RECURRENT ABDOMINAL PAIN
History
Danielle is an 8-year-girl referred to children’s outpatients by her GP. She has been seen several times by different partners over the previous couple of years with abdominal pain. She describes the pain as peri-umbilical, non-radiating, sometimes sharp, but usually an ache. There is no obvious periodicity, including to food. Her appetite is good and there are no concerns about her growth and weight gain. She has her bowels open most days and there has never been any blood or mucus. She occasionally feels nauseated with the pain but has never vomited. There are no urinary symptoms. She started junior school last year and moved house around the same time after her parents separated. She lives with her mother, but she and her 4-year-old brother have frequent contact with their father. She was doing well at infants but is now falling behind, having missed quite a lot of school. She has several badges for gymnastics. There is no family history of note, including migraine. Her mother is worried that this is something to do with puberty and that her periods are about to start.
Examination
Danielle is a generally healthy, cooperative, but slightly anxious girl. Her nails are bitten but there is no clubbing, anaemia, lymphadenopathy or jaundice. Her height is on the 25th centile and her weight is on the 9th. She is prepubertal. Full examination is normal.
INVESTIGATIONS
Normal
Haemoglobin 12.3 g/dL 11.5–15.5 g/dL
White cell count 8.4 109/L 6 17.5 109/L
Platelets 365 109/L 150–400 109/L
Sodium 138 mmol/L 138–146 mmol/L
Potassium 4.5 mmol/L 3.5–5.0 mmol/L
Urea 4.2 mmol/L 1.8–6.4 mmol/L
Creatinine 46 µmol/L 27–62 µmol/L
C-reactive protein 6 mg/L 6 mg/L
Immunoglobulins Normal
Transglutaminase antibodies Negative
Midstream urine Normal
Abdominal ultrasound Normal
Questions
• What is the most likely diagnosis?
• What is the differential diagnosis?
• How would you manage this patient?
Medicine
The most likely diagnosis is chronic abdominal pain of childhood or recurrent abdominal pain (RAP). This is a benign, very common but potentially debilitating condition. The pointers to this not being organic are the chronicity of the characteristic symptoms in an otherwise healthy, physically active child. The commonest identifiable cause for RAP is psychosomatic, as seems likely from the description of this girl who has had many recent changes in her life. However, it is a diagnosis of exclusion and investigations exclude conditions that can have an insidious onset, such as coeliac disease, and reassure the child and family that there is no sinister cause. The latter is crucial because the symptoms are very real and there is understandable anxiety. Among the differentials, abdominal migraine differs in that it is usually associated with pallor and vomiting. There is almost always a family history of migraine. An organic cause is also more likely the further the pain is from the umbilicus. Mothers often worry that RAP heralds menarche but this comes towards the end of puberty. Sexual abuse should be considered in the differential.
Differential diagnosis of chronic abdominal pain
• Psychosomatic
• Urinary tract infections
• Constipation
• Gastro-oesophageal reflux
• Coeliac disease
• Inflammatory bowel disease
• Cow’s milk intolerance
• Abnormal renal anatomy, e.g. pelviureteric junction obstruction
• Abdominal migraine
• Peptic ulcer
• Sexual or other abuse
Management focuses on explanations and reassurance. It is helpful to liken the condition to tension headaches in adults – common and unpleasant but not serious. Acknowledge that there is no question of fabrication. Children rarely fabricate symptoms and, if they do, abuse should be considered. The classic time for RAP is in the morning before school. Most parents recognize this and have often already asked questions about bullying or other worries, but sometimes a cycle sets in where missing school and falling behind worsen the symptoms and cause more anxiety. The child may be recognized as a ‘worrier’ and most can understand the concept of psychosomatic symptoms. Some families still find it difficult to accept that there is nothing medically wrong and pursue a diagnosis such as food allergy. They may seek advice from practitioners of alternative medicine and it is important to discuss openly the dangers of dietary exclusions that they may suggest. In the absence of other symptoms, such as diarrhoea or an association with eating, there is no evidence that such measures are effective. Once a diagnosis has been reached, the child should be discharged from hospital followup to prevent the risk of reinforcing a medical diagnosis. Referral to a psychologist or psychiatrist is sometimes necessary.
KEY POINTS
• Children can have psychosomatic symptoms just as adults – however, these are a diagnosis of exclusion.
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