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Abdominal pain is one of the most common complaints among school aged kids, whether it comes to the doctor’s attention or not. It is estimated in the U.S. to account for 5 percent of all unscheduled pediatrician office visits.
It is somewhat more common in girls, kids aged 4-6 and early adolescence and children of single parents.
In addressing this issue, it is helpful to classify the pain as chronic or acute. By definition, chronic abdominal pain means three or more episodes of abdominal pain over a three month period. In clinically practical terms, pain that lasts more than one to two months can also be classified as chronic.
Trade secret: government employees are not the only ones who are fond of clever acronyms - doctors often use Chronic Recurrent Abdominal Pain (CRAP) in their documentation of this condition.
As an extra bonus, and like the entity that defines itself, the acronym also points to a frequent cause of the pain - as in lots of it and not going anywhere.
Some kids may find the restrooms at school unclean, uncomfortable, or not private enough, so they train their bowels to withhold stool until they get home.
This can lead to a colon that becomes too stretched out and no longer competent at passing stool at all. Any loose stool that sneaks around the packed stuff can leak out and soil the underwear, an often painful and embarrassing condition known as encopresis.
Chronic abdominal pain is most often benign, but tends to not only worry parents but also pressure doctors into performing tests so as not to miss a more serious disease.
The vast majority of kids with chronic abdominal pain have something referred to as functional abdominal pain; i.e., pain without demonstrable evidence of a pathological condition, e.g., anatomic, metabolic, infectious, inflammatory or neoplastic.
There is a set of alarming signs and symptoms to look out for, however, that raises suspicion for something that needs to be evaluated, diagnosed and treated.
This includes weight loss, decreased linear growth, GI blood loss, severe vomiting (especially of blood or bile), chronic and/or severe dehydration and fever.
Research conducted in the 80’s and 90’s suggested that functional abdominal pain was related to motility disorders and psychiatric abnormalities.
More recent research points to an abnormality of bowel reactivity to certain stimuli, which includes normal physiological (eating a Twinkie), noxious or stressful (friend yelling at you for eating his Twinkie) or psychological (feeling guilty and depressed because you ate yet another Twinkie).
Meet the ENS, the Enteric Nervous System. This is a rich and complex nervous system that envelops the entire GI tract, a.k.a. “gut brain.”
There is a bidirectional communication between the CNS (central nervous system) and ENS and a dysregulation in this communication is what leads to functional abdominal pain.
There is increasing evidence that functional abdominal pain is associated with “visceral hyperalgesia”; that is, a lowering of pain threshold of the ENS in response to changes in pressure inside the bowel. Think of a burn or scar as it feels more sensitive for some time than the rest of the skin, even to light touch.
Functional abdominal pain is best treated in the context of the Biopsychosocial model of care. Sometimes simple dietary changes, such as a high fiber diet or decreased lactose intake can ease the pain.
Mind-body techniques like breathing, guided imagery, progressive muscle relaxation and biofeedback show promise as well.
In the end it is the child’s coping skills together with the parents’ care giving strategies that predict effectiveness of treatment.
Dr. Tom Csanadi
Child and Adolescent Medicine