Chronic functional abdominal pain

Question 1

Chronic Functional Abdominal Pain:

What is it?

Answer 1

Recognised syndromes in paediatrics of abdominal related distress

Has a number of common phenotypes
-Functional constipation
-Irritable bowel syndrome
-Functional dyspepsia
-Functional abdominal pain
-Abdominal migraine

90% of paediatric chronic abdominal pain is deemed functional

Question 2

Who and why does it happen?

Answer 2

Who?
Bimodal peak of symptoms
5 -7yo age group equal prevalence among girls and boys
8 - 12yo age group has a female predominance

Why?
Altered brain-gut interaction
sometimes reduced pain thresholds
can be associated with anxiety and depression
DO NOT need to have trauma/emotional distress history

Question 3

Approach to these patients?

Answer 3

History
-Pain characterisation WWQQAAB - ideally get a symptoms diary
dietary intake/pattern
-stool pattern
-social/emotional status

RULE OUT RED FLAGS:
abdominal distension
peritonism
chronic diarrhoea
nocturnal pain
pain that is not centrally located
dysphagia
persistent vomiting or bile in vomit
weight loss
poor growth
prolonged fever
Accurate diagnosis to guide management

*Usually avoid investigations if history fits
*Reasonable options for investigation include:
-urine MSSU
-Stool OCP
-Bloods - CBE, ESR, CRP, coeliac serology
-plus/minus H. pylori serology

Question 4

Diagnostic process?

Answer 4

RULE OUT RED FLAGS:

Stool related
-Constipation + Encoporesis
-retentive posture
-painful motions
-infrequent stools
= Functional Constipation

Diarrhoea + bloating
-pain relieved by defecation
= could be IBS

Food related + early satiety
-post prandial fullness
-epigastric pain
= Functional Dyspepsia

Pain duration
≥ 1hr +
-episodes weeks to months apart (infrequent)
-incapacitating pain
-Associated with ≥ 2 of the following:
anorexia
nausea
vomiting
headache
pallor
photophobia
= Abdominal Migraine

≤ 1hr +
-≥4 episodes per month (frequent)
-Episodic or continuous symptoms
-Other criteria in this algorithm is NOT met
= Functional Abdominal Pain

Question 5

Management?

Answer 5

Reassure and educate that there is not a serious underlying cause for the symptoms
Continue normal daily activities
Non-pharmacological:
muscle relaxation
art
physical activity
imagery

Pharmacological:
Functional Constipation - Polyethylene Glycol (Movicol)

Functional dyspepsia - PPI trial

Anxious/Depressed - TCA, SSRI (weak evidence in paediatrics)

Abdominal Migraine - Simple analgesia plus/minus triptan - specialist for prophylaxis

Functional Abdominal pain - simple analgesia, antispasmodics, CBT