1. DR CH. HAREEN

2. Original Definition
 Recurrent abdominal pain in children described
originally by Apley is defined as paroxysmal abdominal
pain occurring between the ages of 4 and 16 years and
has experienced at least three bouts of pain severe
enough to affect activities over a period of at least 3
months

3. New Definitions
• Chronic abdominal pain is defined as
long-lasting intermittent or constant
abdominal pain
• Functional: without objective evidence
of an underlying organic disorder

4. New Definition
• Recurrent abdominal pain is a
description NOT a diagnosis
– RAP includes children with a variety of
functional gastrointestinal disorders
causing abdominal pain.
• It may also include children with
organic disease

5. Prevalence
• Has been reported to occur in 10-15%
of children.
– Likely just as many experience this but
maintain close to normal activity
– Usually two peak periods
• 5-7 y.o. (beginning of school and
separation issues)- boys and girls
• 9-12 y.o. – girls > boys. Many
have a family history of functional
bowel disease

6. Functional abdominal pain
• Pediatric Rome II Group - 1997
– Functional dyspepsia
• Ulcer-like dyspepsia
• Dysmotility-like dyspepsia
– Irritable bowel syndrome
– Functional abdominal pain
– Abdominal migraine
– Aerophagia
• Prospective Studies
– 30-90% prevalance

7. Functional abdominal pain
• Rome III Criteria – 2006
• Diagnostic Criteria for Childhood
Functional Abdominal Pain
– Must include all at least 1/week for 2
months
• Episodic or continuous abdominal pain
• Insufficient criteria for other FGIDs
• No evidence of an inflammatory, anatomic,
metabolic or neoplastic process to explain the
symptoms.

8. Changes from Rome II to III
• Symptom duration from 3 to 2 months
– Except abdominal migraine and CVS
• No need to “rule out everything”
– Use of the “red flags” to guide dx
• No longer a requirement for
– Continuous pattern or
– Impaired daily activities

9. Diagnosis
• The MOST IMPORTANT step directing
a clinician is a good history.
• Distinguish between acute and chronic
pain.
– As a general rule the more recent the onset of the pain,
the closer one must look for organic causes and
proceed with a stepwise workup.

10. History- Key Elements
• Pain
– Pattern
– Localized vs. generalized
– Does it occur before, during or after meals ?
• How soon after eating does it occur ?
• Is it made better or worse with this ?
• How long does it last ?
• Associated with nausea or vomiting ?
• Associated with certain foods ?
– Does it awaken the child at night ?
• If so what is done to make it better ?

11. History- Key Elements
• What is the timing of the pain ?
– What days of the week ?
– Times of the day ?
• Does the pain keep the child
from school
• Bowel Movements
– Pattern, consistency, completeness

12. History
• Be sure to include a thorough review of systems and
expand on it if any screening questions are positive.
– CNS- migraines, vision problems
– CVS/Respiratory- breathlessness, chest pain
– GU- Sexually active, Dysuria
– Skin- rashes
• Recent use of medications
• Social history, Family history

13. History-
• Genetics
• Intercurrent illnesses
• Food allergies
• Physical and sexual abuse
• Stressful life experiences
• Excessive parental anxiety

14. Alarm signals in the History
• Involuntary weight loss
• Growth retardation
• Persistent vomiting
• Peri-rectal disease
• Dysphagia
• Delayed puberty
• Unexplained fever
• Persistent or nocturnal diarrhea
• Any GI blood loss
• arthritis, rash
• Family history of GI disease
• Persistent RUQ or LUQ pain
• Pain that wakes

15. Physical Examination
• Weight, height and growth patterns
• Check for masses or hernias
• Check for any organomegaly
• pelvic exam
• rectal exam
– Test stool for blood

16. Alarm Signals in the P.E.
• Localized tenderness, fullness or mass
effect
• Hepatomegaly
• Splenomegaly
• Perianal fissure or fistula
• Visible soiling
• Guaiac-positive stools

17. Diagnostic Testing
• Indicated when alarm signals or
abnormal physical findings suggest an
organic disorder
• May be considered to reassure the
parent, patient or physician that the
most likely diagnosis is functional.

18. Routine Workup for R.A.P.
• Urinalysis (include pregnancy if female)
• CBC with differential
• Sedimentation rate/CRP
• Comprehensive metabolic panel
– Electrolytes, BUN, creatinine, glucose,
albumin, protein, calcium, alkaline
phosphatase, AST, ALT, total bilirubin
• Amylase/lipase
• Celiac screen

19. Other Diagnostic Tests
• UGI & S.B. series
• Abd/Pelvic U/S
• Stool for WBC’s
• Occult blood
• Other tests as indicated by history and
physical exam

20. Carnetts test
 This test helps to determine whether pain is arising
from abdominal wall or has an intra abdominal origin.
 The site of maximum tenderness is found through
palpation
 The patient is then asked to cross his or her arms and
assume a partial sitting position or crunch, which
results in tension in the abdominal wall.
 If there is greater tenderness on repeat palpation in
this position , abdominal wall disorders should be
suspected.

21. Subcategories of R.A.P.
 R.A.P. with Dyspepsia
 Isolated R.A.P.
 R.A.P. with Altered BM

22. R.A.P. With Dyspepsia
• G.E.R.D.
• Peptic ulcer
• H. Pylori
• NSAIDs
• Gastroparesis
• Biliary dyskinesia
• Pseudo-obstruction
• Pancreatitis
• IBD
• Giardia, Blastocystis hominis
• HSP
• Chronic hepatitis
• Cholecystitis
• UPJ obstruction
• Abd migraine
• Psychiatric

23. R.A.P. With Dyspepsia
• Key to deciding the extent of the initial
workup is the presence or absence of
vomiting.
• In addition to the previous tests test for H. Pylori
• If vomiting is a significant part of the history an UGI
with SBFT should be done. Consider endoscopy

24. • If the time criteria for R.A.P. has not been met and you
are proceeding with the workup, try acid-reducing
agents as an empiric therapy as long as the symptoms
are consistent with dyspepsia.
• Once you are close to the time criteria you should
introduce R.A.P. as a potential diagnosis.

25. H. pylori
• Incidence in children increases with age
• Positive relation between disease and low
socioeconomic status and high density living
• Increases in families in which an adult has had an ulcer
or documented H. pylori.
• If the serologic testing is positive, then treatment with
triple therapy is indicated.
– 2 antibiotics and an acid blocker

26. R.A.P. with Altered Bowel Pattern
• IBD- Crohn’s or U.C.
• Infectious disorders – Parasitic (Giardia, Blastocystis,
Dientamoeba)
– Bacterial (C.diff, Yersinia, Campylobacter)
• Lactose or Fructose intolerance
• Complication of constipation
• OB/GYN disorders
• Neoplasia
• IBS

27. R.A.P. with Altered Bowel Pattern
• The key to deciding on the extent of
the initial workup is:
– The volume/timing of diarrhea vs. degree
of constipation
– Evidence of gross or occult blood in the
stool
– The presence of encopresis

28. Indications for Colonoscopy
• Evidence of GI bleeding
• Profuse diarrhea
• Involuntary weight loss or
growth deceleration
• Fe deficiency anemia
• Elevated ESR or CRP
• Extra-intestinal symptoms suggestive of
IBD
– Rash, joint pains, aphthous ulcerations

29. Isolated R.A.P.
• Crohn’s disease
• Malrotation
• Intussusception
• Postsurgical
• Musculoskeletal disorders
• Abdominal migraine,adhesions
• OB/GYN
– Dysmenorrheal
– Endometriosis
• Infection
– Yersinia
Vascular disorders
- Mesenteric thrombosis, Polyarteritis nodosa, Acute intermittent porphyria
• Mental disorders
– Factitious, conversion, somatization, school phobia
• Functional abdominal pain

30. Functional Abdominal Pain
• This is NOT the same as saying the pain is non-organic
– However non-organic or psychogenic term is
sometimes used
• Growing body of evidence that points to a disordered
brain-gut communication as the cause

31. Diagnosis of F.A.P.
• Once organic causes have been ruled out via history
and/or serum, radiologic and/or endoscopic tests, then
this diagnosis should be considered
• It is important to emphasize to the patient and family
that it’s the most common cause of chronic pain in
children and that the pain is real.

32. Diagnosis of F.A.P.
If this diagnosis is suspected then even more time
should be spent on the social history to help
determine the trigger.
– Any deaths of family members or friends?
– Serious illness in family, friends or schoolmates?
– Recent parental separation, change of school or
potential of either?
– Has the child started a new school?

33. Functional abdominal pain
• Pediatric Rome III Group
– Functional dyspepsia
• Ulcer-like dyspepsia
• Dysmotility-like dyspepsia
– Irritable bowel syndrome
– Functional abdominal pain
– Abdominal migraine
– Aerophagia

34. Functional dyspepsia
• Must include all the following at least 1
time per week for 2 months
– Persistent or recurrent pain or discomfort centered in
the upper abd
– Not relieved with stool or Associated with change in
Stool freq. or form
– No evidence of an Organic process

35. Functional dyspepsia- 2 Forms
• Ulcer-like
– Most bothersome symptom is pain in upper abdomen
• Dysmotility-like dyspepsia
– Most bothersome symptom is…
• Early satiety
• Upper abdominal fullness
• Bloating
• Nausea

36. Irritable Bowel Syndrome
• Must include both of the criteria, once per week for 2
months
– Abd discomfort or pain associated with 2 or more of
the following 25% of the time
• Improvement with defecation
• Onset associated with a change in freq. of stool
• Onset associated with a change in form of stool
– No evidence of an Organic disease

37. Abd Migraine
• Must include all the criteria 2 or more times in the past
12 months
– Paroxysmal episodes of intense, acute periumbilical
pain that lasts for 1 hour or more
– Intervening periods of usual health lasting
weeks to months
– The pain interferes with normal activities

38. Abd Migraine
• The pain is associated with 2 or more of the following
– Anorexia
– Nausea
– Vomiting
– Photophobia
– Pallor
• No evidence of organic disease

39. Aerophagia
• Pain for 12 weeks in the past 12 months
– Need not be consecutive
– Negative work-up
• Two or more of the following
– Air swallowing
– Abd distension from air
– Repetitive belching and/or flatus

40. Treatment of F.A.P.
• Reassurance
– Direct at the whole family
– Explain how the diagnosis was reached
• Address any lingering concerns
• Show normal growth curves
• Acknowledge the pain is genuine

41. Treatment of F.A.P.
• The parents and child must understand that the
primary goal is resumption of a normal lifestyle NOT
the eradication of the abdominal pain
– Regular school attendance
– School performance to child’s ability
– Extracurricular activities
– Normal sleep pattern

42. Treatment of F.A.P.
• Abdominal pain diary
– Empowers patients and parents
• Date and time of symptom
• Location of pain
• Character and duration of pain
• Preceding onset factors
• Description of daily stool pattern
• Identified relieving factors
• When conservative treatment fails
– Next step is pharmacotherapy and/or
– Behavioral therapy

43. Treatment of F.A.P.
• Dietary modification
– No specific dietary changes have been shown effective.
However some do benefit from a high fiber diet.
• formula for dietary fiber intake
Childs Age + 5 = grams per day
•Review the patients diary and
eliminate
•Foods that trigger the pain
•Excess consumption of sweeteners
•Mannitol or sorbitol or fructose

44. Treatment of F.A.P.
• Anticholinergic agents
– Dicyclomine
– Hyoscyamine
• They block muscarinic effects of acetylcholine on the
GI tract
– Relaxes smooth muscle
– Can be used on an as needed basis 4 X/day
– Can develop tachyphalaxis
• Consider next class of drugs

45. Treatment of F.A.P.
• Tricyclic Antidepressants
– Anticholinergic effect on GI tract
– Mood elevation
– Central analgesia
• Since these are used as a continuous vs.PRN basis, they
are reserved for frequent or continuous pain
• Risk of arrhythmias with prolonged QT
• 0.2mg/kg/day and titrate up to 0.5mg/kg/day as single
bedtime dose

46. Treatment of F.A.P.
• SSRI’s
– May help in patients with unremitting pain
and impaired daily function.
– No published studies of the use in kids with
FAP and little in adults
– May play a role with comorbid psychiatric
conditions
• Anxiety, panic disorders, OCD or depression

47. 5-HT3 receptor antagonists
• Ondansetron
• Granisetron
– Serotonin activates vagal afferents via 5- HT3 receptors
inhibiting emesis
– DO NOT consistently alleviate pain or alter
stool pattern
– Reserved only when nausea is a predominant
symptom

48. 5-HT4 Receptor Agonists
• Tegaserod
– Increases GI motility
– May alter visceral sensitivity
– Three large phase III randomized, double blinded,
placebo trials supported improvement in
• Abd pain
• Stool frequency and
• Consistency in adults
– No pediatric studies yet
Not available in India

49. Psychological Therapies
• Cognitive-Behavioral Therapy
– Coping skills
• Relaxation training
– Biofeedback
• Hypnotherapy
– Body relaxation and mental focus

50.  THANK YOU