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Brief Reports Indian Pediatrics 2000;37: 876-881 |
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Recurrent Abdominal Pain–A Reappraisal |
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From the Division of Pediatric Gastroenterology and Nutrition, Department of Pediatrics; Department of Pathology* and Department of Microbiology** Kalawati Saran Children’s Hospital and Lady Hardinge Medical College, New Delhi 110 001, India.
Reprint requests: Dr. A.K. Patwari, Flat No. 4, Lady
Hardinge Medical College Campus, New Delhi 110 001, India.
The primary objective of management of a child with RAP is just not to label him/her with a diagnosis but to treat him/her. Merely labelling RAP of either organic and non-organic causes and restricting the therapy to one or the other may not ensure successful manage-ment. Psychological problems may co-exist with organic problems(8). Therefore manage-ment of RAP in children demands a much more broad based approach. This prospective study was conducted to evaluate the interplay of organic and psychogenic causes in the activa-tion of RAP in children.
The study was conducted between April ’96 -April ’97 in the Division of Pediatric Gastro-enterology and Nutrition, Department of Pediatrics, Kalawati Saran Children’s Hospital. All the enrolled children with upper abdominal pain fulfilling Apley’s criteria were interviewed to ascertain the details of abdominal pain. Details of history and examination of children included in the study were recorded on a predesigned proforma. Apart from details of abdominal pain and association of any secondary gain patterns, the proforma included a list of stressors (single parent, parental fights, sibling’s birth, death in family, history of abdominal pain in parents, school related problems, joint family and parents, increased limit-setting behavior). All the children were subjected to routine investigations (Hb, TLC, DLC, urine micro-scopy and culture). Stool samples were examined for ova/cyst of intestinal parasites for three consecutive days and were tested for giardia antigen using "Melotest giardiasis Ag kit" manufactured by Melotec, which is an enzyme immunoassay for the detection and semiquantitative measurement of Giardia lambia antigen in stool, in all the children. Those children who were treated for giardiasis, also underwent repeat stool examination for three consecutive days as well as giardia antigen detection test after completing treatment. If a diagnosis was not possible with above investigations and organic cause was a strong possibility in the presence of clinical features such as sharply localized pain, pain away from umbilicus, associated urinary and bowel complaint(9), children were subjected to other investigations like ultrasonography of abdomen and upper GI endoscopy. UGI endoscopy was performed using pediatric endoscope GIF Type PQ 20 (Model Olympus). Endoscopy was performed after ensuring the suitability of the patient for premedication and taking informed consent. Any gross pathology in stomach, duodenum or esophagus was noted. Duodenal and antral biopsies were routinely taken. Biopsy from any other pathological lesion was also taken. Brushings from second portion of the duodenum were also taken using a sheathed brush and brushings were studied for giardia trophozoites, and H. pylori. Biopsies were studied for giardia trophozoites, H. pylori as well as for any other histopathological abnormality. All the children were assessed by a psychiatrist for any pscyhological problem. In addition both parents of the child were also interviewed. All the children were followed in Pediatric Gastroenterology and Nutrition Clinic atleast for three months. Wherever suitable, statistical methods like Pearson Chi-square test and Fischer’s Exact test (WHO-EPI INFO software) were applied to find the significance of data obtained.
The study included 35 children from 5-12 years with 22 males (62.8%) and 13 females (37.2%). While taking history, an obvious secondary gain pattern could be detected in 5 children (14.2%) and history suggestive of stressors could be elicited in 8 (22.8%) children. Stressors included school related problems(3), siblings birth(2), death in family(2), and parental fights(1). Psychological assessment was normal in 23 (65.7%) children (Table I ). Based on clinical examination and initial routine investigations it was possible to attribute an organic cause for RAP in 14 (40%) children and psychological cause in 4 (11.4%) after psychological assessment. The organic causes included urinary tract infection (n = 4), amebiasis (n = 2), worm infestation i.e., ascariasis (n = 2), and giardiasis plus worm infestation (n = 2). Upper gastrointestinal endoscopy was performed in 17 (48.5%) children. Endoscopy revealed esophagitis in 3 (17.6%) children. Histology of biopsy specimen suggested antral gastritis in 7 out of 17 (41.8%) and 5 of these had associated H. pylori infection. Giardia trophozoites were found in duodenal brushings in 4 (23.5%) and in duodenal biopsy in 3 (17.6%) children. Histological examination confirmed esophagitis in 3 (17.6%) children. After thorough investigations and psycho-logical assessment a final diagnosis of the cause of abdominal pain was made and it was seen that an organic cause could be attributed to RAP in 26 (74.2%) children (Table II ). It was seen that 8 (22.8%) children had organic cause in addition to an associated psychological problem. Psychological cause was found in only 4 patients and in 5 patients no cause could be found after subjecting them to all available investigations. Out of 5 children who had history suggestive of secondary gain patterns, only 2 (40%) had history of stressors on complete psychological assessment (Table III). However, an organic cause could be found in as many as 4 (80%) children including giardiasis in 2 (40%), antral gastritis and esophagitis in 1 (20%) each in this group. It was interesting to note that out of 30 children in whom no secondary gain pattern was elicited in the history 6 (20%) cases had history of stressors and in 8 (26.7%) cases RAP was attributed to psychogenic cause alone or in association with an organic cause. Appropriate treatment was given to all the cases depending upon the final diagnosis. Psychotherapy was given to those with psychological problems. In the follow up it was seen that 95% of the children in the organic group were either pain free or had pain episodes less than thrice in 3 months of follow-up. Only one child, who had H. pylori positive gastritis, failed to improve despite two weeks therapy with bismuth, metronidazole, amoxicillin, and ranitidine. The reason for persistence was not clear as repeat endoscopy to document eradication of H. pylori or healing of gastritis could not be done. Also unusual causes of abdominal pain such as porphyria, lead poisoning, etc. could have been the reason for persistence of pain. For these patients no further investigations could be done due to financial constraints. In the psychogenic group and combined organic and psychogenic group, 100% children responded to treatment. In the remaining 5 children in whom no cause could be found, 3 children (60%) continued to have bothering pain while in 2 (40%) pain resolved spontaneously. In these five children EEG and barium meal follow through was also done to exclude abodminal epilepsy and obstructive lesions but were found to be normal. Table I - Psychological Assessment (n = 35)
Table II - Organic Causes of RAP (n = 26)
* 2 cases also had chronic gastritis and esophagitis. Table III - Profile of Patients with Respect to Secondary Gain Patterns
Recurrent abdominal pain is common in school-aged children and young adolescents. Different studies estimate the prevalence at 10-15%. As suggested by Apley(1), the dominant view has been that recurrent abdominal pain is expression of physiological maladjustment in response to family or school problems in predisposed children. In addition the parents of children with RAP have been reported to have pain themselves to model pain behaviour for their children Contrary to this belief, many studies have found organic causes of RAP to be more common. Romanezuk et al. found that 89% of the children in their study group had one or other organic cause of their RAP while only 11% had psychogenic abdominal pain(10). Organic causes in their series included gastro-intestinal diseases in 45.7%, urinary system diseases in 26.8% and extra abdominal diseases in 6.4%. Similarly, Mavromichalis found organic cause, viz., esophagitis, antritis or duodenitis in 93% of the children in their study group(11). Recent Indian studies on RAP also point out important role of organic causes of RAP. Kumar et al. found antral gastritis in 85% of their patients with upper abdominal pain and of these significant number of patients responded to H. pylori eradication therapy/H2 receptor antagonists, proving gastritis to be the cause of RAP(12). Bansal et al.(13) in their study on children with RAP found 47% children to have organic causes such as giardiasis, UTI, worm infestation or amebiasis. Of those children who underwent endoscopy antral gastritis was found in 52% children. Only 9.7% children had psychogenic cause of RAP in their study(13). In agreement with these findings, our study also revealed organic cause of RAP in 74.2% children. Giardiasis is one of the most common pathogenic intestinal protozoal infection world-wide. However, it is not generally regarded as a cause of severe illness. In a retrospective study(14), it was found that out of 125 patients 41% presented with the complaints of abdomi-nal pain. Diarrhea was presenting complaint in 32%. After treatment with metronidazole 78% of the children were free of abdominal pain. Similarly in our study also giardiasis was the most common cause of organic abdominal pain accounting alone for 30.8%. Worm infestation has never been taken seriously as cause of abdominal pain due to high prevalence even in asymptomatic patients. In the light of results of earlier studies(12) cause of pain in two children in whom there was history of passing worms in stool could be attributed to ascariasis which was further supported by the fact that they had symptomatic relief following antihelminthic treatment. However, a possibility of worm infestation as an incidental finding in these two cases can not be ruled out because two other cases without any organic or psychogenic cause also had responded without treatment. Before the advent of newer diagnostic modalities like ultrasonography and UGI endoscopy all the patients without any obvious cause of abdominal pain were labelled to have psychogenic abdominal pain. But with modern diagnostic modalities, organic cause of RAP is more readily detectable. This is supported by our observations that routine initial investiga-tions revealed organic cause in only 14 (53.8%) out of 26 children who were finally diagnosed to have organic cause of RAP. In rest of 12 children endoscopy helped to make the diagnosis. These findings are similar to those of Soeparto who conducted endoscopy in all 62 children in his study and found that in 16 (25.8%) children cause of RAP could be detected only with the help of endoscopy(15). Our study proves the usefulness of endoscopy in the diagnostic work up of a child with RAP. Diagnosis of giardiasis is done most easily by stool examination, sensitivity of which depends on cyst excretion patterns and expertise of examiner and varies between 10-95%. We used giardia antigen detection in stool, duodenal biopsy and duodenal brushings examination in addition to the routine stool examination. It was seen that brush cytology was positive in 4 (66.7%) out of 6 patients with giardiasis (in whom endoscopy was done), duodenal biopsy was positive in only 3 (50%) and stool antigen was positive in 3 (50%) patients. None of these patients had positive stool microscopy, so brush cytology from duodenal mucosa in children subjected to UGI endoscopy appears to be a useful diagnostic aid for giardiasis. Some people are of the view that RAP results from interplay of different factors. Levine et al. proposed that RAP results from interaction of four primary forces, namely, somatic predisposition, dysfunction or disorder, life style and habits, temperament and learned response patterns and milieu and critical life events(16). This hypothesis is supported by studies finding equal incidence of psycho-logical problems in patients with organic cause of RAP and those with non-organic abdominal pain. Most people are of view that children with apparent secondary gain patterns have a psychogenic cause of RAP and therefore such children are not investigated further. Our results clearly disprove this delusion as 80% of the children with secondary gain pattern were found to have an organic cause of RAP. In the study conducted by Raymer et al. in 44 children with organic cause and 16 children with non-organic RAP, the conclusion drawn was that no significant differences occur in problem adjustment between patients with no detectable organic cause of abdominal pain and those with established intestinal disease(8). In confirmity with this, in our study also psychological problems were seen in 8 (22.8%) children in addition to organic cause. Eliciting the history of stressors did not have any significant relationship to suggest RAP to be of psycho-genic origin. It is common to find psychological problems in children with abdominal pain. Whether these difficulties are secondary to underlying chronic pain, of a primary nature, or a combination of the two is not readily apparent. Therefore, management of a patient with RAP should take this into consideration since psychological support alone cannot combat the underlying organic disease. Contributors: AKP coordinated the study (design and analysis) and drafted the paper; he will act as the guarantor for the paper. BB participated in the data collection and helped in drafting the paper. PB and ND were involved in pathological and microbiological investigations, respectively. VKA was involved in endoscopy of patients with RAP. Funding: College Post Graduate Funding Section. Competing interest: None stated.
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