Approach to chronic abdominal pain (pediatrics): Clinical sciences

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.

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.

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. 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.