Abdominal pain is a very common symptom in the childhood. It can be present in acute, or chronic or recurrent manner. In acute abdominal pain, it is important to distinguish between medical and surgical causes. On the other hand, in recurrent abdominal pain, the distinction has to be made between organic and in-organic (psychogenic) pain abdomen.
PATHOLOGY
Abdominal pain may arise because of inflammatory lesions of different intra-abdominal structures. It may also be because of the distension of the hollow viscus, where the discomfort caused by the distension is often felt as pain. Increased peristaltic activity of the hollow organs may be felt as acute or recurrent colicky abdominal pain. The pain is usually felt in the same dermatome, which shares the neurological supply of the underlying organ. Thus pain arising from the stomach is often felt in the epigastric region (T8), from urinary bladder in the supra-pubic region
(S2). Intestinal pain is usually felt in the umbilical region (T 10).
Abdominal pain can also be referred from structures like pleura, spine, etc. which are outside, but whose dermatomes are represented in the abdominal region. Basal pneumonia and caries of the thoracic vertebrae are frequent causes of pain abdomen, which may be missed, if the phenomenon of referred pain is not kept in mind.
ACUTE PAIN
When the child is brought with the complaints of acute pain in abdomen, which is occurring for the first time, a careful evaluation is required for an underlying surgical cause. Age of the child and attendant circumstances are helpful in making a diagnosis.
Whenever pain is the first symptom in the triad of pain, vomiting and fever, underlying surgical causes should be strongly considered. On the other hand, whenever fever and vomiting are preceding symptoms, the underlying cause is more likely to be medical in nature.
Severity of pain is not helpful in determining the cause of the disease. Some of the important causes of acute abdominal pain are as following:
1. Surgical Causes
Acute Intussusception
This is caused by the sliding of the proximal part of intestine into the distal part, causing acute obstruction. Ileocolic intussusception is the most common. Diarrhoeal illness may be a precipitating cause. Usual age group is 6-36 months. It is characterised by the episode of sudden colicky pain abdomen, during which the infant cries severely and draws up his/her limbs over the abdomen. In the between the attacks the infant may appear to be quite normal. It may be accompanied with passage of red currant jelly (mucus with blood) type of stools. Abdominal examination may reveal a saucer shaped mass usually away from the right iliac fossa. Diagnosis can be confirmed by barium enema, which may also help to reverse the intussusception failing which, urgent surgery would be required.
Acute Appendicitis
It can occur in any age, but comparatively less common in childhood. Usual triad of pain, vomiting and fever is seen but the site of pain may be typical in children as the caecum (and the appendix) is quite often in right lumbar or right hypochondria areas due to incomplete descent. Abdominal examination shows rebound tenderness and rigidity. Ultrasound of the abdomen could be diagnostically helpful. Urgent surgery is required for relief.
Acute Intestinal Obstruction
It is often caused by congenital stenosis and strictures of the different parts of the intestines. These usually present in the neonatal period. In older infants and children, acute obstruction may be due to volvulus, round worms, or tuberculosis.
Acute colicky abdominal pain, bilious vomiting, abdominal distension and varying degrees of constipation are the important clinical features. A combined medical and surgical approach is required for the diagnosis and management.
Acute cholecystitis, acute renal colic, and acute pancreatitis are the other causes of the acute abdominal pain in children. Presentations are similar to that of adults, but overall occurrence is less common in children.
2. Medical Causes
Acute Infective Colitis
This is clinically characterized by the passage of the small frequent stools, with mucus and blood, and feeling of the tenesmus. It is very common in childhood. Often colicky abdominal pain may be first symptom, causing confusion in the diagnosis. Fever is often present. The most common cause id shigella infection.
Acute Mesenteric Lymphadenitis
This condition is also characterized by t he presence of pain, vomiting, and fever, and may closely mimic acute appendicitis. However, rebound tenderness is almost never present. Brief period of observation would normally clarify the situation. The usual cause of this otherwise self-limiting condition is viral infection.
Basal Pneumonia
This is very frequent cause of abdominal pain. This is accompanied by upper abdominal distension. There may be rapid breathing and careful examination of the chest would reveal the correct diagnosis.
Acute hepatitis, Congestive heart failure causing sudden enlargement of liver and Acute pyelonephritis are the other medical causes of acute abdominal pain in children.
RECUURENT ABDOMINAL PAIN
The syndrome of recurrent abdominal pain (RAP) is very common in school age children. . Apley defined RAP occurrence of more than 2 episodes over a period of 3 months.
Recurrent abdominal pain in children can be due to variety of causes (mentioned in the table below). Although a very large number of organic causes (as illustrated below) can lead to RAP, they together do not cause more than 5-10 percent episodes of RAP. The clinical features, which suggest organic causes of RAP, are given below.
Whenever anyone or more of these features are present, the child should be completely evaluated using various diagnostic tests. However, if none of these features are present, then only baseline investigations like routine stool, urine examination, and a tuberculin test should be obtained. If anyone of these tests is positive, then appropriate further workup (X-ray chest, barium meal, ultrasound, tuberculin test) may be required. If all these investigations are also negative, it is very unlikely that there is any underlying organic cause of RAP. In such cases, these children are probably having psychogenic pain in abdomen.
Causes of Recurrent Abdominal Pain
1.Organic
A. Gastrointestinal : Gastroesophageal reflex, Peptic Ulcer Disease, Non-ulcer duspepsia, intestinal worms, intestinal tuberculosis.
B. Renal : Urolithiasis, Urinary tract infection
C. Hepatic : Recurrent Cholecystitis
D. Pancreatic : Recurrent Chronic Pancreatitis
E. Extra-Abdominal: Spinal caries, Root pain.
Features suggesting Organic Cause:
• Age < 3 years
• Pain well-localized,consistent, away from umbilicus
• Tenderness/ rigidity on local examination
• Accompanying symptoms like fever, rash, joint pain
• Jaundice
• Raised Blood Pressure
2.Psychogenic
Role model, attention-seeking behaviour
However, for a definitive diagnosis of the psychogenic pain in abdomen, it is very important to establish “Secondary Gain Pattern”, i.e. what is that which the child may be achieving school Absenteeism, attention-seeking from parents, etc. are important secondary gain. Help of specialist would be required to evaluate such children. Most of such type children, usually grown out of this symptom.
3. Uncommon Causes
Abdominal Epilepsy
It is believed to be due to epileptic discharges from the temporal lobe. It manifests as brief episode of pain, accompanied by sudden pallor and may be brief episode of loss of sensorium. EEG is helpful in diagnosis, and the management is on the lines of temporal lobe epilepsy (complex partial seizures).
Acute Hepatic Porphyria
The abdominal pain is severe and colicky in nature, accompanied by passage of dark coloured urine; or urine, which becomes dark on standing. Drugs like Phenobarbitone may be the precipitating cause. Diagnosis is confirmed by demonstrating presence of porphobilinogen in the urine. Management is usually symptomatic and avoidance of drugs which may precipitate the acute attack.
Management of RAP
If the organic cause, like dyspepsia, gastroesophageal reflux disease, peptic ulcer disease, urinary tract infection, chronic colitis, constipation etc. are found, they would need appropriate management.
For psychogenic pain in abdomen, it must be realized that the pain is real as far as the child is concerned. It should never be suggested that the child is only feigning symptom or the pain is the ‘head’. This will only worsen the situation. Brief period of observation and assurance, that there is nothing seriously wrong with the child, helps to manage the child. Most children usually overcome their problem, if less attention is given to their symptom (of pain) and more attention is given to the child himself. In difficult cases, a specialist would be required.
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