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Balani et al.’s
uncontrolled study(1) of a very small number of children with recurrent
abdominal pain (RAP) gives insufficient information and raises many
questions.
1. Selection of patients: Were the
thirty-five children with RAP consecutively taken? What was their age
distribution? Were they referred to the Pediatric Gastroenterology
Clinic? Did they constitute all patients with RAP seen at the hospital
in one year? What is the daily attendance of children at this
hospital?
2. Clinical Features: Was any attempt made
to grade the severity of abdominal pain? Were the intensity of pain,
its duration and frequency and medications taken to relieve the pain
taken into account? Children with RAP usually seek hospital advice
after several months or years of having the symptom (Apley’s
definition of RAP may need a fresh look).
3. Etiology:(i) Isolated urinary
tract infection does not cause RAP, unless there is an associated
underlying anomaly such as urinary tract obstruction (pelviureteric
junction obstruction is an occasional cause of RAP); (ii) Chronic
gastritis: What was the cause of chronic gastritis and
eso-phagitis in patients who did not have H. pylori infection
(presumably responsible for RAP in 5 cases)? What is the pre-valence
rate of H. pylori infection in children in different parts in
India and (iii) Amebiasis, giardiasis and worm infesta-tions
are often detected in asymptomatic children.
4. Treatement: In most cases the authors
have assumed the ‘cause and effect’ relation-ship. How were
children with chronic gastritis treated? How many had complete cure
and how many had reduction of RAP? "Appropriate treatment"
of the underlying organic cause should result in complete and
permanent cure. The 3-month follow-up period is too small to be
meaningful. Spontaneous recovery in children with RAP is not uncommon.
5. Discussion: Psychological problems are
frequent in the child and the family when the child has RAP or indeed
any other chronic or recurrent disorder. The role of such factors may
vary in different socio-economic and cultural settings and the views
of workers in developed countries may not be equally applicable in our
patients. The authors may be correct in proposing that organic causes
may be detected in a majority of children with RAP. It is, however,
not unlikely that giardiasis, amebiasis, UTI were mere associations
and not necessarily res-ponsible for RAP in their patients. One should
be aware of the placebo effect of treatment particularly when the
follow-up period is very short.
The authors recommend that "thorough
investigation is a must " in children with RAP. Are there any
guidelines? Does one take the severity and duration of RAP into account?
Most pediatricians would not consider endoscopy in all patients with
RAP. Only a large, well-designed, controlled study can provide reliable
and significant information. Pediatricians and pediatric
gastroenterologists in the country should take a serious look at this
common and often distressing problem of childhood.
R.N. Srivastava,
Consultant Pediatric Nephrologist,
Apollo Indraprastha Hospital,
New Delhi 110 019, India.
E-mail: [email protected]
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Balani B, Patwari AK, Bajaj P, Diwan N, Anand VK.
Recurrent abdominal pain – A reappraisal. Indian Pediatr 2000; 37:
876-881.
We thank Dr. Srivastava for the interest shown in our
article and have the following clarifications to offer:
1. Children attending the Out Patient Department
with complaints of recurrent abdominal pain (RAP) who fulfilled Apley’s
criteria were consecutively referred to Pediatric Gastroenterology
Clinic where they were investigated and followed up. Age distribution
is clearly mentioned in the text and patients were between 5-12 years
of age. These patients don’t constitute all the patients with RAP
attending Kalawati Saran Children’s Hospital because children
presenting with RAP were seen by different category of
residents/senior doctors and referral of all such cases could not be
assured. The daily attendance of patients at our hospital is
approximately 1000.
2. For inclusion of patients, Apley’s criteria
was used which includes at least three episodes of abdominal pain
severe enough to affect routine activities over a period longer than
three months. No attempt was made to further grade the severity of
abdo-minal pain based on intensity, duration, frequency or medication
taken to relieve pain. Authors do agree that Apley’s definition of
RAP may need a fresh look especially for children younger than 5 years
of age. However, for the purpose of the study this criteria was used
and duration of symptoms before seeking hospital advise does not form
an important constituent of Apley’s criteria except that it should
be more than three months.
3 (i) Regarding the etiology of RAP there
have been reports linking urinary tract infection (UTI) with RAP(1,2).
Authors agree that underlying anomaly such as urinary tract
obstruction may be more important in causing RAP. In none of our
cases, however, ultrasonographic examina-tion revealed any such
abnormality. But we still believe that it is helpful to investigate
patients of RAP for UTI. Four (11.4%) of our cases with RAP were found
to have UTI while being investigated.
(ii) Apart from H. pylori infection
there are other causes of chronic gastritis such as peptic ulcer
disease, drugs, and chronic infections such as tuberculosis. Within
the limitations of the study, apart from docu-menting endoscopic and
histological evi-dence of chronic gastritis and esophagitis, no
further investigation could be per-formed to know the cause. The
reported prevalence of H. pylori in Indian children between
4-15 years from various Pediatric Gastroenterology centers ranges from
18-36% in hospitalized patients(3).
(iii) We agree that amebiasis, giardiasis
and worm infestation can even be detected in asymptomatic children but
at the same time, some children, particularly those with physiological
maladjustment, can have pain because of these etiologies. Moreover
relief of symptoms following therapy for at least three months
justifies the rationale for associating these conditions with RAP.
4. Patients with chronic gastritis received H2
blocker therapy. Those with associated H. pylori infection were
also given metro-nidazole, bismuth and amoxicillin. Overall amongst
patients with organic cause of RAP, 67% were pain free and 28% had
pain of reduced intensity and severity. Of patients with chronic
gastritis. 50% were pain free and 50% had pain of reduced intensity
and severity over the period of three months of follow up. There is no
disagreement that literally speaking, appro-priate treatment should
result in complete and permanent cure but as practicing pediatricians
we also realize that there are conditions, particularly those with
psycho-somatic component, which may take a longer time to resolve. In
such cases reduction in symptoms is quite a rewarding experience.
Spontaneous recovery in children with RAP is not uncommon. However,
one would not expect long standing organic causes to resolve on their
own.
5. We agree that some of these conditions may be
mere associations, rather than being underlying etiology and the drugs
may have had placebo effects, particularly in the presence of
psychological factors. However, as is clear from the "Key
Messages", we would still like to highlight that these children
need to be investigated for these etiological factors (or
asso-ciations) so that they can be treated for these conditions. We
would like to reiterate that in our study only children who fulfilled
Apley’s criteria were included. Abdominal pain (including recurrent
episodes) in children is quite common but the article discusses only a
smaller proportion of children who fulfil Apley’s criteria and these
definitely deserve to be thoroughly investigated. However, it is not
necessary to subject all of them to endoscopy if the baseline
investigations are helpful in reaching a diagnosis. In a tertiary care
center like ours with all the facilities for endoscopy, out of 35
cases of RAP only 17 were subjected to endoscopy since we were able to
make a diagnosis without performing endoscopy.
Bharat Balani,
A.K. Patwari,
Department of Pediatrics,
Kalawati Saran Childrens’ Hospital,
New Delhi 110 001, India.
-
Du JN. Colic as the sole symptom of urinary tract
infection in infants. Can Med Assoc J 1976; 115: 334-337.
-
Soeparto P. Endoscopic examinations in children
with recurrent abdominal pain. Pediatr Indones 1989; 29: 221-227.
- Patwari A.K. Helicobacter pylori infection in Indian
children. Indian J Pediatr 1999; 66: S63-S70.
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