THE SUBACUTE, CHRONIC AND RECURENT ABDOMINAL PAIN
The abdominal pain is one of the most frequently encountered symptoms in
suckling and children. It is often hard to evaluate because its causes are extremely
variable.
In suckling, crying usually suggests hunger. If crying continues after feeding
pain is to be considered.
About 10% of the schoolchildren experience recurent abdominal pain,
although only 10% of this children have organic lesions. The "so" called,
"functional" abdominal pain, a frequent finding in preadolescent youth, is a reality
for the patient whatever the cause may be.
Phisiopatho1ogy:
Generally speaking, the pain is the response to a stimulus that's harmful for
the body. Its utility results in the fact that it signals to the cortex the changes that
such stimuli determine.
The internal organs have highly specialized receptors for: pain
(algoreceptors), temperature (thermoreceptors), pressure (baroreceptors) and
chemical composition of the body fluids (chomoreceptors).
There are two types of nervous fibres inside the abdomen:
-the A fibres from the skin and the abdominal wall muscles, that transmit acute and
well localized pain;
-the C fibres from the perithoneum, abdominal organs and inner muscles that
transmit low intensity and diffuse pain.
The main mechanisms for the abdominal pain are :
1 )The elongation of the mesentery
2)Variations of the blood flow. A low blood flow leads to ischemia,
hypotony and acid accumulation ( thromboses, volvulation, invagination,
strangulated hernia).
3)Prolonged and intense muscular contraction- explaines the pain that occurs in
case of ulcer, renal colic, biliary duct colic and hunger.
4)Wall distension of the stomach, intestines and gall-bladder associates vomiting,
nausea, low blood pressure, palpitations, increased heart rate and subjective
sensation of not getting enough air.
5)Inflamation of any organ or perithoneum tissue increases the sensitivity of the
algoreceptors.
6)Capsule distension :acute hepatosplenomegaly.
The visceral abdominal pain(AP) tends to localize along the middle line of
the abdomen, so that stimuli from liver, pancreas, stomach and upper small
intestine are felt as epigastric pain, stimuli from the end of the small intestine,
caecum, apendix and the ascendent part of the large intestine are felt as
periumbilicus pain and stimuli from the rest of the large intestine, urinary tract and
pelvic organs are felt as suprapubic pain. When the stimulus is very intense the
pain may extend to the aria whose sensitivity is conduced by the same spinal nerve.
The recurent AP is one of the most frequent symptoms that determine
medical examination. There are three reasons that make the diagnosis difficult :
l)The high diversity of the diseases that may determine recurent AP
2)The organic and stress determined AP may occur simultaneously for example
the stress determined gastric ulcerus.
3)The small child is unable to describe and localize the pain. The pain that has no
organic cause is usually diffuse, changes place frequently and has strange spread
areas. The connection with a stress situation and the fact that the pain never
disturbs the sleep suggest emotional pain.
-3No abdominal distension or muscle contraction are found through palpation. Some
authors situate this kind of pain between 4 and 13 years of age, others between 8
and 15 years old. Between the ages of 3 and 5
the AP is more likely to have
organic causes.
In order to find out the cause a complete examination will be performed :
The inquiery :
l)The age of onset, the frequency of pain (daily, weekly, monthly)
2)The localisation : usually diffuse in young children. The most frequent areas are
around the umbilicus and in the epigastrum.
3)The iradiation
4)The evolution :short, prolonged or persistent with paroxism. It may end suddenly
or slowly.
5)Τhe character :
a)Burning : determined by the irritation of the digestive mucosae in case of
oesophageal reflux and excesive gastric acidity;
b)Tension : excesive gas or incomplete evacuation of the stomach, small and large
intestines ;
c)Colics :paroxistic pain due to smooth muscles spastic contraction
d)Penetrating pain :whenever the perithoneum is involved : perforation of acute
ulcer, acute pancreatitis
6)The rate ( permanent, recurent ) and the situation that is followed by AP ( meals,
phisical activity, defecation and spontaneous )
7)Associated symptoms :
-general : fever, headache, paleness, migraine ;
-digestive : anorexia, nausea, vomiting, bitter taste, flatulence, diarrhoea,
constipation ;
-urinary :amount, frequency, character, urine aspect ;
-48)Social data : quarrels, lack of affection, compulsion towards eating, school
dependent pain ;
9)Family histοry : the same symptom during childhood, migraine and ulcer.
THE CLINICAL EXAMINATION
Inspection :
the volume of the abdomen (normal,distension,excavation)
the superficial vein aspects
the movements of the abdomen
scars due to surgery
Palpation :begins with the unaffected areas and slowly reaches the painful region.
The palpation is performed very slowly, with warm hands, paying attention to the
child's face and keeping the child's attention focused on something else. Are to be
determined through palpation : the localisation, the tonus of the abdominal wall
muscles, the size of the parenchimal organs : liver, spleen, kidneys, the presence of
tumours and fake tumours :distension of the bladder, accumulation of worms,
pregnancy. The palpation ends with the checking up of the herniation points plus
rectal and genital exam.
Laboratory findings :
-haemoglobin levels, blood cell counting
-ESR
-transaminase levels
-blood urea
-complete urine examination
-coproparasitologic exam.
-Adler test for faeces
-barium X ray exam of stomach, duodenum and rectum
-urographic exam, sonography, CT scan , MRI
-EEG
-5CLASIFICATION OF THE ABDOMINAL PAIN
Organic AP
Functional AP
Organic ΑP
I.Abdominal causes (organic, inflamatory, noninflamatory ) :
a) Stomach:
1)Air inside the stomach
2)Unproper diet (hard to digest food)
3)Ulcer-mostly of the duodenum,is a rare finding in children. The pain may be
situated arround the umbilicus, epigastric or diffuse, it lasts for minutes to hours
end occurs more often during nights than days. Milk provides with temporary relief
but the pain becomes more intense after some time after meals. Positive Adler test.
Gastroduodenal barium X ray exam and fibroscopic exam are diagnostic.
4)Zollinger-Sllison disease : high acidity levels in the gastric secretion, ulceration
on the stomach, duodenum or small intestine. The disease has been reported in
children over 7 years old.
b)Small and large intestine :
1)Duodenitis
2)Subacute and chronic apendicitis : pain occurs 4 to 5 hours after meals, being
localized in the apendicular region and sometimes arround the umbilicus, in the
right hipocondrium or in the epigastrum. It associates nausea, vomiting and colitis
that show no answer to correct diet.
3)Terminal ileitis (Crohn's disease) -recurent strokes of AP, cramps, anorexia,
vomiting, diarrhoea, fever and loss of weight. The symptoms may simulate
apendicitis.
-64)Meckel diverticule: acute diverticulitis (similar to appendicitis ) or diverticular
ulcerus (acute or prolonged intestinal haemorrhage )
5)Colitis and enterocolitis (Salmonella enteritis, disentery )
6)Ulerative colitis : abdominal pain, diarrhoea.
7) Intestinal tuberculosis
8)Aerocolia
9)Chronic constipation : may determine mild abdominal disconfort and even AP.
10)Malrotation of the small intestine : common mesentery, mobile caecum,
volvulation of the sigmoid colone.
11)Megacolone.
12)Intestinal polipous disease ( rare cause for AP )
13)Intestinal tract duplications : intermitent AP, vomiting.
14)Subacute recurent bowel invagination
15)Intestinal tumours
16)Intestinal wall oedema (with no abdominal wall skin oedema)
17)Lactase deficiency (profuse watery diarrhoea)
18)Cystic fibrosis
19.Food allergy
c)Intestinal parasitic disease :
1)Giardiasis
2)Ascaridiasis
3)Oxiurosis : rare cause for apendicitis
4)Teniasis
d)Perithoneum disease
1)Primitive streptococal or pneumococal peritonitis ( rare nowadays) induces low
intensity diffuse abdominal pain.
2)Perithoneum tuberculosis determines abdominal disconfort.
-73)Adherential developments after surgery
4)Common mesentery
5)Mesentery chists
6)Mesentery lymphadenitis -simulates apendicitis. In most of the cases the
diagnose is established during surgery. The pain occurs during a rinopharingitis,
tonsilitis
or
other
infections
disease
(measles,
scarlett
fever,
rubella,
mononucleosis), although it may also be primitive. The pain is more diffuse and
closer to the middle abdomen line, has an acute character and associates fever,
paleness and flatulence. The abdominal palpation does not find any painful point or
abdominal muscle contraction. The blood leukocyte levels are far more increased
than the clinical findings would suggest. When the abdominal sensitivity remains
stable apendicitis is excluded, otherwise exploratory laparotomy could be
recomanded.
e)Liver and bile tract disease:
1)Viral epidemic hepatitis : may be cause for abdominal disconfort and right
hipocondrium pain. In case of chronic hepatitis the pain is due to liver enlargement
and abnormal biliary tract motility.
2)Angiocolitis and cholecystitis (biliary tract and gall bladder inflamation) are rare
findings during childhood. Associates fever, painful hepatomegaly, mild jaundice
and pain that extends to the right shoulder. Bile examination is recommended in
such cases.
3)Liver tumours (benign, malignant ) may cause abdominal disconfort.
4)Chistic dilatation of the biliary tract and gall bladder : pain, jaundice and positive
palpation of the right hipocondrium.
-85)Cholelithiasis determines recurent pain in the right hipocondrium, nausea,
sensitivity during palpation and ocasionally jaundice. In children cholelitiasis can
result from chronic haemolitic anaemia, Wilson disease, chistic fibrosis.
6)Erythrocyte sludgeing inside the sinusoid capilaries determined by sikle-cell
anaemia crises: determine jaundice, hepatomegaly, abdominal pain, fever,
increased alcaline phosphatas blood levels, high leukocyte levels.
7) Passive liver congestion in case of heart failure.
f)Pancreatic disease :
-chronic pancreatitis-recurent abdominal disconfort and ρain, greasy faeces,
diabetes mellitus and pancreatic calcium deposits.
-chists and tumours of the pancreas
g)Spleen diseases:
-large sρlenomegaly-due to passive congestion in case of portal hypertension and
to cell sequestration in case of blood disease, may determine abdominal disconfort
in both situations.
-perisplenic tissue inflamation (perisplenitis)
h)Reno-urinary diseases :
-Urinary tract obstruction (UTO) with or without any UTI may case AP in the
hypogastrum, lombar region and on the sides of the abdomen. Causes:
-urinary tract malformations
-lithiasis
-kidney tumours
-renal tuberculosis
i) Genital disease:
1) ovarian torsion, chist, tumour (right ovary tumour may be hard to be
differenciated from apendicitis )
-92)rupture of an ovarian folicle during the ovulation determines
AP 2 weeks before menstruation (AP is a frequent finding during menstruations).
3)dysmenorrhoea determines lower abdomen and sacrum region pain, sometimes
associating headache, nausea and vomiting.
4)haematocolpos in teenage girls may be cause for intermitent or permanent AP.
5)ovarian and uterine inflamation that acompanies the gonococal vulvo-vaginitis.
j)Abdominal and retroperitoneal tumours.
k)Mesentery vein trombosys and superior mesentery artery syndrome:
constant or ocasional duodenum obstruction that causes AP,exagerated peristaltic
movements, nausea, vomiting and growth retardation.
II.Abdominal wall disease :
-hernia of the middle abdomen line
-diaphragm hiatus hernias
-inguinal hernias
-haematomas
III.Extraabdominal diseases :
A.Pulmonary disease: pmeumonia: mostly of the right
lobe with associated
diaphragmatic pleuresia.
B.Heart disease :
-hepatomegaly due to congestive heart failure
-pericarditis may determine epigastric pain
-endocardum fibroelastosys -cause for intermitent AP in suckling.
-10
C.CNS and spinal chord disease :
-Abdominal epilepsy: AP may represent the aura. Sudden onset with epigastrum or
periumbilicus pain that lasts for some minutes.
During the seizure a partial loss of conscience and state of confusion have been
noticed. The EEG abnormalities are diagnostic.
-Cerebral tumours ( mostly in the posterior lobes) occasionally determine AP
-The abdominal migraine : vomiting and diffuse abdominal pain that associate no
contraction of the abdominal wall muscles. Personal or family history of migraine
with one sided headache, nausea and photophobia.
-Hysteria- 12-14 years old girls, spoiled by the family, pretend to experience AP in
order to focus the attention on them.
D.Haematho1ogy :
-Acute
haemolisis-in
case
of
chronic
hereditary
haemolitic
anaemia
(microspherocitosis, drepanocitosis)
-Spleen thrombosys -left hypocondrium pain
-Leukaemia
-Hennoch-Schönlein disease : pain and digestive bleeding that occurs either before
or after the skin lesions become manifest.
-The haemophily- may cause retroperithoneal haemorrhage.
-Acute infectious lymphocitisis
E.Metabolism disorders:
-Tetany: phosphorus and calcium metabolism disorder that leads to painful spastic
contraction of the abdominal smooth muscles.
Calcium administration determines relaxation.
-Hypoglicemy: in case of pancreatic adenoma or exces of insulin may determine
AP, cold sweating, headache, convulsions and coma.
-Diabetic acidosis.
-11-Essential hyperlipidemia : violent AP that occurs after a high lipid meal. Low fat
diet and heparine administration provide with relief.
-Phenilkaetonury -diffuse AP
-Addison disease: abdominal pain, vomiting and diarhoea
-Cyclic aketonaemic vomiting
F.Other causes:
-Acute rheumatic fever: diffuse or epigastric AP, fever, vomiting, high leukocyte
levels.
-Diseases
that
determine
high
blood
pressure
(Polyarteritis
nodosa,
Pheocromocitoma, Aortic coarctation, Abnormalities of the renal arteries).
THE FUNCTIONAL ABDOMINAL PAIN
a) The abdominal colics of the suckling : occur in about 10% of the children and
are considered as benign manifestations. They develop during the first three
months of life and manifest through prolonged and violent crying that repeats daily
or every night at the same hour. Holding the child provides with relief. These
children seem to have a good general state of health and the appetite is normal. The
only one gastro-intestinal symptom that can be found is the flatulence. After 9 to
12 weeks the crises disappear. Some authors recommend antispastic therapy.
b) The morning abdominal pain of the schoolchildren
associate anxiety,
headache, fatigue, sleeping disturbances and various unpleasant sensations. The
onset is obviously connected to going to school, conflicts and emotional
difficulties. Such diagnosis is established only after any other cause for AP has
been thought and eliminated.