Chronic Abdominal Pain in Childhood:Diagnosis and Management
ALAN M. LAKE, M.D.Johns Hopkins University School of MedicineBaltimore, Maryland
More than one third of children complain of abdominal pain lasting two weeks or longer. Thediagnostic approach to abdominal pain in children relies heavily on the history provided by theparent and child to direct a step-wise approach to investigation. If the history and physicalexamination suggest functional abdominal pain, constipation or peptic disease, the response to anempiric course of medical management is of greater value than multiple "exclusionary"investigations. A symptom diary allows the child to play an active role in the diagnostic process. Themedical management of constipation, peptic disease and inflammatory bowel disease involvesnutritional strategies, pharmacologic intervention and behavior and psychologic support.
hronic abdominal pain in children is defined as pain of more than two weeks' duration.
The painmay be persistent or recurrent. It is a frustrating concern to the child, the parents and the physician. Thedifferential diagnosis of abdominal pain in children varies with age, gender, genetic predisposition,nutritional exposure and many environmental factors. While efforts to distinguish organic fromfunctional abdominal pain are admirable, these apparently opposing etiologies are not mutuallyexclusive in children, since psychologic complications of organic disease are common.The diagnosis of abdominal pain in children has five components. The relative value of eachcomponent depends on the child's age and, in some cases, on the level of cooperation of the child and parents. The five components include the history, a physical examination, laboratory testing, results of imaging studies and response to empiric therapy. This approach is summarized in
Five Components of the Evaluation of Children with AbdominalPain
• Location, intensity, character and duration of pain, time of day or night that pain occurs• Appetite, diet, satiety, nausea, reflux, emesis• Stool pattern, consistency, completeness of evacuation• Review of systems: weight loss, growth or pubertal delay, fever, rash• Medications and nutritional interventions• Family history, travel• Interference with school, play, peer relations and family dynamics
• Weight, height, growth velocity, pubertal stage, blood pressure• Complete physical examination• Objective abdominal findings: location, rebound, mass, psoas sign• Liver, spleen and renal size, ascites, flank pain• Perianal findings: rectal and pelvic examinations, stool testing for occult blood