Paeds · gastroenterology-hepatology-and-nutrition
Chronic and recurrent abdominal pain
Also known as Recurrent abdominal pain · Functional abdominal pain disorders · Functional abdominal pain · Abdominal pain-related functional gastrointestinal disorder · Disorders of gut-brain interaction · Chronic tummy pain
Fellowship guide to chronic and recurrent abdominal pain in children: the Rome IV functional abdominal pain disorders (functional dyspepsia, irritable bowel syndrome, abdominal migraine, and functional abdominal pain-NOS), the brain-gut mechanism of visceral hypersensitivity, the alarm features that separate functional from organic disease, a targeted rather than shotgun investigation strategy, and stepwise biopsychosocial management from explanation and reassurance through cognitive behavioural therapy, gut-directed hypnotherapy, and selective pharmacology.
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Target exams
Red flags
- Involuntary weight loss, growth faltering, or delayed puberty
- Gastrointestinal blood loss, haematemesis, or melaena
- Persistent right upper or right lower quadrant pain
- Pain that consistently wakes the child from sleep
- Unexplained fever, mouth ulcers, arthritis, or perianal disease
- Bilious vomiting, dysphagia, or persistent vomiting
- Family history of inflammatory bowel disease, coeliac disease, or peptic ulcer
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- Recognises functional abdominal pain as a positive diagnosis, not one of exclusion
- Identifies the alarm features that point toward organic disease
- Explains the brain-gut model of visceral hypersensitivity to families
- Selects a targeted rather than exhaustive investigation strategy
- Constructs a stepwise biopsychosocial management plan
- Interprets the evidence for psychological and pharmacological therapies
- Differentiates functional from organic causes of chronic abdominal pain
- Justifies first-line and second-line investigations
- Outlines evidence-based management of functional abdominal pain disorders
- Takes a focused history from a child and parent with chronic pain
- Communicates a functional diagnosis without dismissing the symptom
- Negotiates a return-to-function plan with family and school
- Stage 1: Recognition of recurrent abdominal pain and its red flags
- Stage 2: Rome IV subclassification and targeted workup
- Level 3: Multidisciplinary management of refractory functional pain
- Rome IV functional abdominal pain disorders and diagnostic criteria
- Pathophysiology of the brain-gut axis and visceral hypersensitivity
- Evidence base for psychological and pharmacological treatment
- History-taking that elicits alarm features and psychosocial context
- Abdominal examination and growth assessment in a child with chronic pain
- Structured explanation of a functional diagnosis to a family
- AAP/NASPGHAN approach to chronic abdominal pain in children
- Judicious use of investigations to avoid overtesting
- Cognitive behavioural and dietary management of functional pain
- Positive diagnosis of functional abdominal pain with limited testing
- Shared decision-making about therapy and school return
- Recognition and referral of organic red flags
- Canadian approach to recurrent abdominal pain and biopsychosocial care
- Coordinated care between primary care, gastroenterology, and psychology
- Function-focused follow-up and relapse prevention
Overview & Definition
A child who repeatedly complains of tummy pain over weeks to months, misses school, and yet grows normally and looks well between attacks is the everyday face of chronic and recurrent abdominal pain. The pain is genuine and disabling, but in the great majority of children no structural, infectious, or biochemical disease is found. These children have a functional abdominal pain disorder, now understood as a disorder of gut-brain interaction rather than a diagnosis of exclusion. [1]
The historical term recurrent abdominal pain described at least three episodes of pain severe enough to affect activity over at least three months. Modern practice has replaced that descriptive label with the Rome IV criteria, which define specific, positively diagnosable functional disorders. The shift matters because it moves the clinician away from an open-ended hunt for hidden disease and toward a confident, symptom-based diagnosis supported by a short, targeted workup. [1]
The central skill in this topic is separating the small minority with organic disease from the majority with a functional disorder. This is achieved not by testing everyone exhaustively but by a careful history and examination that actively seek alarm features. When alarm features are absent and growth is preserved, the clinician can make a positive functional diagnosis and begin treatment rather than defer it pending yet more tests. [2]
References10ShowHide
- [1]Hyams JS, Di Lorenzo C, Saps M, Shulman RJ, Staiano A, van Tilburg M Functional Disorders: Children and Adolescents. Gastroenterology, 2016.PMID 27144632
- [2]American Academy of Pediatrics Subcommittee on Chronic Abdominal Pain Chronic abdominal pain in children. Pediatrics, 2005.PMID 15741394
- [3]Di Lorenzo C, Colletti RB, Lehmann HP, Boyle JT, Gerson WT, Hyams JS, Squires RH Jr, Walker LS, Kanda PT Chronic Abdominal Pain In Children: a Technical Report of the American Academy of Pediatrics and the North American Society for Pediatric Gastroenterology, Hepatology and Nutrition. J Pediatr Gastroenterol Nutr, 2005.PMID 15735476
- [4]Korterink JJ, Diederen K, Benninga MA, Tabbers MM Epidemiology of pediatric functional abdominal pain disorders: a meta-analysis. PLoS One, 2015.PMID 25992621
- [5]Saps M, Youssef N, Miranda A, Nurko S, Hyman P, Cocjin J, Di Lorenzo C Multicenter, randomized, placebo-controlled trial of amitriptyline in children with functional gastrointestinal disorders. Gastroenterology, 2009.PMID 19596010
- [6]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.PMID 11148527
- [7]Levy RL, Langer SL, Walker LS, Romano JM, Christie DL, Youssef N, DuPen MM, Feld AD, Ballard SA, Welsh EM, Jeffery RW, Young M, Coffey MJ, Whitehead WE Cognitive-behavioral therapy for children with functional abdominal pain and their parents decreases pain and other symptoms. Am J Gastroenterol, 2010.PMID 20216531
- [8]Rutten JM, Korterink JJ, Venmans LM, Benninga MA, Tabbers MM Nonpharmacologic treatment of functional abdominal pain disorders: a systematic review. Pediatrics, 2015.PMID 25667239
- [9]Korterink JJ, Rutten JM, Venmans L, Benninga MA, Tabbers MM Pharmacologic treatment in pediatric functional abdominal pain disorders: a systematic review. J Pediatr, 2015.PMID 25449223
- [10]Gulewitsch MD, Schlarb AA Comparison of gut-directed hypnotherapy and unspecific hypnotherapy as self-help format in children and adolescents with functional abdominal pain or irritable bowel syndrome: a randomized pilot study. Eur J Gastroenterol Hepatol, 2017.PMID 29023318