Recurrent abdominal pain

Recurrent abdominal pain (RAP), three distinct episodes of abdominal pain over 3 or more months, occurs in 10% of school-aged children. In only 5-10% of children will an organic cause be found so that in most the cause remains obscure. 8

Organic causes

An organic cause, however, must be considered and excluded. Organic disease is more likely if:

• the pain is other than periumbilical

• the pain radiates rather than remains localised

• the pain wakens the child from sleep

• the pain is accompanied by vomiting

• the child is not completely well between attacks

• there is associated weight loss

• there is failure to thrive

Possible causes

• childhood migraine equivalent (pain with extreme pallor)

• lactose intolerance (symptoms related to milk ingestion)

• intestinal parasites (may disturb child about 60 minutes after falling asleep)

Investigations

• stool microscopy and culture

• urine analysis

• full blood count and ESR

Non-organic RAP Typical clinical features:

• acute and frequent colicky abdominal pain

• pain localised to or just above umbilicus

• no radiation of pain

• pain lasts less than 60 minutes

• nausea frequent and vomiting rare

• diurnal (never wakes the child at night)

• minimal umbilical tenderness

• anxious child

• obsessive or perfectionist personality

• one or both parents intense about child's health and progress

Psychogenic factors

Although psychogenic factors are very relevant in individual cases there is scant hard evidence to support the widely held hypothesis 8 that such factors account for the vast majority of RAP. Some children will have obvious psychological problems or even be school avoidant, a common factor being family disruption.

Management options

• Give explanation, reassurance and support.

• Reassurance can only be given following a careful examination and thoughtfully chosen investigations.

• Emphasise that the disorder is common, and usually traverses childhood without ill effects.

• Identify any life stresses and provide insight therapy.

• Enquire about family structures and function, and school performance.

• Discourage identification with the sick role.

• Refer for psychological assessment and counselling if necessary.

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