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Brief Reports Indian Pediatrics 2002; 39:830-834 |
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Recurrent Abdominal Pain in Children |
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Recurrent abdominal pain (RAP) in children is defined as the presence of at least three episodes of abdominal pain severe enough to affect their activities over a period longer than three months(1). The prevalence of RAP in children ranges between 10-20%(1-2). The incidence of organic and non-organic causes of RAP are variable in different studies(1,3,4). Children below two years usually have organic cause of RAP. However, above 2 years only 10% cases have an organic cause(5). Emotional components like stressful life events, school phobia, sibling rivalry, etc. have been attributed as underlying components in non-organic RAP(1,3-8). Organic causes like H. pylori infection, cholelithiasis and parasitic infestations have also been reported(3,4,9-11). The aim of this study was to determine the organic and non-organic causes of RAP. Since previous studies were chiefly conducted on older children (5 to 12 years)(3,4), we included younger children (1-5 years) too in this study. Subjects and Methods All children between the age of 1-12 years, attending the pediatric outpatient department of Sher-e-Kashmir Institute of Medical Sciences, Srinagar for recurrent abdominal pain from March 2000 to Feb 2001 were studied. All those children, above 3 years of age and fulfilling Apley’s criteria (1) were included in the study. All children below 3 years of age with abdominal pain severe enough to disturb their normal activity and sleep, and of their parents over a period of three months or more were also included. A detailed history and examination, complete hemogram, urine analysis and culture and stool examination (three consecutive days) was done in all cases. Giardiasis was confirmed by concentration method for trophozoites and stool specimens were preserved in 10% formalin for better results. Patients treated for giardiasis were subjected to repeat stool examination after completing their treatment. Special investigations like X-ray chest & abdomen, barium meal study, ultrasonography of abdomen, tuberculin and serological test for tuberculosis, upper gastrointestinal endoscopy and EEG were performed, whenever indicated. Upper gastrointestinal endoscopy was performed in only those cases, where an organic cause was considered likely. Investigations relating to hemolytic disorders, serum lipids and liver function tests were performed, wherever indicated. Children, who were considered to have an organic cause were treated as per the cause and followed for at least 3 months. Organic RAP was labelled when: (a) an organic cause was demonstrated, (b) there was clinical and laboratory response to treatment, and (c) there was sustained remission from abdominal pain for at least three months after treatment. Rest of the patients, labelled as non-organic RAP (NORAP), were assessed by a psychiatrist and accordingly managed for 4-6 months. Three patients of NORAP who were unable to get relief of pain even after 6 months follow up, were subjected to endoscopy, EEG and serum amylase estimation. Results There were 85 children complaining of RAP, which included 45 (52.9%) males and 40 (47.1%) females. Forty one (48.2%) were in the age group of 5-12 years, followed by 24 (28.2%) and 20 (23.5%) in the age groups of 3-5 and 1-3 years respectively (Table I). An organic cause was found in 70 (82.4%) patients and non-organic cause identified (NORAP) in 15 (17.6%) cases. Giardiasis was the commonest organic cause in 57 (67.0%) cases, either alone or with other parasitic infestations including ascariasis, trichuriasis and enterobiasis. In addition to RAP, giardiasis manifested with other clinical features including chronic diarrhea (35.1%), failure to thrive (8.8%) and anorexia (10.5%). Patients presenting with these manifestations alone were excluded from this study, when RAP was not a feature. Table I-Causes of Recurrent Abdominal Pain
Figures in parentheses indicate percentage Upper gastrointestinal endoscopy in 7 patients above the age of seven years revealed esophagitis in one and gastritis in 2, one patient showed H. pylori infection and 2 had giardia trohozoites on specimens taken at endoscopy. Cholelithiasis were found in 4 patients between the age of 8 and 11 years. Gallstones were detected on ultrasonography. None of these patients had clinical features suggestive of chronic hemolytic anemia, liver disease or hyperlipidemia. Gallstones were of mixed type in two patients who underwent surgery. Recurrent urinary tract infection was the cause of RAP in 4 cases, which were diagnosed by routine urinalysis and culture. Two patients had vesicoureteric reflux. Two patients had abdominal tuberculosis confirmed on ultrasonography, tuberculin and ELISA tests and examination of ascitic fluid. NORAP was seen in 15 (17.6%) cases. Factors significantly associated with NORAP were single parent (20%), school phobia (33.3%) (P < 0.005), sibling rivalry ( P < 0.001), RAP in other family members (13.3%) and nocturnal enuresis ( P < 0.05) (Table II). Patients with giardiasis were managed with metronidazole tinidazole. Psycho-therapy was given in patients with NORAP. On follow up, 6 (10.5%) cases of giardiasis had recurrence of pain and stool examination showed recurrences of giardiasis, which was successfully managed with ornidazole. Of patients with NORAP, 80% were pain-free within 4-6 months except 3, who persisted with pain and in whom endoscopy, EEG and serum amylase levels were normal. Discussion RAP is common in school-aged children and young adolescents. However, 23.5% cases in this study were in the age group of 1-3 years, mainly due to giardiasis and other Table II-Factors Associated with RAP
* Figures in parentheses indicate percentage. worm infestations. Infectious causes, therefore, cannot be overlooked even in young children considering our eating habits and contaminated water supply. Contrary to earlier belief(1), NORAP was seen in only 17.6% cases. Psychogenic cause was rare below 2 years(5) as was noted in this study also. Romanezuk, et al.(12) found organic causes in 89% cases, which included gastrointestinal disease (45.7%) and urinary tract disease (26.8%). Mavromichalis, et al(13) noted esophagitis, antritis or duodenitis in 93% cases. Kumar, et al(11) found antral gastritis in 85% cases mainly due to H. pylori, whereas, others have found giardiasis, urinary infection, worm infestation or amebiasis in 47% cases and NORAP in 9.7%(14). Similarly, we found an organic cause of RAP in 82.4% cases. Giardiasis was the most important cause, with or without worm infestation. In addition to RAP, giardiasis can present with chronic diarrhea(15), failure to thrive and anorexia, as was noted by us. As noted earlier(15), most patients responded to metronidazole or tinidazole therapy and only 6 patients required treatment with ornidazole and psychotherapy. With the advent of better diagnostic modalities, organic causes of RAP are readily detected. We could diagnose cholelithiasis (4 cases) and vesicoureteric reflux and gastritis (2 cases each). Gall stones have been reported as cause of RAP in young children(9,10). None of our patients had any known cause of gall stones e.g., hemolytic anemia, chronic liver disorders, hyperlipidemia, etc. Symptoms like jaundice, localized abdominal pain or intolerance to fatty food were not seen in our patients. Similar to previous studies(1-3,5), we found that the patients with NORAP were living in a different psychosocial environment at school and home. Most patients were above 3 years of age. Family history of RAP, single parent, sibling rivalry, school phobia and punishment were associated with NORAP. Nocturnal enuresis, generalized aches and sleep disturbances were common in patients with NORAP. Psychological problems can also be seen in patients with organic RAP(3,4), and should be considered during management. Contributors: NAB coordinated the study and drafted the paper and he will act as its guarantor. SMA participated in data collection and drafted the paper. SZA was involved in radiological investigation. BAC was involved with the statistical work. WA and MH helped in data collection. Funding: None. Competing interests: None stated.
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