Chronic Abdominal Pain

Paula K. Braverman

Chronic abdominal pain is a common complaint among adolescents and young adults (AYAs). The differential diagnosis of chronic abdominal pain includes functional gastrointestinal disorders (FGIDs) and organic disorders related to anatomic abnormalities, inflammation, or tissue damage. The Rome III criteria have been developed to characterize FGID among different age-groups. There is ongoing research into the pathophysiology of the brain-gut axis related to FGID as well as pharmacologic and dietary treatment options. Efforts to treat chronic abdominal pain can lead to intense frustration among patients, families, and health care providers alike. The approach to this problem is particularly challenging, and in most cases, there is no specific organic abnormality found. This chapter reviews the epidemiology, pathophysiology, differential diagnosis, clinical approach, and available treatment modalities for chronic abdominal pain with an emphasis on FGID.

DEFINITION

In the past, children with chronic abdominal pain were commonly diagnosed as having recurrent abdominal pain (RAP). In 2005, the Subcommittee on Chronic Abdominal Pain of the North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition published a report recommending that the term “RAP” be eliminated and concluded that abdominal pain exceeding 1 or 2 months, whether long lasting, intermittent, or constant, should be considered chronic.¹,² The differential diagnosis of chronic abdominal pain includes FGIDs and organic disorders related to anatomic abnormalities, inflammation, or tissue damage. The Rome criteria are a diagnostic system developed to characterize and standardize the diagnosis of FGIDs. FGIDs are disorders of the gastrointestinal (GI) system in which symptoms cannot be explained by organic abnormalities but are based on clinical symptoms in children, adolescents, and adults.³ This chapter will focus on the diagnosis and treatment of chronic abdominal pain with an emphasis on FGID.

DIFFERENTIAL DIAGNOSIS AND CLINICAL MANIFESTATIONS OF CHRONIC ABDOMINAL PAIN

FGID

FGIDs, characterized by persistent and recurring GI symptoms, include a number of separate idiopathic disorders that can affect any part of the GI tract.

Epidemiology

The exact prevalence of FGIDs in AYAs is unknown for several reasons:

There may be overlapping symptoms, and individuals may have more than one FGID as defined by the Rome criteria.⁴,⁵,⁶
The prevalence of FGID differs depending on the version of Rome criteria applied and the population studied, including the geographic region or country, suggesting different perceptions and sociocultural interpretations of symptoms.⁴,⁵,⁷
Many prevalence studies in children/adolescents used the older RAP terminology or simply asked about abdominal pain symptoms rather than using the Rome criteria.
The Rome criteria may not accurately reflect the clinical presentation. This was specifically discussed in the 2012 Multinational Irritable Bowel Syndrome Initiative report indicating that the Rome criteria are not necessarily adequate or most relevant for the clinical diagnosis of irritable bowel syndrome (IBS).⁸

Despite these limitations, the following studies provide some estimates of the prevalence of chronic abdominal pain in children and AYAs:

Results from a systematic review on RAP found a prevalence of 0.3% to 19% in children and adolescents in the US and Europe.⁹
The National Longitudinal Study of Adolescent Health study of a nationally representative sample of 13- to 18-year-olds found 3.2% with daily abdominal pain and 15% with pain more than twice a week.¹⁰
A prospective Norwegian study on 4- to 15-year-olds referred for evaluation of RAP found that 87% met criteria for one or more FGID and 43% had IBS using the Rome III criteria.¹¹
A study in Japan utilizing Rome III criteria in 3,976 students between 10 and 17 years of age found a prevalence of 13.9% for one or more FGID.¹²
A systematic review of the worldwide literature assessing IBS among individuals 15 years and older found prevalence rates from 7% to 21%, with a pooled prevalence of 11% for those less than age 30.¹³

Etiology of FGIDs

The etiology of FGID is still not well understood; however, recent studies indicate multidimensional causes. Current theories suggest that FGIDs are due to the following:

Dysregulation or impairment of the bidirectional communication in the “brain-gut axis” involving¹⁴,¹⁵:
- Neural systems (neurotransmitters, e.g., serotonin, noradrenaline) and the autonomic and enteric nervous systems, which affect motility and secretions
- Gut and peripheral immune systems (e.g., cytokines, mast cell activation, T-cell activation)
- Endocrine systems (hypothalamic-pituitary-adrenal axis)
Visceral hypersensitivity (hyperalgesia) with alteration in the neural processing of visceral stimuli, resulting in lower pain thresholds and/or alterations in pain perception. Possible disturbance in pain processing is evidenced by brain imaging studies demonstrating activation of certain areas of the brain and structural brain changes.¹⁶
Other factors influencing the brain-gut axis, including genetic predisposition psychological factors (stress, anxiety, trauma, pain, mood, cognitive function, expectation, conditioning), and physical factors (infection, mucosal inflammation, alteration in enteric microbiota).¹⁵,¹⁶,¹⁷

Diagnostic Criteria

The Rome III criteria include categories for infant/toddlers, children and adolescents aged 4 to 18 and for adults.³ A key criterion in diagnosing FGIDs is that there is no evidence of structural disease to explain the symptoms. Different FGIDs can co-occur in the same AYAs.⁶ The following are the relevant differences in the Rome III categories by age-group. The Full Rome III criteria are laid out at http://www.romecriteria.org/criteria/

The child/adolescent components are classified by symptom pattern or area of symptom location, whereas the adult components are divided into six domains (Table 36.1).
The Rome III criteria for adults define FGID as abdominal pain starting 6 months prior to diagnosis and meeting criteria for active symptoms for the previous 3 months. For children/adolescents, many of the categories require only active symptoms for 2 months and do not specify a time frame for onset of symptoms.
The criteria for the same diagnostic category of FGID differ by age-group.

Table 36.2 outlines the age-related Rome III criteria for several diagnostic entities common to both the child/adolescent and adult age-groups, including functional abdominal pain, IBS, and functional dyspepsia.

Organic Causes of Chronic Abdominal Pain

Causes of Chronic Pain Commonly Associated with Dyspepsia

Gastroesophageal reflux; peptic ulcer disease; biliary tract obstruction; gall bladder dyskinesia; chronic pancreatitis; gastroparesis

Causes of Chronic Pain Commonly Associated with Altered Bowel Pattern

Inflammatory bowel disease (IBD); celiac disease; lactose intolerance; colitis; complications of constipation (encopresis, megacolon); infection (parasites and bacteria)

IBD can be manifested by the following:

Poor growth
Anemia, elevated erythrocyte sedimentation rate (ESR), and elevated fecal calprotectin¹⁸,¹⁹
Bloody stools—although stools may be positive for hemoccult without signs of diarrhea
Systemic symptoms—arthritis, iritis, hepatitis, and erythema nodosum

TABLE 36.1 Rome III Classification for FGIDs

Adult Categories	Child/Adolescent Categories
Functional Esophageal Disorders	Vomiting and Aerophagia
Functional heartburn Functional chest pain of presumed Esophageal origin Functional dysphagia Globus	Adolescent rumination syndrome Cyclic vomiting syndrome Aerophagia
Functional Gastroduodenal Disorders	Abdominal Pain-Related Functional GI Disorder
Functional dyspepsia Belching disorders Nausea and vomiting disorders Rumination syndrome in adults	Functional dyspepsia IBS Abdominal migraine Childhood functional abdominal pain Childhood functional abdominal pain syndrome
Functional Bowel Disorders	Constipation and Incontinence
IBS Functional bloating Functional constipation Functional diarrhea Unspecified functional bowel disorder	Functional constipation Nonretentive fecal incontinence
Functional Abdominal Pain Syndrome
Functional Gallbladder and Sphincter of Oddi Disorders
Functional gallbladder disorder Functional biliary sphincter of Oddi disorder Functional pancreatic sphincter of Oddi disorder
Functional Anorectal Disorder
Functional fecal incontinence Functional anorectal pain Functional defecation disorders
Adapted from Rome Foundation Available at http://www.romecriteria.org/. Accessed March 15, 2014.

Celiac disease is one of the most common genetic diseases (HLA class II haplotypes DQ2 and DQ8). There is evidence that the prevalence is increasing worldwide, with current estimates of 1% in the general population²⁰ and 10% to 15% in those with an affected first-degree relative.²¹ This disease is often under recognized and under diagnosed by health care providers, with only 10% to 15% of those affected having been diagnosed and treated.²⁰ Celiac disease can be symptomatic or asymptomatic and may not be diagnosed until adulthood. Extraintestinal manifestations become more prevalent with increasing age.²⁰,²² Celiac disease can be manifested by the following signs and symptoms:

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