Disorders

If after a careful history and physical examination there is no obvious organic source for the chronic abdominal pain, the practitioner should explain to the teen that the evaluation seems to indicate a FGID. Although a serious underlying disease is not suspected, the teen should appreciate that the symptoms they are experiencing are real. It is also useful to explain the concepts of visceral hypersensitivity, altered motility, and autonomic dysfunction with disordered brain–gut communication in terms that the adolescent and family can understand. A good analogy would be an explanation of the physiological response to “blushing.” Blushing is physiological response to the feelings of embarrassment or stress, which cause physical symptoms that are not under the complete control of the patient. Other examples include the increased sensitivity of a healing scar or diarrhea during stressful situations. If further clarification of the history is needed, the teen should be asked to keep a pain diary with a follow-up appointment scheduled in 1 to 3 weeks. If there are alarm signals or further diagnostic tests are necessary for reassurance, selected screening utilizing laboratory tests and/or radiological studies can be performed.

Treatment or Therapeutic Approach

FGIDs are best treated in the context of a biopsychosocial model which may include psychological interventions, dietary changes, and some specific pharmacological therapy to reduce the frequency and severity of the symptoms. There are limited studies of pharmacological therapy in children and adolescents. Pharmacological therapy should be used judiciously for specific symptomatology and specific functional GI conditions. Psychological and physical pain triggers should be identified so that they can be modified or reversed. The goal of treatment is to resume normal functioning and return to daily activities rather than focusing on the pain itself.

The Subcommittee on Chronic Abdominal Pain Conclusions on Treatment

The Subcommittee on Chronic Abdominal Pain in Children found a paucity of studies evaluating pharmacological and dietary treatments in children and adolescents (Di Lorenzo, 2005). They concluded the following:

  1. Two weeks of treatment with peppermint-oil capsules may be beneficial for children with IBS.
  2. Evidence for benefit of H2receptor antagonists is inconclusive but may be beneficial in patients with severe dyspepsia.
  3. Evidence for benefit of fiber supplementation in decreasing frequency of pain attacks is inconclusive but a small controlled study showed a small statistically significant decrease in pain episodes in children.
  4. Lactose intolerance and recurrent pain appear to be two different entities. The evidence that a lactose-free diet decreases symptoms for patients with RAP is inconclusive.

Treatment Options For Functional Gastrointestinal Disorders

Treatment options include the following (Boyle, 2004; Weydert et al., 2003; Di Lorenzo et al., 2005; Rasquin-Weber et al., 1999; Lesbros-Pantoflickova et al., 2004).

Pharmacological Treatments

The following medications have some evidence of effectiveness from pediatric and adult studies:

  1. Enteric coated peppermint-oil capsules—thought to have smooth muscle relaxing properties. A 2-week trial in children with IBS revealed a reduction in pain (Kline et al., 2001). A meta-analysis of studies in adults has shown conflicting results (Lesbros-Pantoflickova et al., 2004).
  2. H2receptor antagonists—Placebo-controlled studies in adults have shown that acid reduction therapy may relieve some symptoms of ulcer-like dyspepsia. As such the subcommittee report stated that there may be some benefit in a 4- to 6-week trial of H2 receptor antagonists in patients with severe dyspepsia. One pediatric study conducted with famotidine demonstrated efficacy (See et al., 2001).
  3. Failure to respond or relapse with a step-down of therapy should prompt further evaluation with upper endoscopy.
  4. Proton pump inhibitors can be tried in those with confirmed functional dyspepsia who do not respond to H2receptor antagonists.
  5. Pizotifen—a serotonin antagonist has been effective prophylactically for abdominal migraine. This drug has not yet been approved for use in United States. In

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some studies, propanolol and cyproheptadine have been shown to be effective.

  1. 5-HT4antagonist (tegaserod) has been helpful in adult women with constipation-predominant IBS.
  2. 5-HT3antagonist (alosteron) has been helpful in adult women with severe diarrhea-predominant IBS. Because of potential side effects (severe constipation, ischemic colitis, bowel perforation) it is only available under a restricted prescribing program.
  3. Tricyclic antidepressants (imipramine, amitriptyline) have been used at low doses with improvement in controlled studies in adults with IBS and appear particularly useful in cases of IBS with refractory diarrhea.

Other symptomatic treatment options:

  1. Metoclopramide—there is limited testing in adults with functional dyspepsia but a short course could be tried for dysmotility-like dyspepsia.
  2. Nonstimulating laxatives—mineral oil, milk of magnesia, lactulose—may be helpful in constipation-predominant IBS.
  3. Antispasmodic or anticholinergic agents may be used for symptomatic relief on short-term basis. Efficacy is controversial for visceral pain and a meta-analysis of studies in patients with IBS has shown conflicting results (Lesbros-Pantoflickova et al., 2004).
  4. Treatment for H. pylori-positive patients in the absence of peptic ulcer disease is controversial and not proved. However, some pediatric gastroenterologists would treat cases of functional dyspepsia (Boyle, 2004).

Fiber and Dietary Modifications

  1. High-fiber diet has been recommended in both constipation-predominant and diarrhea-predominant IBS as well as functional abdominal pain. It is important to note however, that both the Subcommittee on Chronic Abdominal Pain in Children and the meta-analysis of studies on adults with IBS did not provide strong evidence of clinical efficacy of fiber in IBS. Excessive fiber should be avoided because it may cause gas and distension. Foods high in fiber are listed in Table 36.2.
  2. Fiber supplements—if foods high in fiber are unsuccessful, one teaspoon of psyllium seed (Metamucil or Citrucel) in orange juice, one to three times a day, can be used. Fiber supplements are also available in tablet form.
  3. Patients with IBS having excessive gas or flatulence may benefit from eating slowly, eliminating gum chewing, and avoiding carbonated beverages, legumes, cabbage, and foods with aspartame.
  4. Dietary carbohydrates—malabsorption may be a provocative stimulant. Avoid excessive carbonated beverages (fructose), starches, and sorbitol products.

Psychological Interventions

Counseling consists of reassuring the adolescent and his or her family that the abdominal pain which accompanies FGID is real and that no specific organic disease has been found. The practitioner should stress that the pain is not “in the adolescent's head” but is a real manifestation which can be exacerbated by stress. It is important to reassure the adolescent that he/she is physically healthy and can continue with all activities. Often teens with FGID miss a lot of school. If this is the case, the family, teachers, and school nurse should work together with the teen to keep him/her in school. Significant changes in or atypical characteristics of the pain should prompt reevaluation.

TABLE 36.2
Examples of High-Fiber Foods

Food

Amount

Plant Fiber (g)

Bran cereal

½ cup

33.1

Popcorn

3 cups

15.5

Wheat cereal

¾ cup

13.1

Cornflakes

¾ cup

11.0

Rye bread

1 slice

10.8

Graham crackers

2 crackers

10.1

Pinto beans

½ cup

10.0

Peas

½ cup

 7.8

If significant depression, anxiety, or family problems are uncovered, the teen and family can be referred for further psychological or family assessment. However, psychological intervention may be helpful even in less severe cases. Cognitive behavioral therapy has been demonstrated to be successful for treating functional disorders in children and adolescents. Other techniques which have been tried include teaching relaxation, self management, coping, and behavior management techniques. Ultimately, the goal is to reduce illness behavior and to help the parents reinforce good coping behavior.

Studies have shown a better response to treatment in adolescents who had signs and symptoms for <6 months compared to those who had complaints for 2 years (Silverberg, 1991;Apley and Hale, 1973). Prompt recognition and intervention is important. Long-term follow-up studies have shown that >25% to 50% of adolescents with functional chronic abdominal pain continue to have symptoms as adults (Hotopf et al., 1998). Children and adolescents with functional abdominal pain are at increased risk for somatic complaints and psychiatric disorders (anxiety and depressive disorders) as adults (Hotopf et al., 1998; Campo et al., 2001; Walker et al., 1995; Magni et al., 1987).

Web Sites

For Teenagers and Parents

http://www.acg.gi.org. Home page for American College of Gastroenterology.

http://www.iffgd.org/. Home page for the International Foundation for Functional Gastrointestinal Diseases.

http://www.naspgn.org. Home page for North American Society for Pediatric Gastroenterology and Nutrition.

For Health Professionals

http://www.acg.gi.org. Home page for American College of Gastroenterology.

http://www.iffgd.org/. Home page for the International Foundation for Functional Gastrointestinal Diseases.

http://www.merck.com.Merck Manual on line. Enter topic of interest.

http://www.naspgn.org/. Home page of North American Society for Pediatric Gastroenterology and Nutrition. Position papers on various topics online including Functional Abdominal Pain.

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References and Additional Readings

Adye B, Ryan JA Jr. Cholecystitis in teenage girls. West J Med 1983;139:471.

Al-Homaidhi HS, Sukerek H, Klein M, et al. Biliary dyskinesia in children. Pediatr Surg Int 2002;18:357.

Ament ME, Zeltzer L. Chronic abdominal pain in children. Clin Perspect Gastroenterol 2000;3:40.

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