1. RecuRRent
AbdominAl
PAin
Dr. Ravi Malik
CMD Radix Hospital
IMA Headquaters
DMC medical education
convenor

2. INTRODUCTION
RAP
3 episodes over 3 months
Severe enough to affect activities
Inter periods of well being
No specific cause identified

3. epIDemIOlOgy
10-12% of school aged children.
Peak incidence at 4-6 years and at 7-12
years.
Obesity and RAP.
Fruits consumption and RAP.

4. ClINICal pROfIle
Pain is genuine
Peri-umbilical pain
Nausea, vomiting
Pallor
Headache & limb pains
Family history

5. ClassIfICaTION
• It can be organic or nonorganic.
• Nonorganic(functional) abd pain
• Functional dyspepsia
• Irritable bowel syndrome
• Abdominal migraine
• Functional abdominal pain

6. eTIOlOgy
Organic Pain (10%) Non-organic Pain (90%)
Site Flanks, suprapubic Central and often epigastric
Family History - VE + VE
Psychological History - VE + VE
Headache - VE + VE
Weight Loss +VE - VE
Abnormal Signs +VE - VE
Abnormal Investigations +VE - VE
Alarming Symptoms + VE - VE

7. Functional dyspepsia
Pain or discomfort in the upper abd.
Stomach fullness
Bloating
Nausea
Retching or vomiting.
Irritable bowel syndrome

8. Abdominal migraine
Intense abdominal pain
Mid-abdomen
Anorexia, nausea, vomiting, pallor,
headache, or sensitivity to light
A family history of migraine
Functional abdominal pain syndrome

9. Rap (ORgaNIC)
GIT
Infections – ameba, giardia, dysentry, H.
pylori
Inflammatory-IBD, Hepatitis,
appendicitis
Constipation
GI reflux disease
Acid peptic disease

10. CaUses Of Rap
Urinary tract (ORgaNIC)
Gynecological Miscellaneous
Urinary tract Ovarian cyst
infection Abdominal
Urinary calculi epilepsy
Endometriosis
Pelvi-ureteric Physical,
junction Pelvic emotional and
obstruction inflammatory sexual abuse
disease
Chronic
pancreatitis

11. paThOphysIOlOgy
Gastrointestinal motility- High levels of
emotional stress and abnormalities in
autonomic nervous system may contribute.
Visceral hypersensitivity-
Intensity of signals from GIT is exaggerated.
Abnormal bowel sensitivity to physiological,
psychologic or noxious stimuli may be present.
May occur following viral gastroenteritis or
after psychologically traumatic events.

12. Emotional stress
Patients can sometimes date the onset of pain to
a specific stressful event, such as change in school,
birth of a sibling or separation of parents, family
member's illess.
Higher levels of anxiety and depression are found
in patients with RAP than in healthy children.
Starting school may also trigger recurrent
abdominal pain.

13. Psychological factors:-
A child can develop chronic abdominal pain related
to his or her need for attention.
Parental response to child's pain can reinforce the
child's behavior. If parents are worried about child's
pain, the child may become more anxious, and the
pain may worsen.
Parents should pay attention to the child's other
activities, this might satisfy the child's need for
attention & reduce the abdominal pain.

14. alaRm sympTOms
(NeeDINg fURTheR INvesTIgaTIONs)
Features that suggest an organic disorder may include one or
more of the following:
 Pain that awakens the child,
 Significant vomiting/constipation/bloating
 Persistent right upper/lower quadrant pain
 Unexplained fever
 Dysphagia
 Chronic severe diarrhea
 G.I. blood loss
 Unintentional weight loss or slowed growth
 Delayed puberty
 Pain/ bleeding with urination
 Family H/O inflammatory bowel disease, celiac or peptic ulcer disease

15. alaRm sIgNs
(NeeDINg fURTheR INvesTIgaTIONs)
Localized tenderness in right upper/lower quadrant
Localized fullness or mass
Hepatomegaly/Splenomegaly
Jaundice
Costovertebral angle tenderness
Arthritis
Spinal tenderness
Perianal disease
Unexplained physical findings
Pallor/Rash
Hernia

16. DIagNOsIs
RAP should not require an exhaustive
series of diagnostic tests to rule out organic
causes
History – absence of alarming symptoms
Meticulous examination
Other associated symptoms
Normal investigations
Organic & nonorganic may co-exist

17. INvesTIgaTIONs IN ReCURReNT
abDOmINal paIN
Basic investigations (1st line investigations)
 Full blood count
 ESR/C-reactive protein
 Urine analysis & Urine culture
 Stool for ova, cysts and parasites
Second line investigations
 Plain X-ray abdomen
 LFT & KFT
 Celiac panel
 Abdominal ultrasound
 Breath hydrogen test for lactose intolerance
 Tests for Helicobacter pylori
 Barium follow through
 Esophageal manometry and pH-metry
 Upper and lower gastrointestinal endoscopy
 Intravenous urogram/micturition cystourethrogram

18. Only basic urine, stool and blood examinations are
recommended to exclude organic causes in the
diagnosis of RAP.
Ultrasound scanning, extensive radiographic
evaluation and invasive investigations like endoscopy
in these children are rarely diagnostic or cost
effective.
Presence of an abnormal test result alone does not
pinpoint to a diagnosis unless it is clinically relevant.

19. abDOmINal paIN
TReaTmeNT
Treat organic cause if present.
For functional abdominal pain variety
of treatments.
Close follow up required.

20. gUIDelINes fOR maNagemeNT
Of ReCURReNT abDOmINal
paIN
Rule out organic cause
Reassurance & education of the family.
Discuss the apprehensions of family.
Explore stressors.
Acknowledge but no undue attention.
Avoid psychological labelling.

21. gUIDelINes fOR maNagemeNT Of
ReCURReNT abDOmINal paIN-(II)
Allow normal activity.
Establish regular follow-up system of return visits to
monitor the symptoms.
Be available Assure parents that you are available to see
the child if changes occur or the parents become anxious.
Allow appropriate time, in an unrushed environment for
them.
Make judicious use of “second opinions”

22. DRUg TheRapIes
Pharmacological treatments are commonly used in an
effort to manage symptoms despite the lack of data
supporting their efficacy.
Usually a part of the multidisciplinary approach.
Commonly used medications include acid suppressants
for dyspepsia symptoms, antispasmodics & low dose
amitriptyline .
For chronic abdominal pain with IBS symptoms,
antidiarrheals and nonstimulating laxatives are used.
Peppermint oil found to be very effective in the treatment
of irritable bowel syndrome in children.
PPIs and anticholinergics are often unhelpful.

23. DIeTaRy mODIfICaTIONs
There is no evidence that lactose-restricted diet and
fiber supplements decrease the frequency of attacks
in chronic abd. pain.
In some children, there are foods, drinks, and
medicines that make symptoms worse.
Common triggers include: High-fat foods, Caffeine &
foods that increase gas (beans, onions, raisins,
bananas, apricots, prunes, cabbage, cauliflower,
broccoli etc.)
Medicines that can cause upset stomach include
aspirin and ibuprofen etc.

24. behavIORal TheRapIes
Recommended for children or adolescents with functional
abdominal pain that has severely impacted activities of
daily living.
Cognitive-behavioral therapy is help full in short term for
managing pain and functional disability.
Relaxation techniques, hypnosis, biofeedback, and
psychotherapy help to reduce a child's anxiety levels, help
them to participate in normal activities and to better
tolerate the pain.
A significant improvement of symptoms and fewer school
absences in children with RAP following a short period of
cognitive behavioral family treatment is reported.

25. pROgNOsIs
With this approach, approximately 30% to 60% of
children have resolution of their pain.
Remainder continue to exhibit symptoms and go
on to be adults with abdominal pain, anxiety, or
other somatic disorders.
Other studies have reported development of irritable
bowel syndrome in 25-29% of them in later life.