Recurrent Childhood Abdominal Pain
Recurrent abdominal pain in childhood can be a calling card for a myriad hidden agendas. More than 85 causes have been listed, and as in most areas of general practice, the trick is to sift through the morass of information to find the keys to the diagnosis and open the way to effective management. The underlying cause in the most persistent cases is usually non-organic (90% of those referred to hospital).
- Recurrent Viral Illnesses
- Anxiety and Depression (Sometimes Known as Periodic Syndrome or Abdominal Migraine)
- Recurrent UTI
- Gastritis and GORD
- Infant Colic (Which is Assumed to Cause Abdominal Pain)
- Cow’s Milk Protein Intolerance (in Infants)
- Crohn’s and Coeliac Disease
- Duodenal Ulcer (DU)
- Irritable Bowel Syndrome
- Diabetes Mellitus
- Henoch–Schönlein Purpura
- Hydronephrosis, Renal Stones and Ureteric Reflux
- Meckel’s Diverticulum
- Parasitic Infestation of the Gut
- Food Allergy
- Sickle-Cell Disease
- Tuberculosis (TB)
- Hirschsprung’s Disease
- Temporal Lobe Epilepsy
Key distinguishing features of the most common diagnoses
|Recurrent Viral Illness||Anxiety/ Depression||Recurrent UTI||Constipation||Gastritis/ GORD|
|Related to Eating||No||No||No||Possible||Possible|
Likely: Urinalysis, MSU.
Possible: FBC, blood film, ESR/CRP, anti-endomysial and anti-gliadin antibodies.
Small Print: Faecal calprotectin, plain abdominal X-ray, abdominal ultrasound, further hospital-based investigations (after referral).
- Urinalysis and MSU: Urinalysis will reveal evidence of a UTI, which will be confirmed with an MSU for microscopy and culture. Urinalysis will also reveal glucose in diabetes and possible haematuria in Henoch–Schönlein purpura.
- FBC: Hb may be reduced in any chronic disorder; leucocytosis in bacterial infection; eosinophilia in parasitic infestation or genuine food allergy. Blood film may show sickling. Raised ESR/CRP suggests organic disease.
- Anti-endomysial and anti-gliadin antibodies: A positive result suggests coeliac disease.
- Faecal calprotectin: If Crohn’s suspected.
- Ultrasound: Non-invasive first line investigation of renal tract. Other investigation for confirmed UTI will be arranged by the paediatrician.
- Further hospital-based investigations: If there is a high suspicion of organic disease, e.g. endoscopy for DU, barium meal and follow-through for Crohn’s disease.
- The majority of children with recurrent abdominal pain will not have organic pathology – take the problem seriously and assess carefully, but avoid reinforcing worries with unnecessary investigation or referral.
- Explore the parents’ concerns – a child’s anxiety may be fed by parents unnecessarily worrying about sinister and unlikely diagnoses.
- Talk to children alone – this may reveal relevant problems at home or school which they would not have been able to admit in front of parents.
- If recurrent UTI is a possibility, provide the parents with the necessary bottle and lab form so that an MSU can be taken during the next episode of pain.
- Infants with perceived abdominal pain are often taken to various doctors and/or A&E. They may well end up with diagnoses of GORD, cow’s milk protein intolerance, infant colic or some combination of these. It may take trials of treatment to ease the problem (which is likely to resolve on its own given time anyway). But if the infant is otherwise unwell or not thriving, it should be referred promptly for a paediatric opinion.
- Organic disease is suggested by pain distant from the umbilicus which wakes the child and which is associated with loss of appetite or weight, or a change in bowel habit.
- Beware the unlikely event of an acute cause for the pain supervening, e.g. appendicitis, torsion of the testis – ensure that parents know that a different, acute pain should not be dismissed as ‘the same old problem’, but should be presented urgently.
- Children proven to have a UTI should be managed according to NICE guidelines.
- Avoid colluding in parental somatisation and overlooking the existence of family dysfunction or other causes of unhappiness.
- Don’t forget the rare possibility of sickling in the appropriate ethnic groups.