Recurrent Abdominal Pain in Children

Constipation is a major cause of chronic or recurrent abdominal pain in children from toddler age to the preteen years. Constipation is best defined as the failure to achieve complete evacuation of the lower colon rather than regarding infrequency or firmness of stool. Many children experience crampy abdominal pain especially after large meals, reduced appetite and abdominal distension which typically worsen in the evening. Passing hard stools can be very painful. Hence, most constipated children avoid passing stools and this, in turn, leads to hard impacted stools – the vicious cycle of constipation. However, one must also remember that some of the children can have overflow incontinence – where watery stool leaks around the hard-impacte stool and can be mistaken as diarrhea. A careful examination of the abdomen might reveal fecolith at the lower quadrant of the abdomen.

The peptic disorders include reflux esophagitis, antral gastritis, gastric and duodenal ulcer, and H. pylori infection. Children with peptic disease usually present with early morning pain – usually epigastric or periumbilical, early satiety and night arousal. The pain is not relieved by defecation and there is usually no change in bowel habit. However, there is often a positive family history; fifty percent of children with duodenal ulcer have a first-degree relative with peptic ulcer disease. On the other hand, the role of H. pylori infection in RAP remains unclear, as many children suffering from RAP with associated H. pylori has persistent pain even after successful treatment.

It can be challenging to diagnose lactose intolerance as the pain only appears a few hours after milk ingestion. Most children have increase in flatulence, with or without diarrhoea. Other carbohydrates that may be responsible for RAP include sorbitol, a food additive. Mostly, diagnosis of carbohydrate intolerance can be made by means of food withdrawal and challenge. Laboratory tests, such as breath hydrogen test, are often unnecessary.

Abdominal migraine is another possible cause of recurrent abdominal pain. By definition, there must be no evidence of an inflammatory, anatomical, metabolic, or neoplastic process that explains symptoms. There should be two or more episodes in the preceding 12 months and must include all of the following:

• Paroxysmal episodes of intense, acute periumbilical pain lasting for one or more hours.
• Intervening periods of usual health, lasting weeks to months.
• The pain interferes with normal activities.
• The pain is associated with two or more of the following: anorexia, nausea, vomiting, headache, photophobia, pallor.

Children with Inflammatory bowel disease often have pain which typically occurs in the lower abdomen, is cramping in nature and increases after meals or activity. Some may also have loss of appetite, general lethargy, fever, diarrhoea and nonintestinal manifestations such as arthralgia, arthritis or delay in pubertal developments. Patients with ulcerative colitis might present with abdominal pain with bloody stools. The diagnosis is established by small bowel barium contrast x-ray and colonoscopy with biopsies.

Some surgical conditions can present as RAP. These include recurrent intussusceptions, Meckel diverticulitis, intestinal malrotation, choledochal cyst and intestinal lymphoma.