Evidence-Based Reviews

8 steps to manage recurrent abdominal pain

Current Psychiatry. 2004 June;3(6):25-36

References

1. American Psychiatric Association Diagnostic and statistical manual of mental disorders (4th ed, revised). Washington, DC: American Psychiatric Association, 2000.

2. Apley J, Naish N. Recurrent abdominal pains: a field survey of 1,000 school children. Arch Dis Child 1958;33(168):165-70.

3. Scharff L. Recurrent abdominal pain in children: a review of psychological factors and treatment. Clin Psychol Rev 1997;17(2):145-66.

4. Boyle JT. Recurrent abdominal pain: an update. Pediatr Rev 1997;18(9):310-20.

5. Campo JV, Bridge J, Ehmann M, et al. Recurrent abdominal pain, anxiety, and depression in primary care. Pediatrics 2004;113(4):817-24.

6. Campo JV, Di Lorenzo C, Chiappetta L, et al. Adult outcomes of pediatric recurrent abdominal pain: do they just grow out of it? Pediatrics 2001;108(1):E1.-

7. Starfield B, Gross E, Wood M, et al. Psychosocial and psychosomatic diagnoses in primary care of children. Pediatrics 1980;66(2):159-67.

8. Hyams JS, Burke G, Davis PM, et al. Abdominal pain and irritable bowel syndrome in adolescents: a community-based study. J Pediatr 1996;129(2):220-6.

9. Campo JV, Comer DM, Jansen-McWilliams L, et al. Recurrent pain, emotional distress, and health service use in childhood. J Pediatr 2002;141(1):76-83.

10. Stickler GB, Murphy DB. Recurrent abdominal pain. Am J Dis Child 1979;133(5):486-9.

11. Rasquin-Weber A, Hyman PE, Cucchiara S, et al. Childhood functional gastrointestinal disorders. Gut 1999;45(suppl 2):II60-8.

12. Campo JV, Fritz G. A management model for pediatric somatization. Psychosomatics 2001;42(6):467-76.

13. Campo JV, Garber J. Somatization. In: Ammerman RT, Campo JV (eds). Handbook of pediatric psychology and psychiatry. Vol 1 Boston: Allyn and Bacon, 1998;137-61.

14. Fritz GK, Bergman AS. Child psychiatrists seen through pediatricians’ eyes: results of a national survey. J Am Acad Child Psychiatry 1985;24(1):81-6.

15. Huertas-Ceballos A, Macarthur C, Logan S. Dietary interventions for recurrent abdominal pain (RAP) in childhood. Cochrane Database Syst Rev 2002;(2):CD003019.-

16. Weydert JA, Ball TM, Davis MF. Systematic review of treatments for recurrent abdominal pain. Pediatrics 2003;111(1):e1-11.

17. Campo JV, Perel J, Lucas A, et al. Citalopram treatment of pediatric recurrent abdominal pain and comorbid internalizing disorders: An exploratory study (poster). Miami Beach, FL: American Academy of Child and Adolescent Psychiatry annual meeting, October 2003.

18. Geller B, Reising D, Leonard HL, et al. Critical review of tricyclic antidepressant use in children and adolescents. J Am Acad Child Adolesc Psychiatry 1999;38(5):513-6.

19. See MC, Birnbaum AH, Schechter CB, et al. Double-blind, placebo-controlled trial of famotidine in children with abdominal pain and dyspepsia: global and quantitative assessment. Dig Dis Sci 2001;46(5):985-92.

20. Kline RM, Kline JJ, Di Palma J, Barbero GJ. Enteric-coated, pH-dependent peppermint oil capsules for the treatment of irritable bowel syndrome in children. J Pediatr 2001;138(1):125-8.

21. Sanders MR, Rebgetz M, Morrison M, et al. Cognitive-behavioral treatment of recurrent nonspecific abdominal pain in children: an analysis of generalization, maintenance, and side effects. J Consult Clin Psychol 1989;57(2):294-300.

22. Sanders MR, Shepherd RW, Cleghorn G, Woolford H. The treatment of recurrent abdominal pain in children: a controlled comparison of cognitive-behavioral family intervention and standard pediatric care. J Consult Clin Psychol 1994;62(2):306-14.

High rates of anxiety disorders and temperamental harm avoidance also are seen in patients with RAP, along with a tendency to develop pain when faced with unexpected events. Whether these children are more likely than others to perceive novel internal or external perceptions as threatening is open to debate.

Table 1

Recurrent abdominal pain: 8 steps to assessment and diagnosis

Explicitly acknowledge the patient’s pain and the family’s concerns, especially their fears Communicate to the patient and parents your unwillingness to prejudge the pain’s cause Review previous assessments and treatments Document the pain’s timing, context, and characteristics Consider the possibility that the patient has an unrecognized physical disease Avoid excessive or unnecessary medical tests and procedures Avoid diagnosis by exclusion State your diagnostic impression clearly and frankly

Explicitly acknowledge the patient’s pain and the family’s concerns, especially their fears
Communicate to the patient and parents your unwillingness to prejudge the pain’s cause
Review previous assessments and treatments
Document the pain’s timing, context, and characteristics
Consider the possibility that the patient has an unrecognized physical disease
Avoid excessive or unnecessary medical tests and procedures
Avoid diagnosis by exclusion
State your diagnostic impression clearly and frankly

Serotonin communicates nociceptive information between the gut and brain and may mediate visceral hyperalgesia. Gut enterochromaffin cells contain more than 90% of the body’s total serotonin. They act as sensory transducers, releasing serotonin in response to increased intraluminal pressure or inflammation.

The released serotonin can cause abdominal discomfort by stimulating 5-HT 3 receptors on vagal afferents and can influence gut peristaltic activity by stimulating enteric afferents. The same serotonin transporter responsible for CNS serotonin reuptake is expressed throughout the gut.

A constellation of clues

The ideal RAP evaluation includes information from the child, parents, educators, and other health care professionals (Table 1).

Begin by acknowledging the patient’s suffering and the parent’s concerns; do not challenge the pain’s subjective reality. Rather than prejudging its cause, document the pain’s timing, context, and characteristics, and review the patient’s history. A constellation of clues is most suggestive of RAP (Table 2); single clues are not definitive.^12,13

Table 2

Clues that suggest functional pain*

Temporal relationship between pain and psychosocial stressors Comorbid anxiety, depression, or other psychiatric disorder Personal or family history of functional disorders or somatization Evidence of social or familial reinforcement of pain Family or social milieu includes model for pain or disability Symptoms violate known anatomic or physiologic patterns Pain responds favorably to psychological treatment, suggestion, or placebo
* No single clue is definitive.
Source: Adapted from reference 12.

Diagnostic testing. Be judicious in selecting diagnostic tests and procedures. Continuing to order studies in a haphazard effort to rule out disease can generate concerns that “the doctor doesn’t know what’s wrong” and heighten the family’s fear that a disease has been missed.

The process of “ruling out” physical disease may have no apparent end. Unless you are reasonably comfortable that a serious physical disease has not been missed, it is difficult to explain RAP to the patient and family and lay the foundation for intervention.

On the other hand, you must balance the importance of minimizing your own and the family’s anxiety about unrecognized disease against the physical and psychological risks and costs associated with medical tests and procedures.

Social assessment. Assess social and familial reinforcement (secondary gain) of the pain. Parents sometimes inadvertently encourage their children’s sick-role behaviors by providing excessive attention, rewards, or opportunities to avoid uncomfortable situations. RAP can become an excuse for poor performance (self-handicapping), particularly in children with a learning disorder.

How to deliver the diagnosis

Functional abdominal pain is essentially a clinical diagnosis that relies on presentation, course, and findings. As mentioned, a constellation of “clues” is most supportive, as is having typical IBS symptoms.

Before declaring the diagnosis, discuss with the family the patient’s physical, emotional, and behavioral symptoms and the context in which RAP developed. Doing so can help maintain your credibility and establish a consensus.

Once you declare the diagnosis, discuss it clearly and frankly. Families are not likely to be reassured if you do not offer a plausible explanation for the lack of physical findings.

Precautions. When a definitive diagnosis is not possible, acknowledge that uncertainty. Although you must discuss any recognized psychiatric comorbidity, attempting to “explain” that the disorder is causing the pain is usually impractical and intellectually dishonest.

Also, given the pervasive nature of stigma, do not convey embarrassment or unease about diagnosing functional RAP or any comorbid psychiatric disorder.

Follow-up testing. Once you diagnose functional RAP, further testing is generally not necessary. Tests might be indicated if you:

receive new information
observe a change in clinical status
or are convinced that treatment will not work unless the family is reassured by further investigation.

Collaborative treatment

Reassurance and education. Reassurance that the patient does not have a serious physical disease is necessary but rarely sufficient. Explain that the child’s pain does not appear to reflect tissue damage and is not threatening. On the other hand, avoid giving excessive reassurance, particularly when obsessional illness worry and hypochondriacal fears are prominent. Address illness worry as a problem to be solved together.