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Original Article

Abdominal epilepsy in chronic recurrent

abdominal pain
V. Y. Kshirsagar, Suhel Nagarsenkar, Minhajuddin Ahmed, Sylvia Colaco, K. C. Wingkar1
Departments of Pediatrics, 1Physiology, Krishna Institute of Medical Sciences University, Krishna Hospital, Karad, Maharashtra, India

Address for correspondence: Dr. V. Y. Kshirsagar, Department of Pediatrics, Krishna Institute of Medical Sciences University,
Krishna Hospital, Karad, Maharashtra ‑ 415 110, India. E‑mail: drkshirsagarvy@yahoo.com

ABSTRACT
Background: Abdominal epilepsy (AE) is an uncommon cause for chronic recurrent abdominal pain in children
and adults. It is characterized by paroxysmal episode of abdominal pain, diverse abdominal complaints, definite
electroencephalogram (EEG) abnormalities and favorable response to the introduction of anti‑epileptic drugs (AED).
We studied 150 children with chronic recurrent abdominal pain and after exclusion of more common etiologies
for the presenting complaints; workup proceeded with an EEG. We found 111 (74%) children with an abnormal
EEG and 39 (26%) children with normal EEG. All children were subjected to AED (Oxcarbazepine) and 139 (92%)
children responded to AED out of which 111 (74%) children had an abnormal EEG and 27 (18%) had a normal
EEG. On further follow‑up the patients were symptom free, which helped us to confirm the clinical diagnosis.
Context: Recurrent chronic abdominal pain is a common problem encountered by pediatricians. Variety of
investigations are done to come to a diagnosis but a cause is rarely found. In such children diagnosis of AE
should be considered and an EEG will confirm the diagnosis and treated with AED. Aims: To find the incidence of
AE in children presenting with chronic recurrent abdominal pain and to correlate EEG findings and their clinical
response to empirical AEDs in both cases and control. Settings and Design: Krishna Institute of Medical Sciences
University, Karad, Maharashtra, India. Prospective analytical study. Materials and Methods: A total of 150 children
with chronic recurrent abdominal pain were studied by investigations to rule out common causes of abdominal
pain and an EEG. All children were then started with AED oxycarbamezepine and their response to the treatment
was noted. Results: 111 (74%) of the total 150 children showed a positive EEG change suggestive of epileptogenic
activity and of which 75 (67.56%) were females and 36 (32.43%) were male, majority of children were in the age
of group of 9‑12 years. Temporal wave discharges were 39 (35.13%) of the total abnormal EEG’s. All the children
were started on AEDs and those with abnormal EEG showed 100% response to treatment while 27 (18%) children
with normal EEG also responded to treatment. Twelve (8%) children did not have any improvement in symptoms.
Conclusions: A diagnosis of AE must be considered in children with chronic recurrent abdominal pain, especially
in those with suggestive history, and an EEG can save a child from lot of unnecessary investigations and suffering.

Key words: Abdominal epilepsy, chronic recurrent abdominal pain, electroencephalogram

Introduction pediatricians. Among the various causes of pain, abdominal

epilepsy (AE) is a relatively uncommon cause and hence, is
Abdominal pain is a common complaint of children. Chronic frequently ignored. It is said that Trousseau first described AE
recurrent abdominal pain is a perplexing problem for in 1868.[1] Later, Stille in 1912 suggested that periumbilical
pain might be a form of “masked epilepsy” and Wilson in 1940
Access this article online suggested that some visceral discomfort might be epileptic.[1]
Quick Response Code: During the past 30 years, scattered reports have appeared in
Website:
www.pediatricneurosciences.com
the literature describing a condition that has been variously
designated “the periodic syndrome,” abdominal migraine, AE
and abdominal equivalents.[2] Apley accepted that abdominal
DOI: pain as an “epileptic equivalent” occurred very occasionally
10.4103/1817-1745.106468
and that it was nearly always associated with a history
of transient impairment of consciousness or with typical
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Kshirsagar, et al.: Abdominal epilepsy as a cause of chronic recurrent abdominal pain in children

convulsions.[3] The fact that abdominal sensations like nausea, system used was digital, and the amplified signal was digitized
vomiting, bloating and diarrhea can occur prior to epileptic via an analog‑to‑digital converter after being passed through
attacks is widely accepted, and the sequence of events an anti‑aliasing filter. The representation of the EEG channels
occur frequently in temporal lobe epilepsy.[4] A particular is referred to as a montage; the representation used in our
and consistently reproducible electroencephalogram (EEG) case was bipolar montage. All EEGs were reported by experts.
pattern has lately been found to occur in children having
paroxysmal attacks of headache, abdominal pain and
associated autonomic disturbances such as pallor, sweating, Results
temperature changes, etc.[2] In this study, an attempt will be
made to determine the incidence of AE in children suffering Of the 150 cases, EEG changes were seen in 111 (74%) patients
from chronic recurrent abdominal pain, with the help of between the ages of 6 and 15 years with chronic recurrent
clinical symptoms and EEG, and to study the response to abdominal pain. Of the 111 patients with an abnormal EEG
empirical anti‑epileptic drug (AED). suggestive of AE, 75 (67.56%) were girls and 36 (32.43%) were
boys [Table 1]. Of the 111 abnormal EEG cases, 39 (35.13%)
cases had temporal type of EEG changes, 36 (32.43%) cases
Materials and Methods had fronto‑temporal type of EEG changes, 33 (29.72%) cases
had generalized type of EEG changes and 3 (2.70%) cases
The study was carried out in the Department of Pediatrics, had parieto‑temporal type of EEG changes [Table 2]; the
Krishna Institute of Medical Sciences University, Karad, India. most common pattern was sharp wave in 99 (89.18%) cases
This prospective study involved 150 children, in the age group and 12 (10.81%) cases had spike and wave pattern [Table 3].
of 6‑15 years, suffering from chronic recurrent abdominal The age and sex distribution were as follows [Table 4], with
pain (i.e., pain severe enough to affect child’s activity or three females being the most affected, between the age group of 9
episodes of abdominal pain within 3 months and abdominal and 12 years. All 150 patients, along with chronic recurrent
pain associated with nausea, vomiting, bloating, headache abdominal pain, had other neurological symptoms [Table 5].
and diarrhea) from May 2007 to March 2010.
Of the 111 (74%) patients with abnormal EEG, all the patients
Children included in this study were having chronic had symptomatic improvement after treatment with the AED
recurrent abdominal pain, which means pain that fits in the oxcarbazepine. Of the 39 (24%) patients with a normal EEG
above‑mentioned criteria. Children below 6 years and above
15 years of age and those who were unable to give a proper
history and those having acute abdominal pain of duration Table 1: Pattern of electroencephalogram according
to sex
less than 3 months, having visceral disease, were excluded
Pattern of EEG Boys (%) Girls (%)
from the study.
Abnormal EEG 36 (32.43) 75 (67.56)
Normal EEG 18 (46.15) 21 (53.48)
A detailed present, past and family history was obtained Total 54 (36) 96 (64)
from the patients or their parents. Clinical and systemic EEG: Electroencephalogram
examination was performed with a special focus on abdominal
and central nervous system (CNS) examination. Informed
consent was taken from the parents for inclusion in the study Table 2: Types of electroencephalogram
and consent regarding treatment with AED (oxcarbazepine). Total abnormal EEG Abnormal EEG Total Percentage
Consent for use of oxcarbazepine was also taken from the distribution (%)
institutional review board. 111 Temporal 39 35.13
Fronto‑temporal 36 32.43
All children were investigated for stool and urine examination Generalised 33 29.72
Parieto‑temporal 3 2.70
to rule out worm infestation, acute gastrointestinal infection and
EEG: Electroencephalogram
urinary tract infection. Urine porphobilinogen was performed
before starting AED and to rule out intermittent porphyria.
Complete blood count was performed to rule out anemia and Table 3: Type of waves
systemic infections. Abdomen and pelvis ultrasonography was Type of EEG changes Sharp waves Spike and waves Spikes
done to rule out organic intra‑abdominal cause for chronic No of cases (%) 99 (89.18) 12 (10.81) Nil
recurrent abdominal pain. EEG was done in every child to EEG: Electroencephalogram
correlate the findings of EEG with clinical diagnosis of AE.

If any other investigation done showed a positive finding then Table 4: Age and sex wise distribution
the child was treated accordingly and excluded from the study. Age (years) No. of children Males Females
6‑8 24 6 18
An EEG was performed on all children with a Recorders 9‑12 75 21 54
and Medicare systems (RMS) EEG 24 BRAINVIEW PLUS 13‑15 12 9 3
(24 channel EEG machine) from RMS Chandigarh. The EEG Total 111 36 75

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Kshirsagar, et al.: Abdominal epilepsy as a cause of chronic recurrent abdominal pain in children

record, 27 (18%) patients had asymptomatic improvement The pathophysiology of AE remains unclear. Temporal lobe
after treatment and 12 (8%) patients had normal EEG; seizure activity usually arises in or involves the amygdala. Thus,
however, they did not have any significant improvement in patients who have seizures involving the temporal lobe usually
the symptoms after treatment with oxcarbazepine [Table 6]. have gastrointestinal symptoms as discharges arising in the
amygdala can be transmitted to the gut via dense projections
to the dorsal motor nucleus of the vagus.[12] Patients with
Discussion AE usually have specific EEG abnormalities, particularly a
temporal lobe seizure disorder, although some studies had
AE is now considered a definite clinical entity. [5] It is reported an extratemporal origin (parietal or even frontal).[13,14]
characterized by: (1) otherwise unexplained, paroxysmal
gastrointestinal complaints, (2) symptoms of a CNS The diagnosis of AE is essentially a clinical one; however,
disturbance, (3) an abnormal EEG with findings specific for EEG forms an important supportive evidence for the diagnosis
a seizure disorder and (4) improvement with anti‑convulsant of epilepsy. EEG was done in all of our 150 patients with
drugs. [6] Although its symptoms may be similar to those chronic recurrent abdominal pain, of which 111 (74%)
of functional gastrointestinal abnormalities, detailed children had an abnormal EEG record. EEG analysis
history taking and a high index of suspicion enable it to revealed that temporal lobe (35.15%) EEG changes was the
be distinguished from the latter condition. [7] Among the most common, fronto‑temporal (32.45%) was the second
diagnostic possibilities are migraine and AE.[8,9] In our study, most common, followed by generalized (29.75%), whereas
all the 150 children had chronic recurrent abdominal pain. parieto‑frontal (2.7%) EEG changes had the least incidence.
The other commonly associated symptoms were headache, Peppercorn[7] and Babb, Eckman[15] observed that AE was the
giddiness, nausea, vomiting and loose stools. History of aura most commonly associated EEG abnormality in one or both
or prodrome, as suggested by Gowers in 1907, or post‑ictal temporal lobes, and could include paroxysmal positive spikes
phenomenom like exhaustion or sleep, as reported by at 14 and/or 6/s or generalized slow wave dysrhythmias. Schade
Livingstone et al. in 1971,[10] were not seen in any of our cases. et al.[11] reported that a temporal focus was seen in 22 patients
among the 46 patients reviewed. Livingstone[10] reported in his
Past history of febrile seizures, CNS infections and trauma are study on 14 children that majority of the patients had a temporal
considered important events in history in case of epilepsy, as focus on EEG records. Another study by Peppercorn and
postulated by many authors in the past.[1,10,11] No such history Herzogin in 1989 reported 10 patients, all of who had specific
was reported in any of our cases. EEG abnormalities consisting of bursts of sharp waves and/or
spikes over one or both temporal regions. In our study, we found
Table 5: Symptoms
that sharp waves were seen in 99 (89.1%) of the 111 patients and
the spike and wave pattern was seen in 12 (10.9%) patients. The
Symptoms Cases Percentage
diagnostic yield of EEG is increased by activation procedures
Abdominal pain 150 100
like photic stimulation and hyperventilation; thus, we used
Headache 30 20
Vomiting and nausea 27 18 activation procedures in all our patients during EEG recording
Giddiness 21 14 and found no change in the EEG recording.
Loose stool 3 2
In various previous studies, the incidences of AE were as
follows:
Table 6: Response to treatment
Total no. No. of children responded No. of children not In our study, of the 111 children with AE (based on EEG
of children to AED responded to AED and symptoms), it was found that the incidence was higher
With abnormal With normal With abnormal With normal in girls (67.56%) than in boys (32.43%). In studies by Schade
EEG (%) EEG (%) EEG EEG (%) and Hoffman,[11] the incidence in boys was 56.5% and in
150 111 (74) 27 (18) ‑ 12 (8) girls was 43.5%. In other studies by Douglas and White,[1]
EEG: Electroencephalogram, AED: Anti‑epileptic drugs
the incidence in boys was 40% and that in girls was 60%.
Peppercorn and Herzog[16] reported 10 cases of AE, and all
10 cases were females. Neuroendocrine dysfunction has been
Table 7: Studies showing the incidence of AE
described in women with temporal lobe epilepsy, but the
Authors Total Children with Incidence of
no. of EEG suggestive abdominal
relationship of such abnormalities to the occurrence of GI
children of abdominal epilepsy based symptoms has not been studied in such patients.
studied epilepsy on EEG (%)
Livingston[10] (1951) 14 11 78.5 Historically, patients of AE were being treated using various
Douglas and White[1] (1971) 28 5 17 drugs. Schade et al.[11] used diphenylhydantoin, mephobarbital,
Kellway et al.[2] (1960) 599 511 86
Schade et al.[11] (1960) 46 22 46.5
phenobarbital and primidone. The best results obtained
Apley and Naish[3] (1957) 97 14 14.4 from their study were with the use of diphenylhydantoin
Our study 150 111 74 combined with one of the barbiturates. Livingstone et al.
EEG: Electroencephalogram used diphenylhydantoin in all 14 of these patients of AE.
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Kshirsagar, et al.: Abdominal epilepsy as a cause of chronic recurrent abdominal pain in children
Three patients did not respond to diphenylhydantoin and hence
the drug was discontinued and these patients were later started
on 3‑methylhydantoin and mesantoin. Douglas et al.[1] used
phenobarbital and diphenylhydantoin in the treatment of their
patients with AE. Peppercorn and Herzog[16] used phenobarbital,
phenytoin, valproic acid and carbamazepine for the treatment of
their patients with AE. A sustained response to anti‑convulsants
has been accepted as one of the criteria for the diagnosis of
patients with AE.[7,17] In our study, all the 150 children were
treated with oxcarbazepine, irrespective of abnormal or normal
EEG. On follow‑up, all the 111 (74%) patients had an abnormal
EEG and 27 (18%) patients with a normal EEG had significant
decrease in all the symptoms. Twelve (8%) patients did not
respond to treatment. None of the other studies conducted have
started AED in patients with a normal EEG.
All the patients were advised to continue AED and follow‑up
till they were symptom free or a normal EEG was recorded
or, maximum, up to a period of 2 years. AED was started in
another group of children with normal EEGs suffering from
chronic abdominal pain as abnormal brain waves are not
always present in children suffering from epilepsy, and the
presence of a normal EEG need not necessarily eliminate the
diagnosis of AE in any given case if history and therapeutic test
validate such a diagnosis, as was stated by Livingstone et al.[10]
Patients with epilepsies may have normal inter‑ictal records
of EEG, and treatment should not be based on EEG alone;
correlation with the clinical condition is important.[18]
Conclusion
To conclude, therefore, a diagnosis of AE must be considered
in children with chronic recurrent abdominal pain, especially
in those with suggestive history, and an EEG can save a child
from a lot of unnecessary investigations and suffering.
Acknowledgment
The authors are thankful to Dr. Manal Ahmed and Dr. Sanket
Makadiya for technical support.
166 / Journal of Pediatric Neurosciences / Volume 7 / Sep-Dec / 2012
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Cite this article as: Kshirsagar VY, Nagarsenkar S, Ahmed M, Colaco S,
Wingkar KC. Abdominal epilepsy in chronic recurrent abdominal pain.
J Pediatr Neurosci 2012;7:163-6.
Source of Support: Nil. Conflict of Interest: None declared.