Abdominal pain, recurrent

Question 1

RAP is

Answer 1

3 distinct episodes of pain over 3 or more mths

occurs in 10% of school-aged children.

In only 5–10% will an organic cause be found.

Question 2

Probability diagnosis

Answer 2

Non-organic recurrent abdominal pain (RAP)

Constipation

Recurrent viral illness (mesenteric adenitis)

Childhood migraine

Lactose intolerance

Question 3

Serious disorders not to be missed

Answer 3

Infection:

• recurrent urinary infection/ureteric reflux
• parasitic infection of gut (e.g. pinworm, strongyloides, whipworm)
• tuberculosis

Cancer:

• colon cancer (rare)

Other:

• hydronephrosis

Question 4

Pitfalls (often missed)

Answer 4

Inflammatory bowel disease (IBD)

Childhood migraine equivalent (periodic syndrome)

Food allergy (incl. lactose intolerance)

Gastritis/oesophageal reflux

Rarities:

• Meckel’s diverticulum
• Temporal lobe epilepsy
• Sickle cell disease
• Henoch-Schönlein purpura
• irritable bowel syndrome (IBS)

Question 5

Masquerades checklist

Answer 5

Depression

Diabetes

Drugs

Spinal dysfunction

UTI

Question 6

Is the patient trying to tell me something?

Answer 6

Highly likely as non-organic (functional) RAP is common.

Consider anxiety and depression.

Question 7

Key history

Answer 7

A very careful history includes the site, radiation, onset, duration and periodicity of the pain, and aggravating, relieving and associated factors.

Ask if the pain wakes the child at night, interferes with activities and is associated with anorexia, vomiting, diarrhoea, dysuria or weight loss, or is related to food.

FHx of abdominal pain, migraine, IBD or IBS.

Social history, school difficulties, stressors and anxiety.

Question 8

Key examination

Answer 8

Usual systematic examination including rectal examination

Growth chart is important

Question 9

Key investigations

Answer 9

Urine analysis and M&C

FBE/ESR/CRP

Plain abdominal X-ray to assess any faecal retention

Ultrasound for suspected kidney tract or ovarian pathology

Question 10

Diagnostic tips

Answer 10

Avoid the trap of excessive investigations.

90% of RAP referred to hospital no underlying cause is found, but take the problem seriously.

Talk to the child alone, if possible.

Organic disease is indicated by;

• pain distant from the umbilicus
• and/or waking with pain at night
• associated with vomiting
• loss of appetite or weight
• change in bowel habit
• failure to thrive
• inability to undertake normal activities.