Approach to chronic abdominal pain (pediatrics): Clinical sciences

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Introduction0:00–0:38

Chronic abdominal pain is defined as constant, intermittent, or recurrent abdominal pain that’s present for at least two months.
Associated symptoms to consider during an evaluation of chronic abdominal pain include growth and weight gain, changes in bowel habits, as well as the timing, pattern, and nature of the pain.
Underlying causes of chronic abdominal pain can be categorized as organic disorders, which have an anatomic, histologic, or physiologic etiology; and functional disorders, which do not have a clear organic cause.

Unstable0:38–1:12

When a pediatric patient presents with chronic abdominal pain, your first step is to perform an ABCDE assessment to determine if they’re stable or unstable.
If unstable, stabilize their airway, breathing, and circulation; obtain IV or IO access; and administer intravenous fluids or packed red blood cells if indicated.
Finally, implement continuous vital sign monitoring, including heart rate, respiratory rate, blood pressure, and pulse oximetry; and provide supplemental oxygen if needed.

Stable1:12–1:41

Okay, let’s return to the ABCDE assessment and discuss stable patients. First, perform a focused history and physical examination.
Your patient will report constant, intermittent, or recurrent abdominal pain, occasionally with symptoms like nausea, vomiting, diarrhea, or fever.
The physical examination might reveal abdominal tenderness or distension. To evaluate further, assess your patient’s growth curve.
If your patient has had poor linear growth or suboptimal weight gain, your next step is to assess for bloody stools. The presence of blood in the stool should make you consider inflammatory bowel disease.

Inflammatory bowel disease1:41–2:42

These patients often report diffuse, crampy, periumbilical pain and fecal urgency. Some patients might have extraintestinal manifestations, like joint pain and swelling; eye redness or pain; and skin nodules or ulcers.
There may also be a family history of inflammatory bowel disease. The physical exam usually demonstrates abdominal tenderness, and you might notice skin findings, like erythema nodosum, which are painful nodules; a type of skin ulcer called pyoderma gangrenosum; or psoriatic lesions.
To evaluate further, obtain a fecal calprotectin level, and order a colonoscopy with biopsies. If the fecal calprotectin is elevated; if the colonoscopy shows a continuous pattern of edematous, erythematous, friable mucosa and erosions or ulcerations; and if the biopsy reveals mucosal and submucosal inflammation with erosions, ulcerations, and crypt abscesses; diagnose ulcerative colitis.

Ulcerative colitis2:42–3:06

Crohn disease3:06–3:30

On the other hand, if the fecal calprotectin is elevated; but the colonoscopy demonstrates cobblestoning, a discontinuous pattern of skip lesions, with linear serpiginous ulcerations, and rectal sparing; and the biopsy shows transmural inflammation, and possibly granulomas; diagnose Crohn disease.

Celiac disease3:30–5:08

Now let’s move on and discuss patients with non-bloody stools. In this case, you should consider celiac disease.
These patients might report bloating, and they often have diarrhea with or without constipation, as well as steatorrhea.
Your patient might have a history of autoimmune or genetic conditions, such as thyroid disease, or a family history of celiac disease.
The physical exam may demonstrate abdominal distension, short stature or delayed puberty, and dermatitis herpetiformis, which refers to an itchy, vesicular rash that typically appears bilaterally on the elbows and knees.
Next, obtain total IgA and anti-TTG IgA levels, while your patient is on a diet containing gluten, and perform an esophagogastroduodenoscopy, or EGD, with biopsies.
In celiac disease, the total IgA will be normal, and the anti-TTG IgA will be positive. If the EGD with biopsy demonstrates villous atrophy, crypt hyperplasia, and increased intraepithelial lymphocytes, you can confirm a diagnosis of celiac disease.
Here’s a high-yield fact! The combination of chronic diarrhea, weight loss, and abdominal pain should prompt you to consider a Giardia intestinalis infection.
This protozoan is a common cause of diarrheal outbreaks in daycare centers, causing acute or chronic symptoms. Okay, now let’s consider those with normal growth and weight gain.

Lactase deficiency5:08–6:15

First, assess for a change in stool frequency. Let’s start with patients who report increased stooling frequency.
In this case, consider lactase deficiency. History might reveal diarrhea after ingesting dairy products or lactose-containing foods, as well as generalized, crampy abdominal pain with gas and bloating.
Some patients may report a recent gastrointestinal illness or a family history of lactase deficiency. The exam might reveal abdominal tenderness or distension.
Next, recommend a lactose elimination diet, and if your patient’s symptoms resolve, diagnose lactase deficiency. Here’s a clinical pearl!
More than half of the world’s population has some degree of lactase deficiency. Symptoms are related to the quantity of lactose ingested, but each individual has a different dose threshold at which symptoms develop!
Now, in some cases, stools may alternate between diarrhea and constipation. Here, you should consider irritable bowel syndrome, or IBS for short.

Irritable bowel syndrome6:15–7:13

These patients report symptoms for at least two months with abnormal frequency, form, or passage of stool; and the physical exam is typically normal.
To confirm the diagnosis, assess the Rome IV criteria for IBS. These include abdominal pain at least four days per month, plus one or more of the following: pain related to defecation, a change in stool frequency, or a change in stool appearance.
Additionally, in children with constipation, the pain does not resolve after constipation resolves; and symptoms cannot be explained by another medical condition.
If all of these criteria are met, diagnose irritable bowel syndrome. Next let's look at the scenario where stool frequency is reduced.

Functional constipation7:13–8:17

In this case consider functional constipation. History will reveal infrequent bowel movements, straining with defecation, and an absence of systemic symptoms like fever.
The physical examination is usually normal, but some patients may have abdominal tenderness or distension, and you might detect palpable stool in the lower abdomen.
In this case, your next step is to assess the Rome IV criteria for functional constipation. Patients must fulfill two or more criteria, at least once per week for at least one month.
These criteria include two or fewer defecations per week; stool retention with retentive posturing; fecal incontinence; painful, hard bowel movements; a large fecal mass on rectal exam; and large diameter stools that are hard to flush.
If the criteria are met, diagnose functional constipation. Okay, let’s move on to patients who report no change in stool frequency.

GERD8:17–9:20

As a next step, assess for signs and symptoms suggesting gastroesophageal reflux disease, or GERD. Here, caregivers typically report that their infant spits up frequently.
These infants may also become irritable or arch their backs during feeding. Older children might report heartburn, anorexia, nausea, recurrent vomiting, and epigastric or chest pain.
This history in combination with normal exam findings should lead you to consider GERD, which is usually a clinical diagnosis.
Next, begin treatment by recommending lifestyle and dietary changes, such as thickening feedings or elevating the head of the bed during sleep.
You can also consider a trial of a proton pump inhibitor. If symptoms improve with these measures, you can confirm a diagnosis of GERD.

Functional abdominal pain9:20–11:02

Now, let’s look at patients without any signs or symptoms suggesting GERD. Here your next step is to assess the timing and pattern of your patient’s symptoms.
First, let’s discuss patients with intermittent pain, which should make you consider functional abdominal pain disorders.
In this case, your patient’s symptoms will have been present for at least two months and are often associated with life stressors.
The pain can be mild to severe and might occur with nausea, pallor, headaches, or vomiting. These symptoms may also result in decreased school attendance.
Patients will report no blood in the stool, and the physical examination will be normal. To evaluate further, consider obtaining labs, such as a CBC or C-reactive protein, and possibly abdominal imaging.
If the labs and imaging are normal, assess the Rome IV criteria to determine the subtype of functional abdominal pain. Now, here’s a high-yield fact!
Functional abdominal pain disorders, or FAPDs, include irritable bowel syndrome, functional dyspepsia, abdominal migraine, and functional abdominal pain not otherwise specified.
These disorders are characterized by a brain-gut interaction and are affected by both physical and emotional stressors. Patients with FAPDs have normal physical examination findings and normal labs.
Although there is no clear organic etiology for these disorders, it’s important to keep in mind that the associated pain is not imaginary.
First, let’s assess the Rome IV criteria for functional dyspepsia. Patients must experience at least one of the following for at least four days per month: postprandial fullness; early satiety; epigastric pain or burning not associated with defecation; no underlying disorder to explain the symptoms.

Functional dyspepsia11:02–11:30

If these criteria are met, diagnose functional dyspepsia. Next, let’s assess the Rome IV criteria for abdominal migraine.

Abdominal migraine11:30–12:48

Patients must experience each criterion at least twice for at least six months. These include sudden, episodic, intense pain lasting at least one hour; weeks or months of either mild pain or no pain between each episode; pain interfering with daily life; episodes occur in typical patterns for each child; and pain associated with symptoms like nausea, vomiting, anorexia, headache, pallor, or photophobia.
If these criteria are met, diagnose abdominal migraine. Here’s another clinical pearl!
Infantile colic is defined as crying that occurs for more than three hours per day, at least three days per week, for at least three weeks in infants under three months old.
These infants are otherwise healthy, and there is no obvious reason for the crying, although caregivers often report that their infants appear to be in pain.
Still, it isn’t clear if colic is related to discomfort or other factors, such as immature motor regulation or a normal variation in temperament.

Primary dysmenorrhea12:48–13:52

Finally, let’s discuss patients who report cyclic abdominal pain. If your patient is biologically female, consider primary dysmenorrhea.
In this case, symptoms typically begin within the six to twelve months after menarche, and the pain is usually associated with menses.
Patients might also report crampy pain in the lower back, pelvis, or upper thighs. Some also experience nausea, vomiting, or diarrhea; as well as headache, muscle cramps, and difficulty sleeping.
If physical exam findings are normal, diagnose primary dysmenorrhea. Here’s one more clinical pearl!
Primary dysmenorrhea is the most common menstrual-related condition in adolescents and is not associated with underlying pelvic pathology.
On the other hand, secondary dysmenorrhea can be attributed to underlying pathology such as endometriosis or pelvic inflammatory disease.

Review13:52–14:39

Alright, as a quick recap… Chronic abdominal pain in children refers to constant, intermittent or recurrent abdominal pain that is present for at least two months.
It’s associated with a wide variety of diagnoses that may be organic or functional. These include conditions that can affect growth or weight gain, such as ulcerative colitis, Crohn disease, celiac disease, and gastroesophageal reflux disease.
Conditions that do not affect growth or weight gain include lactase deficiency, irritable bowel syndrome, functional constipation, functional dyspepsia, abdominal migraine and primary dysmenorrhea.
Approach to chronic abdominal pain (pediatrics) | Osmosis