Clinical features of organic and functional causes of recurrent abdominal pain

Patterns of functional abdominal pain:

• Functional abdominal pain (continuous or recurrent periumbilical pain without disturbance in bowel habit) occurs in 20% of school aged children.
• Irritable bowel syndrome (abdominal pain associated with bloating, constipation or diarrhoea) is common in adolescents but can occur in younger children.
• Functional dyspepsia is common in adolescents whereas peptic ulcer is rare.
• Abdominal migraine consists of bouts of pain associated with nausea and fatigue with periods of wellness between.

Abused children are prone to functional bowel disorders although abuse is rare in those with a functional bowel condition.

Adolescent girls; don't forget to ask about sexual activity and menstruation. Consider pregnancy test.

Examination

• Measure weight and height at each visit. Growth charts are available in the 'Red Book' (parent held record).
• Perianal inspection; if multiple skin tags and anal fissures or fistula consider perianal Crohn's.

• Food bolus obstruction/dysphagia.
• Persistent vomiting, especially if bilious (third of patients with Crohn's don't have diarrhoea and vomiting may be the main symptom)
• Chronic severe diarrhoea, especially if colitic features (urgency with night time stooling or faecal incontinence).
• Unexplained fever.
• Gastrointestinal blood loss.
• Involuntary weight loss.
• Abnormal growth.
• Anaemia raised inflammatory markers, raised faecal calprotectin or positive coeliac serology.

Tests are not always needed but if considering a blood test do all of the following in one go:

• FBC
• Renal blood (urea not needed)
• C-reactive protein (CRP)
• Immunoglobulin A (IgA)
• Coeliac screen

Faecal calprotectin

• If diarrhoea consider faecal calprotectin and ensure infectious gastroenteritis excluded (always do stool cultures ova cysts and parasites as well).
• Do not measure if abdominal pain is the only symptom or if pre-school child as many false positives.
• Elevated in IBD but also infectious gastroenteritis. Patients should be off NSAIDS and PPIs for one month as these elevate calprotectin.
• If red flag symptoms refer even if negative.

If urinary symptoms or loin pain

• Urine dipstick

Abdominal Ultra Sound (US) is not routinely indicated but could be considered if:

• Loin pain
• Right upper quadrant (RUQ) pain

H. Pylori does not cause functional abdominal pain. If dyspepsia despite PPI or relapses off PPI; referral for consideration of oesophago-gastroduodenoscopy (OGD) may be more appropriate than testing for H.Pylori stool antigen since most infections are asymptomatic.

Management of functional bowel disorders

• Reassurance and explanation are the cornerstones of management.
  • Explaining visceral hypersensitivity and the biopsychosocial model of pain is helpful.
• Lifestyle modifications.
  • Distraction is helpful. Advise parents not to ask about pain.
  • Increase exercise. Regular sleep, avoid skipping meals, limit caffeine and sugary carbonated drinks.
• Social impact.
  • If regular school absence explore reasons for this with child and parent.
  • Consider referral to school nurse.
  • Consider advising a graded return to school.
• Diet. There are no effective dietary interventions for childhood functional bowel disorders however in trials the placebo response rates are high.
  • Exclusion diets:
    • There is evidence that a lactose free diet makes no difference but placebo response rates are high.
    • Perceived food intolerances/allergies are common but true food allergy is unlikely unless a strong history of atopy and onset as infant.
    • Avoiding the classical 4 'C' trigger foods of cheese, chocolate, citrus fruits and caffeinated drinks may reduce the frequency of abdominal migraines.
    • The fermentable oligosaccharides, disaccharides, monosaccharides and polyols (FODMAP) diet is not recommended for children as it is very restrictive.
• Probiotic capsules containing Lactobacillus rhamnosus GG has a modest clinical effect in reducing symptoms for patients with IBS and FAP. Consider advising a 1-month trial as capsules bought over the counter, as there is no prescribed form.
• There are no effective pharmacological interventions for functional bowel disorders however placebo response rates are high.
  • Parents can be reassured that occasional use of paracetamol is safe. NSAIDs, including ibuprofen, should be avoided.
  • Peppermint oil capsules. There is limited evidence for the use of peppermint oil capsules for FAP and IBS but it is only licenced for children 15 years and older. Peppermints (Polos or Tic Tacs) have not been studied but consider advising as required use.
  • Anti-spasmodics: There are no good quality trials of anti-spasmodics in children. Mebeverine is listed in the paediatric BNF for use in children over 12 years with IBS (unlicensed).
  • Constipation. If constipation consider a macrogol. Stimulant laxatives such as senna may exacerbate abdominal pain. Lactulose may increase bloating. Note it is common for the abdominal pain to persist even when constipation treated.
  • Do not use amitriptyline or SSRIs. Although there is evidence that amitriptyline can help in adults with IBS, the two trials in adolescents did not show benefit. There are no trials of SSRIs.
  • Abdominal migraine. If regular episodes causing school absence consider a 1 month trial of prophylaxis with pizotifen. 0.5mg at night. Maximum single dose 1mg, maximum daily dose 0.5mg morning and 1mg night. Increased appetite and weight gain are common. Rarely mood disturbance and liver dysfunction are reported. Withdraw gradually.
  • Functional dyspepsia. Consider 1 month trial with an H2 antagonist or PPI.
• Psychological therapies
  • When there is impaired social functioning associated with the abdominal pain, such as school absence, involve the school counsellor and consider pointing parents and children to www.minded.org.uk (unexplained physical symptoms section).
  • There is evidence that cognitive behavioural therapy and hypnotherapy are effective but GPs can't refer directly to clinical psychology and access via paediatrics is limited.
  • Mental health problems. Children with anxiety or depression may present with functional abdominal pain. If significant mental health symptoms consider referral to CAMHS. If eating disorder suspected refer to paediatrics and CAMHS.

Devon Formulary Chapter 1. Gastrointestinal

Devon Formulary Chapter 10 – NSAIDs

Referral Criteria

Functional abdominal pain should be managed in primary care

• Consider referral if school attendance is less than 85% despite above management

Children with dyspepsia

• Consider a 1 month trial of PPI. If relapse off PPI refer to paediatrics for consideration of OGD
• Refer if red flags

Suspected inflammatory bowel disease or red flags

• Refer urgently via e-Referrals to paediatric gastroenterology

Patients with positive coeliac serology

• Should not be started on a gluten free diet until the diagnosis is confirmed in secondary care.
• Refer to paediatric gastroenterology

Please include recent weight in referral letter if available.

Children already under care of paediatrician should be referred back to same paediatrician

Referral Instructions

e-Referral Service Selection

• Priority: urgent/routine
• Specialty: Children's & Adolescent Services
• Clinic Type: Gastroenterology
• Service: DRSS-South Devon & Torbay-Children's & Adolescent Services- Devon ICB - 15N

Referral Forms

DRSS referral form

Torbay and South Devon seeking advice form

Patient Information

Recurrent Abdominal Pain in Children

Evidence

Practical management of functional abdominal pain in children L K Brown, R M Beattie, M P Tighe. Archives Disease Childhood. 2016

Pharmacological interventions for recurrent abdominal pain (RAP) and irritable bowel syndrome (IBS) in childhood. Angela A Huertas-Ceballos, Stuart Logan, Cathy Bennett, Colin Macarthur Cochrane review. 2008

Antidepressants for the treatment of abdominal pain-related functional gastrointestinal disorders in children and adolescents. Angela Kaminski, Adrian Kamper, Kylie Thaler, Andrea Chapman, Gerald Gartlehner. Cochrane review. 2011.

Biopsychosocial model of pain

Pathway Group

This guideline has been signed off on behalf of NHS Devon.

Publication date: August 2017