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Recurrent Abdominal Pain Syndrome

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  1. Definition
    1. Pain occurs at least once/month for at least 3 months
    2. Ages 4 - 16 years (peaks at age 9 years)
    3. Affects activity, school attendance
  2. Epidemiology
    1. Prevelance in school age children: 10%
  3. Pathophysiology
    1. Autonomic Dysfunction with altered intestinal motility
    2. Hyperalgesia and altered sensory pathways
  4. Etiology
    1. School Phobia (and related stresses) closely associated
    2. These children often get lower grades than peers
  5. Associated Conditions
    1. Anorexia Nervosa
  6. Symptoms
    1. Nonspecific recurrent Abdominal Pain
    2. Not related to meals or movement
    3. No associated Nausea, Vomiting, or Dysuria
  7. Signs
    1. Well appearing child
    2. Exam is often normal or mild abdominal tenderness
  8. Signs: Red flags
    1. Pain location distant from Umbilicus
    2. Pain that awakens child at night
    3. Erythrocyte Sedimentation Rate (ESR) elevated
    4. Weight loss
  9. Labs (Limited and focused work-up)
    1. Stool for Ova and Parasites for 3 samples
      1. Giardia is common cause of recurrent Abdominal Pain
    2. Urinalysis
    3. Complete Blood Count (CBC)
    4. Consider Erythrocyte Sedimentation Rate (ESR)
  10. Radiology
    1. Flat and upright abdominal XRay (KUB)
    2. Consider RUQ Ultrasound
    3. Consider pelvic ultrasound
  11. Differential Diagnosis
    1. Peptic Ulcer Disease
    2. Carbohydrate intolerance
    3. Appendiceal colic
    4. Nephrolithiasis (Ureteropelvic junction obstruction)
    5. Giardia
    6. Blastocystis hominis
    7. Hereditary Pancreatitis
    8. Conversion reaction
    9. Abdominal Migraine
    10. Epilepsy
    11. Gynecologic disorder
  12. Management
    1. Avoid Medications
    2. Emphasize the patient's response to pain
    3. Involve the parents
    4. Reassure that the problem is NOT life threatening
    5. Be realistic and frank
      1. Problem may persist for extended period of time
    6. Treat suspected Constipation aggressively
      1. Mineral Oil
      2. Lactulose
      3. Fleet Enema
    7. Promote full activity and a sense of health
    8. Encourage a well balanced diet
    9. Encourage adequate hydration
    10. Encourage adequate fiber intake
    11. Maintain school attendance
  13. Course
    1. Usually resolves by age 20 years
    2. Irritable Bowel Syndrome may develop
  14. References
    1. Thiessen (2002) Pediatr Rev 23(2):39

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