JRSM >
Volume 98, Number 3 >
Pp. 101-106
Paediatric Medical Unit, Southampton General Hospital, Tremona Road, Southampton SO16 6YD, UK
Correspondence to: R M Beattie E-mail: Mark.beattie{at}suht.swest.nhs.uk
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| PREVALENCE |
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Apley defined the syndrome of recurrent abdominal pain in childhood as three episodes of abdominal pain occurring in the space of three months, severe enough to affect daily activities.1 These criteria were intended to eliminate trivial cases and focus on functional impairment. In Apley's original study, the prevalence of recurrent abdominal pain in a population of schoolchildren was 10%. In subsequent studies using his criteria the prevalence ranged from 11% to 45%.2–5 The width of this range is probably attributable to differences in age, geographical area and social factors and methodology. Nevertheless, recurrent abdominal pain is clearly no less troublesome now than when Apley described it in 1958.
| CLASSIFICATION BY SYNDROME |
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In 1997, a consensus meeting defined criteria for 'functional gastrointestinal disorders' in infancy and childhood and adolescence.6 Revised in 1999, these 'Rome II' criteria (Box 1) classify abdominal pain disorders as functional dyspepsia, irritable bowel syndrome, functional abdominal pain, abdominal migraine and aerophagia. This classification, though yet to be validated, is expected to be useful both clinically and in research on the principle that subgroups of patients with similar symptoms are likely to have similar underlying aetiologies. Hence, further investigation in these subgroups may yield individual treatment options. In a prospective series of 107 children who met Apley's criteria for recurrent abdominal pain, Walker et al.7 were able to group 73% according to the Rome II criteria. However, the fact that 27% of the patients could not be classified is a weakness and critics say that Rome II should be reserved for research until further validated.8
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| AETIOLOGY |
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Visceral hyperalgesia
It has been postulated that psychological stress leads to changes in the
'brain–gut axis', altering the perception of visceral
sensation. This may lead to a phenomenon known as 'visceral
hyperalgesia'. Di Lorenzo et
al.13 demonstrated
visceral hyperalgesia in small groups of children with recurrent abdominal
pain or irritable bowel syndrome, and also found high rates of anxiety in
these groups.
Biopsychosocial model
Another focus of attention is the psychological environment within the
family. The biophysical model proposes that recurrent abdominal pain is the
child's response to biological factors, governed by an interaction
between the child's temperament and the family and school environments.
Crushell et
al.14
postulated that the child's symptoms might be influenced by the parental
conceptual model of illness. Investigating families of patients with severe
recurrent abdominal pain requiring hospital admission they found that the
child was more likely to have recovered at follow-up if his or her parents had
attributed symptoms to psychological factors. These workers therefore
concluded that acceptance by parents of a biopsychosocial model of illness is
an important factor in resolution of symptoms.
Organic disease
Since Apley's day, advances in medical investigations have allowed
more complete assessment for underlying organic disease: whereas in his
original population only 8% had an identifiable 'organic' cause for
their
pain,1,15
a recent study in Bristol found an organic cause in as many as 30% of children
presenting with recurrent abdominal
pain.16 This
difference could have several explanations. Firstly, the researchers used
investigations not available to Apley in 1958 such as Helicobacter
pylori serology. Secondly, the study population consisted of children
referred to hospital, whereas Apley's were schoolchildren undergoing
routine medical assessment. Thirdly, many organic abnormalities may be
incidental findings—e.g., minor gastritis on endoscopy.
Infection with H. pylori
Performing upper gastrointestinal endoscopy in 82 children presenting with
recurrent abdominal pain, Ashorn et
al.17 found
evidence of infection with H. pylori (based on histology and/or
culture) in 22%. Thus, organic disease was much more prevalent than others had
supposed, and a sizeable proportion was due to H. pylori. However,
conflicting evidence has come from other similar studies. Hyams et
al.18 looked
for H. pylori infection in 127 children presenting with dyspepsia and
found it in only 5.
Even if H. pylori infection were common, there is no strong evidence that it causes pain in the absence of peptic ulceration. Donohue et al.19 reported a 16.7% prevalence of H. pylori positive serology in a large sample of urban schoolchildren but there was no relation between positive serology and a history of recurrent abdominal pain.
Gastrointestinal motility disorders
Another postulated organic cause of recurrent abdominal pain, especially
the dyspepsia type, is abnormal small-bowel transit. Studying 57 children with
symptoms of functional dyspepsia Chitkara et
al.20 found
that 40% had slow small-bowel transit; furthermore, children with fast
small-bowel transit were less likely to report pain. They concluded that upper
gastrointestinal transit studies may be useful in the evaluation of children
with dyspeptic symptoms.
Abdominal migraine
Many researchers have proposed that abdominal migraine accounts for some
cases of recurrent abdominal pain. Indeed, the Rome II criteria recognize this
as a phenomenon in its own right, affecting 2% of
children.6 The
concept of abdominal migraine is supported by the positive response to
anti-migraine treatments such as pizotifen in carefully selected
cases.21
Food allergies
There is no convincing evidence for food allergy or intolerance as
aetiological factors in large cohorts of children with recurrent abdominal
pain. Nevertheless some patients report benefit from dietary
restriction—e.g., lactose-free or wheat-free diets—and dietary
exclusion is frequently tried by 'alternative' healthcare
practitioners. Although adverse food reactions may be implicated in some
cases, at present there are no reliable diagnostic investigations other than
food
challenge.22
Constipation/incomplete rectal evacuation
Constipation may be a factor in recurrent abdominal pain as part of the
irritable bowel syndrome symptom complex. Factors such as incomplete rectal
evacuation are important. Lifestyle issues may be relevant, including poor
diet, poor fluid intake and lack of exercise.
| THERAPEUTIC OPTIONS |
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Psychological interventions
Cognitive–behavioural therapy
In many instances, all that is needed from the doctor is acknowledgment of
the symptoms and reassurance that there is no serious underlying organic
disease. When Sanders et
al.23 compared
this approach (standard paediatric care) with cognitive–behavioural
therapy they found that both groups improved though the response was somewhat
better in the cognitive–behavioural therapy group. They suggested that
psychological intervention may have a role in difficult cases. The aims of
psychological therapy are to modify thoughts, beliefs and behavioural
responses to symptoms and the effects of illness. In addition to
cognitive–behavioural therapy the modalities include biofeedback,
relaxation therapy, coping skills training, hypnosis and family therapy.
Janicke and Finney24 reviewed the published evidence regarding the effectiveness of cognitive–behavioural therapy, operant procedures and fibre treatment as interventions in recurrent abdominal pain. Although none of the treatment approaches met the criteria for well-established interventions, cognitive–behavioural therapy emerged as a 'probably efficacious intervention'. The conclusion of a Cochrane review of published data25 was that there was no evidence for the role of any psychological therapies in attenuating pain in childhood in any conditions other than headache; the reviewers were indeed able to find only two studies for recurrent abdominal pain that met their selection criteria.
Self-hypnosis
Self-hypnosis has been studied in 5 patients by
Anbar.26 After a
single session of instruction in self-hypnosis 4 lost their symptoms within
three weeks. This approach has yet to be tested in a prospective controlled
trial.
Dietary management
Data on dietary intervention are scarce and deal mainly with fibre
supplementation and lactose exclusion. Whereas dietary fibre supplementation
is a recognized strategy for management for childhood constipation, its value
in recurrent abdominal pain is uncertain. The two randomized trials comparing
fibre treatment with
placebo27,28
have yielded conflicting results. The data on lactose-free diets are likewise
inconclusive, and a Cochrane review calls for 'well-designed trials of
all recommended dietary
interventions'.29
A sensible course, despite lack of published evidence, is to recommend healthy eating including plenty of fruit and vegetables, regular sensible meals and plenty of fluids. This should be coupled with a daily routine with plenty of physical activity.
Pharmacological therapy
Although many pharmacological interventions have been tried, few have been
formally tested. Simple analgesics and antispasmodics are commonly prescribed.
A Cochrane systematic review of pharmaceutical therapies for recurrent
abdominal pain30
found only one randomized trial. This compared the effectiveness of pizotifen
and placebo in 14 patients with abdominal
migraine.21
Pizotifen was superior to placebo as a prophylactic drug but the study size is
too small to allow firm conclusions. A more recent systematic
review31 identified
further studies, including a double-blind crossover trial of famotidine versus
placebo in 25 children with recurrent abdominal pain featuring dyspepsia. A
lessening of dyspepsia symptoms by
famotidine32
suggested a role for such H2 antagonists. A further randomized
trial assessed the effectiveness of peppermint oil in 50 children aged
8–12 with irritable bowel
syndrome.33
Severity of symptoms was reduced in 76% of the treatment group and only 12% of
the placebo group. The different modes of action of these interventions
reflect the multiple causation of recurrent abdominal pain and strengthen the
case for targeted approaches to management.
| OUTCOME/PROGNOSIS |
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The above observations suggest that childhood recurrent abdominal pain can be a precursor for anxiety disorders in later life. This would support the model of 'somatosensory amplification' described by Barsky et al.39 which states that anxious children perceive novel bodily perceptions as threatening and are thus more likely to report somatic symptoms than controls (biopsychosocial model). The findings also indicate that recurrent abdominal pain should not be dismissed as a transient reaction to adverse stress. The implications for the future have to be considered, along with careful assessment of the patient for evidence of stress and anxiety disorders that may become more prominent or generate other somatic symptoms in later life.
| RECOMMENDED CLINICAL APPROACH |
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TOPINTRODUCTIONPREVALENCECLASSIFICATION BY SYNDROMEAETIOLOGYTHERAPEUTIC OPTIONSOUTCOME/PROGNOSISRECOMMENDED CLINICAL APPROACHCONCLUSIONSREFERENCES |
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1. Exclude organic disease
In taking the history and examining the child, the clinician's first
task is to rule out the wide range of organic disorders that may present with
recurrent abdominal pain (Box
2).
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In the absence of likely underlying organic disease, it is useful to elicit features known to be associated with childhood recurrent abdominal pain such as psychological stress and anxiety. Many of these will become apparent when a detailed social history is taken. Typical social factors leading to psychological stress are bereavement, altered peer relationships, school problems and illness in a family member. It is important not just to ask about illnesses in the family but also to ask about how those illnesses impact on the family. This part of the assessment may also reveal a family history of anxiety disorders, or an anxious temperament in the child.
2. Classify by symptomatology and target the investigations
The next logical step is to attempt to classify the symptoms according to
the Rome II criteria (Box 1).
Although not strictly validated, these help the clinician to target further
investigation and management. The mainstay of management is reassurance. In
cases where the symptoms impact on the child's and family's
functioning enough to warrant further investigation, I suggest beginning with
the following: full blood count; erythrocyte sedimentation rate/C-reactive
protein; renal and liver function; coeliac antibody screen; urine microscopy
and culture. Investigations such as ultrasound, barium radiology, and
endoscopy may be indicated when symptoms dictate or when there are pointers
from tests of blood or urine.
3. Treatment
The mainstay of treatment is reassurance with an emphasis on
rehabilitation. Therefore, the first step is to acknowledge to the family and
child that the pain is a real symptom. It is then necessary to recognize and
treat any underlying or contributing factors, including a tendency to
constipation. Avoid excessive medications such as non-steroidal
anti-inflammatory drugs (NSAIDs). Promote a healthy diet and lifestyle.
Assessment with a dietitian may be helpful. It is worthwhile identifying
dietary triggers and suggesting alternatives. If the patient has an anxious
temperament, consider psychological therapy. Many families are looking for an
explanation for the symptoms and need to have discussed with them the
inseparability of physical and psychological causes of symptoms.
Rehabilitation should be goal-based, with simple targets such as optimizing
school attendance, a graded exercise programme and reduction of NSAIDs. The
choice should be followed up until symptoms resolve and to give an opportunity
for any psychiatric comorbidity to emerge.
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TOPINTRODUCTIONPREVALENCECLASSIFICATION BY SYNDROMEAETIOLOGYTHERAPEUTIC OPTIONSOUTCOME/PROGNOSISRECOMMENDED CLINICAL APPROACHCONCLUSIONSREFERENCES |
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| REFERENCES |
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TOPINTRODUCTIONPREVALENCECLASSIFICATION BY SYNDROMEAETIOLOGYTHERAPEUTIC OPTIONSOUTCOME/PROGNOSISRECOMMENDED CLINICAL APPROACHCONCLUSIONSREFERENCES |
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