chronic abdominal pain done by mohammad amjad uqu

Chronic Abdominal Pain

Done byMohammad Amjad

UQU


Classified into

5-10% 90-95%


•at least 3 pain episodes over at least 3 months that severe enough to affect daily activity (1,3,4)

Evaluation (dilemma)

• Individual children differ in their perception & tolerance to abdominal pain

In Clinical PracticeA pain that exceeds 1 or 2

months, can be considered chronic (1)

• chronic abdominal pain in children is usually a functional disorder rather than organic disease (1)

Recurrent Abdominal pain??

• An episodes of pain occurring at least monthly for 3 consecutive months with a severity that interrupt a routine functioning (3)

Organic Abdominal Pain (3,4)

Causes of must be considered :

Less common :• Pancreatitis• Cholelithiasis

•Chronic constipation•GERD, peptic ulcer & H. pylori•Parasitic infection•Inflammatory bowel disease•Lactase deficiency

• Porphyrias• Abdominal epilepsy

Organic Abdominal Pain (3,4)

• Symptoms that suggest an organic causes:Age <6 yrPain awake the patient from sleepVomiting & diarrheaRelation to mealsFeverWeight looseJoint symptomsfamily history of inflammatory bowel disease

Organic Abdominal Pain

• Signs that suggest an organic causes:• Pain localized away from umbilicus (apley’s rule)• Abdominal tenderness• rectal fissures• Occult blood in the stool• Abnormal growth (serial growth points should be

plotted)• Hepatomegaly & splenomegaly

Message:Message:Specific pain suggest Specific pain suggest

organicorganic rather than functional rather than functional (2(2)

Functional Abdominal Pain

(FAP)

Irritable bowel syndrome

Non-ulcer dyspepsia

Abdominal migraine


• Refers to pain that can not be explained on a structural, physiologic, or biochemical basis. (3)

• Important to look for possible sources of stress (i.e. school, friend & family) (5)


• Refers to pain that can not be explained on a structural, physiologic, or biochemical basis. (3)

• Important to look for possible sources of stress (i.e. school, friend & family) (5)

• Majority of functional abdominal pain will diagnosed as IBS (3)


• There is evidence that anxiety may lead to altered motility which may perceived by the child as pain??? (5)

Pain typically central, around amblicus & the children are otherwise entirely well (5)

Pain typically central, around amblicus & the children are otherwise entirely well (5)

It just hurts (4)

Clues: • Pain that occurs in every school morning .doesn’t occurs in weekend or holiday or awaken

him/her during night ???Presence of stressor (like exam or school),

Relocating or death of relative

Functional Abdominal pain

• In children 4 to 18 years of age with chronic abdominal pain when there are no alarm symptoms or signs, the physical examination is normal, and the stool sample tests are negative for occult blood, without the requirement of additional diagnostic evaluation (1)

Cont. (3)

Clues: Most common location is periumbilical.Other location :If epigastric associated with nausea that not

respond to acid-blocking medication think (nonulcer dyspepsia)

If below umbilicus it usually accompanied by abdominal cramp, bloatining & distention with an altered bowel pattern think IBS

Match The ColorIrritable Bowel Syndrome Dyspepsia Abdominal Maigrain

• abdominal pain or discomfort in the upper abdomen & not respond to acid blocking medicaton

• abdominal pain associated with alteration in bowel movements

• abdominal pain associated with anorexia, nausea, vomiting, or pallor


• abdominal pain or discomfort in the upper abdomen


• abdominal pain associated with anorexia, nausea, vomiting, or pallor


• abdominal pain or discomfort in the upper abdomen


• abdominal pain associated with anorexia, nausea, vomiting, or facial pallor + Family H/x of maigrain

If still Non-Specific??

Functional abdominal pain syndrome

Lab Work

• Lab testing & procedures should be minimal & guided by clinical evaluation (3)

Lab Work

Management

• Very important that a full history & examination are not only done, but seen to be done• Examination will establish that, the

child is growing normally & there are no abnormalities on examination (5)

Management

Reassure the family regarding the absence of

organic disease

Explain in simple language that although the pain is real, most likely no underlying

serious disease & chronic abdominal pain is a common

symptom in children. like a headache, which experienced at some time by most adults, which very

rarely is associated with serious disease (1)

Management

• Main aim being the return to normal function (1) , (e.g. return to school) AND avoidance of causes that encourage pain behaviors (e.g. by providing attention, rest, special treatment, distraction, or medication) is equally important

• Relief of symptoms is a secondary goal (2)

Management

• Avoid overmedication• Maintain an open mind in term of

reassessing the diagnosis if the clinical presintation changed (3)

• benefit of treatment with H2 receptor agonists, supplemental fiber, or a lactose-free diet is inconclusive (2)

Prognosis (5)

• 50% of affected children rapidly become free of symptoms

• In 25%, the symptoms take some months to resolve

• In 25%, symptoms continue or return in adulthood

Poor prognosis

• Factors that have been suggested to be associated with :painful family male genderAge < 6 years at diagnosis> 6 months duration of pain before seeking

treatmenthigh levels of depression and anxiety symptoms

and negative life-events

Thank You!

Reference

• (1)http://www.pediatrics.org/cgi/content/full/115/3/812

• (2) Up To Date, Management of the child and adolescent with chronic abdominal pain literature review for version 16.3

• (3) Nelson Text Book of Pediatrics 18th edition• (4) Kaplan pediatric 2008• (5)Illustrate text book of pediatrics

chronic abdominal pain done by mohammad amjad uqu

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