Continuing Education Column Practical Diagnostic Approaches to Chronic Abdominal Pain in Children and Adolescents Jin-Bok Hwang, MD Department of Pediatrics, Keimyung University School of Medicine E - mail : pedgi@kmu.ac.kr Sung Hoon Jeong, MD Department of Pychiatry, Kyungpook National University School of Medicine E - mail : jshun@knu.ac.kr J Korean Med Assoc 2009; 52(3): 271-284 Abstract Chronic abdominal pain (CAP) in children and adolescents remains one of the pathogenetically ambiguous disorders and a great trouble to their caretakers as well as patients. Although the symptom does not usually lead to a crucial problem, the parents may be terribly worried, the child may be in distress, and the practitioner may be concerned about ordering tests to confirm a serious occult disease. Systemized diagnostic approaches are needed to overcome this unique difficulty. The presence of red flag symptoms or signs is a general indication to pursue diagnostic testing for organic etiologies of CAP on the basis of specific symptoms in an individual case. Functional abdominal pain can be normally diagnosed when there are no red flag symptoms or signs. According to the Rome III criteria for pediatric functional gastrointestinal disorders, functional disorders of CAP can be classified into functional dyspepsia, irritable bowel syndrome, abdominal migraine, and chronic functional abdominal pain syndrome. Cyclic vomiting syndrome and pathologic aerophagia are also major functional causes of CAP. Modern concepts of the pathogenesis of functional abdominal pain include brain-gut interaction, visceral hypersensitivity, autonomic dysfunction, and psychosocial factors. In addition, psychiatric disorders, presented with red flag symptoms or signs, may induce the CAP in children and adolescents. We introduce practical and systemized diagnostic approaches by illustrating clinical cases of CAP in children and adolescents. Keywords: Chronic abdominal pain; Functional gastrointestinal disorder; Organic disease; Psychiatric disorder; Children 271
Hwang JB Jeong SH Figure 1. Major etiologies of chronic abdominal pain in children and adolescents. Figure 2. Practical diagnostic approaches of chronic abdominal pain in children and adolescents. 272
Chronic Abdominal Pain in Children and Adolescents 273
Hwang JB Jeong SH 274
Chronic Abdominal Pain in Children and Adolescents Figure 3. Four diagnostic steps of chronic abdominal pain in children and adolescents. 275
Hwang JB Jeong SH Table 1. Differential diagnosis of organic etiologies in childhood chronic abdominal pain based on age and prevalence Years Common > 1/100 Rare < 1/100 4 ~10 Functional RAP Intussusception Constipation Malrotation, choledochal cyst Acid peptic disease* Eosinophilic esophagitis Irritable bowel disease Post- surgical adhesions Abdominal migraine Lead poisoning Infectious colitis Urolithiasis, Menetrier s disease Urinary tract infection Parasitic infestation Henoch-Schonlein purpura Uretero- pelvic junction obstruction 10~18 Irritable bowel syndrome Chronic appendicitiis Functional RAP Gilbert s syndrome Acid peptic disease* Pancreatitis, choledochal cyst Lactose intolerance Eosinophilic esophagitis Abdominal migraine Post- surgical adhesions Infectious and inflammatory colitis Cholelithiasis, Urolithiasis Dysmenorrhea Biliary of oddi dysfunction Chronic hepatitis Abuse: sexual and physical PAN, SMA, SLE, MVO, AIP Musculo-skeletal, Discitis, lymphoma *Acid peptic disease; gastroesophageal reflux disease, esophagitis, gastritis, H. pylori - associated. Abbreviations: RAP; recurrent abdominal pain, PAN; polyarteritis nodosa, SMA; superior mesenteric artery syn- drome, SLE; systemic lupus erythematosis, MVO; mesenteric vein obstruction, AIP; acute intermittent por-phyria. Adapted from reference 2. Decreasing Prevalence for Common Disorders Decreasing Prevalence for Common Disorders 276
Chronic Abdominal Pain in Children and Adolescents 277
Hwang JB Jeong SH Table 2. Rome III functional gastrointestinal disorders in child and adolescent H. Child/Adolescent H1. Vomiting and aerophagia H1a. Adolescent rumination syndrome H1b. Cyclic vomiting syndrome H1c. Aerophagia H2. Abdominal Pain-related FGIDs H2a. Functional dyspepsia H2b. Irritable bowel syndrome H2c. Abdominal migraine H2d. Childhood functional abdominal pain H2d1. Childhood functional abdominal pain syndrome H3. Constipation and incontinence H3a. Functional constipation H3b. Non-retentive fecal incontinence * Boldface indicates discussion in this article. Adopted from (5). 278
Chronic Abdominal Pain in Children and Adolescents 279
Hwang JB Jeong SH 280
Chronic Abdominal Pain in Children and Adolescents 281
Hwang JB Jeong SH 282
Chronic Abdominal Pain in Children and Adolescents 11. Hyams JS, Burke G, Davis PM, Rzepski B, Andrulonis PA. Abdominal pain and irritable bowel syndrome in adolescents: a community-based study. J Pediatr 1996; 129: 220-226. 12. Kohli R, Li BU. Differential diagnosis of recurrent abdominal pain: New considerations. Pediatr Ann 2004; 33: 113-122. 13. Boey CCM, Goh KL. Psychosocial factors and childhood recur- 283
Hwang JB Jeong SH rent abdominal pain. J Gastroenterol Hepatol 2002; 17: 1250-1253. 14. Apley J, Naish N. Recurrent abdominal pains: a field survey of 100 school children. Arch Dis Child 1958; 50: 429-436. 15. Di Lorenzo C, Colletti RB, Lehmann HP, Boyle JT, Gerson WT, Hyams JS, Squires RH Jr, Walker LS, Kanda PT. Chronic abdominal pain in children: a clinical report of the American Academy of Pediatrics and the North American Society for Pediatric Gastroenterology, Hepatology and Nutrition. J Pediatr Gastroenterol Nutr 2005; 40: 245-248. 16. Kolts RL, Nelson RS, Park R, Heikenen J. Exploratory laparoscopy for recurrent right lower quadrant pain in a pediatric population. Pediatr Surg Int 2006; 22: 247-249. 17. Park MH, Choi WJ, Hwang JB. Topical tacrolimus resulting in a marked resolution of perianal Crohn s disease. Korean J Pediatr Gastroenterol Nutr 2005; 8: 70-75. 18. Zinkin NT, Peppercorn MA. Abdominal epilepsy. Best Pract Res Clin Gastroenterol 2005; 19: 263-274. 19. Song JY, Kim JS, Hwang JB. A case of abdomonal epilepsy presenting with recurrent abdominal pain. Korean J Pediatr Gastroenterol Nutr 2007; 10: 202-205. 10. Hong SP, Shin HJ, Kim YH, Choe BK, Choi WJ, Kim AS, Hwang JB. A case of PFAPA syndrome mimicking cyclic vomiting syndrome. Korean J Pediatr Gastroenterol Nutr 2006; 9: 85-91. 11. Yang HR. New approach to chronic recurrent abdominal pain in children. Korean J Pediatr 2006; 49: 129-135. 12. Raquin A, Di Lorenzo C, Forbes D, Guiraldes E, Hyams JS, Staiano A, Walker LS. Childhood functional gastrointestinal disorders: child / adlescent. Gastroenterology 2006; 130: 1527-1537. 13. Hwang JB, Oh HJ, Choi KH. Long term follow-up of cyclic vomiting syndrome. Korean J Pediatr Gastroenterol Nutr 2000; 3: 75-83. 14. Hwang JB, Choi WJ, Kim JS, Lee SY, Jung CH, Lee YH, Kam S. Clinical features of pathologic childhood aerophagia: early recognition and essential diagnostic criteria. J Pediatr Gastroenterol Nutr 2005; 41: 612-616. 15. von Baeyer CL. Understanding and managing children s recurrent pain in primary care: A biopsychosocial perspective. Paediatr Child Health 2007; 12: 121-125. 16. Raymer D, Weininger O, Hamilton JR. Psychological problems in children with abdominal pain. Lancet 1984; 1: 439-440. 17. Robinson JO, Alverez JH, Dodge JA. Life events and family history in children with recurrent abdominal pain. J Psychosom Res 1990; 34: 171-181. 18. Tarbell S, Li BU. Psychiatric symptoms in children and adolescents with cyclic vomiting syndrome and their parents. Headache 2008; 48: 259-266. 19. Alfven G. One hundred cases of recurrent abdominal pain in children: diagnostic procedures and criteria for a psychosomatic diagnosis. Acta Paediatr 2003; 92: 43-49. Peer Reviewers Commentary 284