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Recurrent Abdominal Pain in Children (RAP)

  

Recurrent Abdominal Pain (RAP) is a common paediatric problem affecting between 10-20% of children.


Definition

Recurrent Abdominal Pain is defined as:

Three separate episodes of abdominal pain, severe enough to affect daily activities, over a three month period.

The most common cause for RAP is functional, having excluded organic conditions.

The consultation with the child and parent is an opportunity to identify whether the pain has any features to suggest a significant organic cause.

Red Flags in Recurrent Abdominal Pain
  • Age <5 years
  • Pain further away from the umbilicus, pain waking at night
  • Abdominal mass
  • Fever of unknown origin
  • Weight loss
  • Impact on growth and puberty
  • Diarrhoea with tenesmus, urgency or night-time defecation
  • Blood or mucus in stools
  • Mouth disease, mouth ulcers or perianal disease
  • Arthritis symptoms
  • Rash
  • Urinary symptoms- such as dysuria, frequency
  • Family history of Inflammatory Bowel Disease
  • Reduced appetite
  • Change in bowel habit – although constipation is often associated with functional abdominal pain
Initial Primary Care Assessment

History including:

  • Family history (emotional and physical)
  • Previous Surgical
  • Travel
  • Diet
  • Bowel habits
  • Impact on daily activities
  • Mental health
  • Systems enquiry – symptoms associated with pain such as headaches, photophobia, vomiting, nausea.

Examination:

Abdominal examination (including testicular examination).

Assessment for signs of autoimmune conditions including, skin, hands, mouth.

Height and weight on age and gender appropriate growth chart.

Bloods- FBC, LFT, amylase, CRP, ESR, glucose, IgA and TTG IgA

Stool sample – MC&S, faecal calprotectin (if suggestive of IBD), H. pylori antigen

Urine sample – MC&S, pregnancy test (if applicable)

Abdominal USS – if felt necessary

Possible Organic Causes:
  • Constipation
  • Inflammatory Bowel Disease
  • Coeliac Disease
  • Reflux / Eosinophilic Oesophagitis
  • Helicobacter pylori
  • Abdominal Migraine
  • Surgical Causes: Meckel’s diverticulitis, intra-abdominal mass, gall stones, recurrent intussusception, pancreatitis
  • Gynaecological causes- dysmenorrhea
  • UTI
Referral

If any RED FLAG symptoms, consider acute admission rather than Outpatient referral.

Please refer for outpatient review if:

Following the above guidance there remains uncertainty about diagnosis

There are ongoing clinical concerns (excluding those that require urgent inpatient review)

Patient is not clinically improving from initial management

References:

Recurrent abdominal Pain in Children: A clinical approach. Seng Hok Quak.

Singapore Med J 2015; 56(3): 125-128doi: 10.11622/smedj.2015038

BSPGAHN- The British Society of Paediatric GASTROENTEROLOGY, Hepatology and Nutrition Recurrent

Abdominal Pains: A field Survey of 1,000 school Children. John Apley, Nora Naish. Arch Dis Child. 1958 Apr; 33(168): 165–170.doi: 10.1136/adc.33.168.165

Recurrent Abdominal Pain in Childhood. Bufler P et al. Dtsch Arztebl Int. 2011 Apr; 108(17): 295–304.

Chronic Abdominal Pain in Childhood: Diagnosis and Management. LAN M. LAKE, M.D., Johns Hopkins University School of Medicine, Baltimore, Maryland

Am Fam Physician. 1999 Apr 1;59(7):1823-1830.

 

 

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