Diseases & Conditions
Chronic and Recurring Abdominal Pain
Chronic and recurring abdominal pain occurs for more than 3 months and interferes with the child's life. The cause can be anxiety or other psychologic distress but may be a physical disorder. Functional abdominal pain is most commonly vague and located around or above the navel. The diagnosis is based on symptoms and a physical examination. Pain in children who are under the age of 5 years or who are losing weight, bleeding, or producing severe vomiting or diarrhea is probably caused by a physical disorder. Physical causes are treated, or measures to relieve psychologic distress are taken.
Chronic and recurring abdominal pain affects about 10 to 15% of children between 5 and 16 years of age, particularly those between 8 and 12 years of age. It is uncommon among children under 5 years of age. It is somewhat more common among girls.
There are over 100 different causes of chronic abdominal pain in children, but the most common are functional pain, dairy (lactose) intolerance, constipation, and gastroesophageal reflux.
Functional Pain: Functional pain is real pain that results from stress or anxiety (from problems at school, home, or with friends) rather than from an underlying physical disorder. It is similar to a tension headache. In a tension headache, the pain is real, but there is no underlying problem such as a brain tumor or stroke. The headache is just how the body reacts to stress. Instead of a tension headache, children tend to have a tension stomachache. The pain can be severe and typically alters the child's life. For example, children who are very stressed by school are frequently absent. The exact mechanism of functional abdominal pain is unknown, but many doctors think the pain occurs when the nerves of the digestive tract become hypersensitive to stimuli (such as expansion or contraction of the intestines) that most people do not find uncomfortable. Why these nerves become hypersensitive is unclear but may involve a preceding infection or allergy. Genetic factors, life stresses, and the child's personality, social situation, and any underlying mental disorders (such as depression or anxiety) all may help cause functional pain.
Lactose Intolerance: Lactose is the predominant sugar found in milk and other dairy products. Lactase is an enzyme needed to break down lactose. Children who lack lactase cannot digest and absorb lactose, which leads to diarrhea and abdominal cramping (see Malabsorption: Lactose Intolerance ).
Constipation: Children who consume insufficient fluids or fiber are often constipated (see Digestive Disorders: Constipation ). A lack of fluid and fiber causes stool to become hard and difficult to pass. These stools may cause abdominal discomfort, pain with defecation, or both.
Gastroesophageal Reflux: The disorder that causes the backward movement of food and acid from the stomach into the esophagus and sometimes into the mouth is called gastroesophageal reflux (see Digestive Disorders: Gastroesophageal Reflux ). The reflux can cause abdominal pain, heartburn, and nausea.
Some Causes of Chronic and Recurring Abdominal Pain
Gastrointestinal disorders Hiatal hernia Esophagitis Peptic ulcer disease* Liver disease (such as hepatitis)* Gallbladder disease (such as cholecystitis)* Pancreatic disease (such as pancreatitis)* Inflammatory bowel disease (such as Crohn's disease)* Meckel's diverticulum Appendicitis Intussusception Parasitic infection (such as giardiasis)* Tuberculosis of the intestine Celiac disease (such as celiac sprue)* Constipation* Lactose intolerance due to lactase deficiency* Functional pain* Gastroesophageal reflux* Genital/urinary disorders Structural anomalies Urinary tract infection Kidney disease (such as kidney stone)* Normal monthly ovulation (in girls) Menstrual cramps (in girls) Pelvic inflammatory disease (in girls) Ovarian cysts (in girls) Endometriosis (in girls) General illnesses Heavy metal poisoning (lead) Henoch-Schönlein purpura Sickle cell disease Food allergy Musculoskeletal disease (such as bruised abdominal muscles or ribs) Porphyria Familial Mediterranean fever Hereditary angioedema Abdominal migraine
*Indicates the most common causes.
The symptoms vary depending on the cause of the pain.
Functional Pain: For children with functional abdominal pain, the pain is most commonly vague and located around or above the navel. The further the pain is away from the navel the less likely it is to be functional. The intensity ranges from mild to severe. Pain most commonly lasts from minutes to several hours, but about 10% of children have pain that lasts all day. There are no obvious factors associated with the pain other than stress or anxiety, and the pain rarely wakes children from sleep. If school is the major problem, pain is commonly worse on weekdays and better on weekends and during vacations.
Children with functional pain may also show immaturity, unusual dependence on parents, anxiety or depression, apprehension, tension, and perfectionism. Often, parents see the child as special because of the position in the family (for instance, an only child, the youngest child, or the only boy or girl among a large group of siblings) or because of a medical problem.
Lactose Intolerance: Children with lactose intolerance commonly have pain similar to those with functional pain, except parents occasionally notice a relationship between the pain and the consumption of dairy products. The child may pass an excessive amount of gas (flatus). Passing gas or defecating relieves the pain. However, the pain may intensify before the child is able to defecate.
Constipation: Children whose pain is caused by chronic constipation have pain that is frequently crampy in nature and located in the lower abdomen. The pain is reduced by defecation.
Gastroesophageal Reflux: In children with gastroesophageal reflux, pain commonly is worse after eating (the most common time to reflux). The pain is burning in older children but may be vague in younger children. Most nonadolescent children feel the pain of gastroesophageal reflux just below the ribs, above the navel, or around the navel. Adolescents are more likely to describe the classic heartburn pain.
The symptoms and physical examination suggest the cause and help doctors decide what tests, if any, are needed. Children with symptoms typical of functional pain may not require testing. Certain signs make the diagnosis of functional pain unlikely. These signs include weight loss, bleeding, significant vomiting or diarrhea, and age under 5 years. If these factors are present, or the cause is unclear, doctors usually perform basic blood and urine tests. Many doctors also perform tests for lactose intolerance (usually with a breath test) and for celiac disease with special blood tests. If needed, specific tests include x-rays, upper endoscopy, computed tomography (CT), and a colonoscopy (see Symptoms and Diagnosis of Digestive Disorders: Diagnostic Procedures ).
Physical causes of recurring abdominal pain are treated. When a physical cause for the child's symptoms cannot be found, a doctor may suspect a psychologic cause.
When the cause is functional pain, the parents are frequently concerned that something very serious is causing the pain. A doctor should provide reassurance that the pain, while real, is not serious. The child's pain should be acknowledged, both by parents and doctors, which helps build the child's confidence and trust. Having the doctor monitor the child's progress is important, and frequent visits may be necessary.
Pain symptoms are treated with acetaminophen Some Trade Names TYLENOL or other mild analgesics. A high-fiber diet and fiber supplements can also help. Many drugs have been tried with varying success, including antispasmodics, peppermint oil, cyproheptadine Some Trade Names PERIACTIN , and acid-suppressing drugs.
Children are encouraged to fulfill their normal responsibilities, particularly attending school, despite pain. If pain is related to anxiety about school, then missing school may increase the child's anxiety and make the problem worse. Any other sources of stress or anxiety are dealt with when possible. If causes of anxiety cannot be eliminated, the doctor may prescribe antidepressants or antianxiety drugs. If the child is severely depressed or has significant psychologic or mental problems, consultation with a mental health practitioner is wise.
Giving children extra attention because of their pain may only reinforce any undesired behavior. Instead, children can be given rewards and attention for not having the pain. For example, for every day children do not have any abdominal pain, they can have special time with one or both of the parents.
Last full review/revision December 2007 by William J. Cochran, MD
Source: The Merck Manual Home Edition