Pedia Flash
Pedia Flash 2018 › Pedia Flash Vol-4, No-1, 2018

Acute Abdominal Pain in Children: Evaluation and Differential Diagnosis

Overview

Pediatric abdominal pain is one of the most common reasons for visiting primary care physicians and pediatric surgeons.1Iwanczak B, Stawarski A, Czernik J, Bronowickip K, Iwanczak F, Pytrus T, et al. Diagnostic difficulties in pediatric abdominal pain with potential appendicitis. Przegl Lek. 2007;64 Suppl 3:56-60.    Although it is a frequent problem and while majority of these episodes are benign and self-limiting, persistent abdominal pain may engender considerable concern.2Evaluation of abdominal pain in children. Available at: http://us.bestpractice.bmj. com/best-practice/monograph/787.html. Accessed on: 24-10-17.    Children with abdominal pain that is chronic in nature have heterogeneous presentations, attributing to either organic or functional underlying gastrointestinal disorders. 3Berger MY, Gieteling MJ, Benninga MA. Chronic abdominal pain in children. BMJ 2007;334:997.    Lack of any structural or biochemical abnormalities usually indicate towards a functional cause; the organic disorder on the other hand is diagnosed when an underlying pathology is identified.2Evaluation of abdominal pain in children. Available at: http://us.bestpractice.bmj. com/best-practice/monograph/787.html. Accessed on: 24-10-17.   3Berger MY, Gieteling MJ, Benninga MA. Chronic abdominal pain in children. BMJ 2007;334:997.    Prevalence of organic disease has been reported to vary significantly between 5% to 40% in the general population to a pediatric gastroenterologist practice, respectively.3Berger MY, Gieteling MJ, Benninga MA. Chronic abdominal pain in children. BMJ 2007;334:997.

Cases of acute abdominal pain are generally benign, however, many a times the clinical symptoms may be uncharacteristic.1Iwanczak B, Stawarski A, Czernik J, Bronowickip K, Iwanczak F, Pytrus T, et al. Diagnostic difficulties in pediatric abdominal pain with potential appendicitis. Przegl Lek. 2007;64 Suppl 3:56-60.   4Leung AK, Sigalet DL. Acute abdominal pain in children. Am Fam Physician. 2003 Jun 1;67(11):2321-6.    This often causes diagnostic dilemma and poses considerable diagnostic problems. 1Iwanczak B, Stawarski A, Czernik J, Bronowickip K, Iwanczak F, Pytrus T, et al. Diagnostic difficulties in pediatric abdominal pain with potential appendicitis. Przegl Lek. 2007;64 Suppl 3:56-60.   3Berger MY, Gieteling MJ, Benninga MA. Chronic abdominal pain in children. BMJ 2007;334:997.    With increase in diagnostic uncertainty and failure of pain to resolve over time, it becomes harder to reassure the parents, which is why abdominal pain is considered a time consuming and therapy-resistant disorder.3Berger MY, Gieteling MJ, Benninga MA. Chronic abdominal pain in children. BMJ 2007;334:997.    Since it may be a manifestation of an underlying pathology, therefore, timely evaluation and intervention are warranted, which are imperative in preventing untoward sequelae in children presenting with abdominal pain.2Evaluation of abdominal pain in children. Available at: http://us.bestpractice.bmj. com/best-practice/monograph/787.html. Accessed on: 24-10-17.   

The diagnosis of abdominal pain in children can be challenging and since its spectrum of etiologies is vast, the differential remains broad. In most cases, a complete history and an extensive physical exam can narrow the broad differential. In addition, certain investigation tools (depending on the age of the child) may help in delineating diseases that present with similar symptoms. However, sometimes a comprehensive history is often difficult to obtain, even with the assistance of parents or guardians, and the diagnosis therefore significantly relies on the clinical acumen of the practitioner.2Evaluation of abdominal pain in children. Available at: http://us.bestpractice.bmj. com/best-practice/monograph/787.html. Accessed on: 24-10-17.   

Evaluation of Abdominal Pain

Approach to abdominal pain comprises a thorough history and physical examination and often laboratory tests and/or imaging studies. The history is obtained keeping in mind three components: the pain itself, associated symptoms, and predisposing conditions.5Hijaz NM, Friesen CA. Managing acute abdominal pain in pediatric patients: current perspectives. Pediatric Health, Medicine and Therapeutics. 2017:8;83-91.    A classic PQRST mnemonic has been suggested for a complete pain history, which is as follows:

P3 – Positional, palliating, and provoking factors for pain

Q – Quality of pain

R3 – Region, radiation, and referral of pain

S – Severity of pain

T – Temporal factors (such as time and mode of pain onset and progression, and previous episodes).

The mnemonic contributes toward obtaining a thorough history.6Macaluso CR, McNamara RM. Evaluation and management of acute abdominal pain in the emergency department. International Journal of General Medicine. 2012;5:789-797.    Key questions while evaluating abdominal pain should include- where is the pain felt (location), what kind of pain it is (character), when and how it began (onset), how bad it is (intensity), and where else is the pain felt or where does it radiate, what makes it worse or better, how it has changed over time, were there any previous episodes, and what are the associated symptoms.5Hijaz NM, Friesen CA. Managing acute abdominal pain in pediatric patients: current perspectives. Pediatric Health, Medicine and Therapeutics. 2017:8;83-91.   6Macaluso CR, McNamara RM. Evaluation and management of acute abdominal pain in the emergency department. International Journal of General Medicine. 2012;5:789-797.   These key points are discussed in the section below.

Location: Pain contracting from foregut structures- the stomach, pancreas, liver, biliary system, and the proximal duodenum tends to get localized to the epigastric region. Visceral pain associated with the remaining small bowel and the proximal third of the colon including the appendix (midgut structures) is perceived in the periumbilical region. Dysfunction of hindgut structures such as the bladder, and distal two-thirds of the colon, as well as pelvic genitourinary organs usually result in pain in the suprapubic region. Pain is generally reported in the back for retroperitoneal structures such as the aorta and kidneys.6Macaluso CR, McNamara RM. Evaluation and management of acute abdominal pain in the emergency department. International Journal of General Medicine. 2012;5:789-797.

Character: The character of the pain can be dull, poorly localized, aching, or gnawing, which when traced down, can be found to be generated by viscerally innervated organs. It becomes important to distinguish it from “sharp”, more defined and localized somatic pain that can be caused by irritation of the parietal peritoneum or other somatically innervated structures.6Macaluso CR, McNamara RM. Evaluation and management of acute abdominal pain in the emergency department. International Journal of General Medicine. 2012;5:789-797.

Onset: Abdominal pain may be of sudden, rapid, or gradual onset. Sudden onset is described when pain occurs within few seconds. Common causes of sudden onset of pain include perforation of the gastrointestinal tract from a gastric or duodenal ulcer, a colonic diverticulum, a foreign body, a ruptured ectopic pregnancy, mesenteric infarction, ruptured aortic aneurysm, and embolism of an abdominal vessel. Pain beginning within a few seconds and steadily increasing in severity over the next several minutes is referred to as pain of rapid onset; it is commonly associated with cholecystitis, pancreatitis, intestinal obstruction, diverticulitis, appendicitis, ureteral stone, and penetrating gastric or duodenal ulcer. Progressive increase in severity of pain over a number of hours or days is termed as pain of gradual onset. Pain of gradual onset is found as a manifestation of chronic inflammatory processes, large bowel obstruction, and many other intra-abdominal conditions. Making an accurate diagnosis from the history of gradual pain onset is more difficult than tracing pain of sudden or rapid onset.7Sherman R. Abdominal Pain. In: Walker HK, Hall WD, Hurst JW, editors. Clinical Methods: The History, Physical, and Laboratory Examinations. 3rd edition. Boston: Butterworths; 1990. Chapter 86. Available from: https://www.ncbi.nlm.nih.gov/books/NBK412/

Intensity: Severe pain could have a serious underlying cause, which further heightens the concern. On the other hand, mild pain does not necessarily exclude the diagnosis of serious illness.6Macaluso CR, McNamara RM. Evaluation and management of acute abdominal pain in the emergency department. International Journal of General Medicine. 2012;5:789-797.

Pattern: Functional disorders in childhood sometimes occur as a part of normal development process, such as infant regurgitation or toddler’s diarrhea.8Rasquin-Weber A, Hyman P, Cucchiara S, et al. Childhood functional gastrointestinal disorders. Gut. 1999;45(Suppl 2):II60-II68.    However, a large proportion of children with functional abdominal pain continue to complain of pain.9Czyzewski DI, Self MM, Williams AE, Weidler EM, Blatz AM, Shulman RJ. Maintenance of Pain in Children with Functional Abdominal Pain. Journal of pediatric gastroenterology and nutrition. 2016;62(3):393-398.    Pain becomes chronic in nature and manifests as an altered sensation due to a complex interaction between emotions, behavior, and gut function. Probably this is why children with chronic abdominal pain more often experience anxiety disorders, depressive episodes, and other somatic symptoms in comparison to those unaffected.10Geitling MJ, Bierma-Zeinstra SMA, Lisman-van Leeuwen Y, et al. Prognostic factors for persistence of chronic abdominal pain in children. J Pediatr Gastroenterol Nutr. 2011;54(2):154–161.   Besides, many a times, pattern of pain corresponds to the type of food ingested; other way round, eating may also alleviate the pain.

It is important to consider role of diet in functional abdominal pain. For many patients, symptoms aggravate with eating. Allergy or intolerance to foods like milk, gluten, and fermentable oligosaccharides, disaccharides, monosaccharides, and polyols usually result in abdominal pain.11van Tilburg MA, Felix CT. Diet and functional abdominal pain in children and adolescents. J Pediatr Gastroenterol Nutr. 2013 Aug;57(2):141-8.    Allergy to cow’s milk has also been documented, especially in children. In infants, acute and unexplained abdominal pain that results in crying or fussing for 3 or more hours per day, during 3 or more days in the preceding week is referred to as ‘infantile colic’. Although motility disorders of the gastrointestinal tract can be a predominant cause, in most such cases, pain is assumed to be associated with milk indigestion.12Zeevenhooven J, Koppen IJN, Benninga MA. The New Rome IV Criteria for Functional Gastrointestinal Disorders in Infants and Toddlers. Pediatric Gastroenterology, Hepatology & Nutrition. 2017;20(1):1-13.

Associated symptoms: It is often helpful to enquire about associated symptoms such as nausea, vomiting, diarrhea, constipation, hematochezia, as a variety of etiologies cause abdominal pain in children and since these are generally documented in most of the patients, these may therefore help in making a diagnosis. For instance, abdominal pain with cough, shortness of breath, or sore throat can be due to respiratory infection; similarly, presence of urinary symptoms can indicate an associated urinary tract infection or pyelonephritis.13Reust CE, Williams A. Acute Abdominal Pain in Children. Am Fam Physician. 2016 May 15;93(10):830-837.    In addition, the history should also typically comprise the bowel movement pattern, presence of fever, type of stool, amount of vomiting and the timing, the sequence of pain and vomiting, and the presence of a productive cough.14Yang W-C, Chen C-Y, Wu H-P. Etiology of non-traumatic acute abdomen in pediatric emergency departments. World Journal of Clinical Cases: WJCC. 2013;1(9):276-284.

The clinical approach to a child with acute abdominal pain involves an overall assessment of the child’s appearance (lethargy, eye contact, comforted by family member, interactive), food and fluid intake (decreased intake or urine output, normal intake and output), and activity level (lying still, moving about in discomfort, or active).13Reust CE, Williams A. Acute Abdominal Pain in Children. Am Fam Physician. 2016 May 15;93(10):830-837.    In critically ill appearing patients, an attempt should be made to immediately rule out the surgical causes, particularly those associated with obstruction or ischemia. An urgent need for surgery in acute abdominal pain is likely if the bowel sounds are absent, or if there is bilious vomiting, bloody diarrhea or occult blood in stool, elevated temperature (≥ 100.4°F), rebound tenderness, rigidity (involuntary guarding), or voluntary guarding.5Hijaz NM, Friesen CA. Managing acute abdominal pain in pediatric patients: current perspectives. Pediatric Health, Medicine and Therapeutics. 2017:8;83-91.   13Reust CE, Williams A. Acute Abdominal Pain in Children. Am Fam Physician. 2016 May 15;93(10):830-837.    Therefore, a thorough history along with complete assessment of vital signs and patient’s overall appearance can help triage between clinically stable and critically ill patients who may require an urgent surgical procedure (Table 1). A non-urgent diagnosis can be safely reevaluated at a later time in the course without increased risk of morbidity.5Hijaz NM, Friesen CA. Managing acute abdominal pain in pediatric patients: current perspectives. Pediatric Health, Medicine and Therapeutics. 2017:8;83-91.

table 1

Differential Diagnosis of Acute Abdominal Pain in Children by Age

Age of the child plays a critical role in indicating toward diagnosis as the etiology of acute abdomen varies greatly in different age groups (Table 2).13Reust CE, Williams A. Acute Abdominal Pain in Children. Am Fam Physician. 2016 May 15;93(10):830-837.   14Yang W-C, Chen C-Y, Wu H-P. Etiology of non-traumatic acute abdomen in pediatric emergency departments. World Journal of Clinical Cases: WJCC. 2013;1(9):276-284.    Acute abdomen in infants younger than 2 years is very difficult to evaluate as the only feature may be inconsolable crying and finally lethargy. In fact, it has also been found that infants with recurrent or chronic abdominal pain in this age group may not present with any typical feature. The differential diagnosis includes recurrent intussusceptions, malrotation with intermittent volvulus, milk allergy syndrome and various malabsorptive diseases, such as lactase deficiency.14Yang W-C, Chen C-Y, Wu H-P. Etiology of non-traumatic acute abdomen in pediatric emergency departments. World Journal of Clinical Cases: WJCC. 2013;1(9):276-284.

Lactase deficiency is a widely prevailing condition among all age groups, which has the tendency to become significant with age. More than one-third of Indians suffer from lactase deficiency. As a result, the affected individuals develop intolerance to foods containing lactose.15Di Stefano M, Veneto G, Malservisi S, Strocchi A, Corazza GR. Lactose malabsorption and intolerance in the elderly. Scand J Gastroenterol. 2001 Dec;36(12):1274-8.   16Data on File. Walter-Bushnell.    Lactose intolerance is a very important contributory factor to consider in children with recurrent abdominal pain. Studies have shown that abdominal pain in children due to lactose intolerance can be up to 25%.17Blumenthal I, Kelleher J, Littlewood JM. Recurrent abdominal pain and lactose intolerance in childhood. British Medical Journal (Clinical research ed). 1981;282(6281):2013-2014.

table 2

Another common cause of recurrent abdominal pain in children is irritable bowel syndrome (IBS). About 10-15% of older children and adolescents are estimated to suffer from IBS. It is characterized by abdominal pain, which manifests with a change in stool form and/or frequency (not explained by structural, biochemical abnormalities, or any well-recognizable infective cause) and tends to improve with defecation.18Sandhu BK, Paul SP. Irritable bowel syndrome in children: Pathogenesis, diagnosis and evidence-based treatment. World Journal of Gastroenterology: WJG. 2014;20(20):6013-6023.    Meteorism, abdominal spasms, diarrhea, casually obstipation, flatulence and nausea are symptoms of fructose malabsorption and/or lactose intolerance, but are also the characteristic features of IBS.19Litschauer-Poursadrollah M, El-Sayad S, Wantke F, Fellinger C, Jarisch R. Abdominal spasms, meteorism, diarrhea: fructose intolerance, lactose intolerance or IBS?. Wien Med Wochenschr. 2012 Dec;162(23-24):506-12.

The premise is that the diagnosis of abdominal pain in children should be formulated through a complete history, physical examination and even whole abdominal and pelvis ultrasound scan. A further survey, such as abdominal CT is recommended if the abdominal pain still persists without improving after a period of light diet or no oral intake.14Yang W-C, Chen C-Y, Wu H-P. Etiology of non-traumatic acute abdomen in pediatric emergency departments. World Journal of Clinical Cases: WJCC. 2013;1(9):276-284.

A Quick Work up and its Need

A quick workup is required for a sick-appearing child, with proper evaluation of hydration status and pain control. In case urgent surgical consultation is needed (Table 1), delay should not be long while awaiting diagnostic workup. If the diagnosis is undetermined in a child who does not have an acute surgical abdomen, the examination should be repeated in 24 to 48 hours. Up to 30% of children will have a change in their diagnosis.17Blumenthal I, Kelleher J, Littlewood JM. Recurrent abdominal pain and lactose intolerance in childhood. British Medical Journal (Clinical research ed). 1981;282(6281):2013-2014.   20Zhou H, Chen Y-C, Zhang J-Z. Abdominal pain among children re-evaluation of a diagnostic algorithm. World Journal of Gastroenterology. 2002;8(5):947-951.

Management

There are a range of management options for children with abdominal pain, which include medications, dietary interventions, probiotics and psychological and complementary therapies. These interventions help in improving the understanding and maximizing the quality of care for children affected with this condition.21Korterink J, Devanarayana NM, Rajindrajith S, Vlieger A, Benninga MA. Childhood functional abdominal pain: mechanisms and management. Nat Rev Gastroenterol Hepatol. 2015 Mar;12(3):159-71.    Commonly used pharmaceutical agents for treatment of symptoms associated with recurrent abdominal pain are analgesics, H(2) blockers, proton-pump inhibitors, anticholinergics, antiemetics, antidepressants, antispasmodics, and simethicone.22Joy A. Weydert, Thomas M. Ball, Melinda F. Davis. Systematic Review of Treatments for Recurrent Abdominal Pain. Pediatrics. 2003;111(1):e1-e11.   23Miranda A, Sood M. Treatment options for chronic abdominal pain in children and adolescents. Curr Treat Options Gastroenterol. 2006 Sep;9(5):409-15.

box-1

Pharmacological therapy

Analgesics: Choice of analgesics in patients with acute abdominal pain is based on numerous factors, which include severity of the pain, need for diagnostic testing, consultants’ availability, and the treating physician’s comfort with diagnosis or analgesic use.24Kim MK, Strait RT, Sato TT, Hennes HM. A Randomized Clinical Trial of Analgesia in Children with Acute Abdominal Pain. Academic Emergency Medicine. 2002;9(4):281-287.    For children, analgesics are calculated on mg/kg body weight basis.25Pain Management Handbook. Ministry of Health, Malaysia. 2013.    The conventional approach to treatment of abdominal pain has disapproved of the use of analgesics for the fear of interfering with accurate evaluation and diagnosis. However, a change in the concept has surfaced with time. It is now believed that analgesics when used judiciously may actually help in enhancing the diagnostic accuracy by permitting detailed examination of a more cooperative patient.4Leung AK, Sigalet DL. Acute abdominal pain in children. Am Fam Physician. 2003 Jun 1;67(11):2321-6.    This was validated by the Agency for Healthcare Research and Quality (AHRQ) that the appropriate use of analgesics in patients with acute abdominal pain not only effectively ameliorates pain, but also does not interfere with diagnosis or treatment.24Kim MK, Strait RT, Sato TT, Hennes HM. A Randomized Clinical Trial of Analgesia in Children with Acute Abdominal Pain. Academic Emergency Medicine. 2002;9(4):281-287.

However, in pediatric cases, risk of suboptimal analgesia persists, as there is data that shows that analgesia is underutilized, its administration may get delayed, or may be dosed insufficiently in the emergency department. Although the therapies available to treat pain are numerous, standard of analgesic care for children with undifferentiated abdominal pain is still lacking.26Poonai N, Paskar D, Konrad SL, Rieder M, Joubert G, Lim R, Golozar A, Uledi S, Worster A, Ali S. Opioid analgesia for acute abdominal pain in children: A systematic review and meta-analysis. Acad Emerg Med. 2014 Nov;21(11):1183-92.    Therefore, further multicenter trials are warranted to study analgesia for abdominal pain and evaluate the associated improvement in diagnostic accuracy. Besides, satisfaction level, subjective comfort achieved from variable doses of different opioid analgesics, adverse events, long-term outcomes, and effects in younger children require addressal.24Kim MK, Strait RT, Sato TT, Hennes HM. A Randomized Clinical Trial of Analgesia in Children with Acute Abdominal Pain. Academic Emergency Medicine. 2002;9(4):281-287.

Antispasmodics: Abdominal pain in functional disorders to a major extent can be attributed to the interactions between the CNS, enteric nervous system and GI tract, and may therefore be considered an abnormal perception of visceral sensations or alterations in motility. On the basis of these observations, potential pharmacological treatments for abdominal pain have been identified.27Chiou E, Nurko S. Management of functional abdominal pain and irritable bowel syndrome in children and adolescents. Expert review of gastroenterology & hepatology. 2010;4(3):293-304.    Smooth muscle relaxants, commonly referred to as antispasmodics, have been extensively used for more than two decades in the management of abdominal pain.28Lacy BE, Weiser K, De Lee R. The Treatment of Irritable Bowel Syndrome. Therapeutic Advances in Gastroenterology. 2009;2(4):221-238.   Antispasmodic medications, which exert anticholinergic effects on smooth muscle, are thought to be helpful for functional abdominal pain (FAP) and IBS, as these reduce the smooth muscle spasms. However, use of anticholinergic drugs is occasional and for short period of time, as their long-term use has been associated with anticholinergic side effects such as dry mouth, urine retention, blurred vision, tachycardia, drowsiness and constipation.27Chiou E, Nurko S. Management of functional abdominal pain and irritable bowel syndrome in children and adolescents. Expert review of gastroenterology & hepatology. 2010;4(3):293-304.    Moreover, since it often masks the physical symptoms of ‘acute abdomen’ making it difficult to achieve a rapid diagnosis, their use is discouraged, especially in emergency situations. This warrants the need for a benchmark pharmacological agent that does not mask the acute symptoms, does not interfere with the diagnosis, is free of side effects (so that it can be safely given to children), and is capable of managing the symptoms more effectively. Drotaverine, a tolerable oral spasmolytic agent, offers a great potential in management of abdominal pain.29Blasko G. Pharmacology, mechanism of action and clinical significance of a convenient antispasmodic agent. JAMA India. 2001;4(12):59-66.

Drotaverine, which is a synthetic isoquinoline derivative, exerts a powerful spasmolytic action on smooth muscle cells. It selectively inhibits phosphodiesterase isoenzyme IV, which makes it a potential agent of choice in spastic and motility disorders of the smooth muscle.30Misra SC, Pandey RM. Efficacy of drotaverine in irritable bowel syndrome: a double blind, randomized, placebo-controlled clinical trial. The American Journal of Gastroenterology. 2000;95:2544.    In contrast to the conventional spasmolytics, which inhibit intestinal passage, preclinical studies have determined that the therapeutic concentrations of drotaverine do not have any inhibitory effect on gastrointestinal motility. It is a highly potent spasmolytic agent that is capable of relieving or preventing smooth muscle spasm of various organs. It offers a favorable tolerability profile and is suitable for oral administration. It does not interfere with the diagnosis of abdominal pain and is devoid of side effects, therefore, it can be used in children for the management of acute and recurrent abdominal pain, particularly in long-term. In practice, drotaverine holds a relevant application as it does not interfere with diagnosis formulation. This is essentially because its anti-spasmodic and pain-killing effect does not mask the symptoms of “acute abdomen”.29Blasko G. Pharmacology, mechanism of action and clinical significance of a convenient antispasmodic agent. JAMA India. 2001;4(12):59-66.    Moreover, it is well tolerated, does not exhibit any morphine or dextropropoxyphene like effect (thereby, no addiction), and is free from anticholinergic-associated adverse reactions. Advantages of drotaverine are listed in Box 1.16Data on File. Walter-Bushnell.   29Blasko G. Pharmacology, mechanism of action and clinical significance of a convenient antispasmodic agent. JAMA India. 2001;4(12):59-66.

Investigators evaluating its efficacy in different gastrointestinal indications have posited that 72-86% of patients report relief in pain. Drotaverine is even known for prolonged pain relief and maintenance of spasmolysis.29Blasko G. Pharmacology, mechanism of action and clinical significance of a convenient antispasmodic agent. JAMA India. 2001;4(12):59-66.    In the first of its kind pediatric study, Narang et al31Narang M, Shah D, Akhtar H. Efficacy and Safety of Drotaverine Hydrochloride in Children with Recurrent Abdominal Pain: A Randomized Placebo Controlled Trial. Indian Pediatrics. 2015; 52(10):847-51.    evaluated the efficacy of drotaverine in cases of recurrent abdominal pain. It was observed that the number of episodes of abdominal pain significantly reduced in the drotaverine group in comparison to placebo group [mean (SD) = 10.3 (14) vs. 21.6 (32.4), respectively]. Moreover, lesser number of school days missed were reported in drotaverine group than in those on placebo [mean (SD) = 0.25 (0.85) vs. 0.71 (1.59), respectively]. The number of pain-free days were also slightly higher with drotaverine versus placebo [17.4 (8.2) vs 15.6 (8.7), respectively].31Narang M, Shah D, Akhtar H. Efficacy and Safety of Drotaverine Hydrochloride in Children with Recurrent Abdominal Pain: A Randomized Placebo Controlled Trial. Indian Pediatrics. 2015; 52(10):847-51.    The European report on the survey of all medicinal products for pediatric use stated that drotaverine is used commonly in preschool and school children.32Report on the survey of all paediatric uses of medicinal products in Europe. Available at: http://www.ema.europa.eu/docs/en_GB/document_library/Report/ 2011/01/WC500101006.pdf. Accessed on: 31-10-17.

Lactase Supplements

Dietary interventions, including fiber supplements, lactose free diets or lactobacillus supplementation, have been found effective in the treatment of abdominal pain, yet there is dearth of high quality evidence.32Report on the survey of all paediatric uses of medicinal products in Europe. Available at: http://www.ema.europa.eu/docs/en_GB/document_library/Report/ 2011/01/WC500101006.pdf. Accessed on: 31-10-17.    In a study conducted by Carlo Tolone et al34Tolone C, Pellino V, Piccirillo M, Letizia M, Belfiore I, Tolone S. Recurrent abdominal pain in children: underlying pathologies in the absence of “alarm” symptoms. Minerva Pediatrica. 2017 August;69(4):239-44.    on children with recurrent abdominal pain, lactose intolerance was found to be a cause of abdominal pain in 22.6% of children.34Tolone C, Pellino V, Piccirillo M, Letizia M, Belfiore I, Tolone S. Recurrent abdominal pain in children: underlying pathologies in the absence of “alarm” symptoms. Minerva Pediatrica. 2017 August;69(4):239-44.    Replacement of lactase enzyme is thus another option; it has been observed that symptoms of abdominal pain could be relieved by adding lactase supplements in the infant feed.35Heyman MB; Committee on Nutrition. Lactose intolerance in infants, children, and adolescents. Pediatrics. 2006 Sep;118(3):1279-86.    Infants can be administered lactase till 4 to 6 months of age, subsequent to which they start producing sufficient amount of lactase. In a double-blind placebo-controlled crossover study,36Kanabar D, Randhawa M, Clayton P. Improvement of symptoms in infant colic following reduction of lactose load with lactase. J Hum Nutr Diet. 2001 Oct;14(5):359-63.    about 53 infants with colic were either treated with placebo or preincubated lactase feed. It was observed that total crying time and breath hydrogen levels were significantly lower in the active group (about 45% lower) than in the placebo group.36Kanabar D, Randhawa M, Clayton P. Improvement of symptoms in infant colic following reduction of lactose load with lactase. J Hum Nutr Diet. 2001 Oct;14(5):359-63.    Similarly in another study,37Trial 1 – A Trial of Lactase in the Management of Infant Colic. Available at: http:// colief-cy.com/trial1/. Accessed on: 31-10-17.   the infants were randomized to receive either lactase or placebo drops to their formula feeds for 1 week, followed by 2 days “wash out”. In the second week, the addition was changed and the subjects were made their own control. The formulas were refrigerated for 24 hours prior to ingestion and the parents were asked to maintain a diary of the infants’ crying time. A significant improvement in symptoms was noted; the lactase-treated formula decreased crying time by 1.14 hours/day.37Trial 1 – A Trial of Lactase in the Management of Infant Colic. Available at: http:// colief-cy.com/trial1/. Accessed on: 31-10-17.

Conclusion

Acute abdominal pain is common in the pediatric population and establishing the cause is particularly challenging due to broad differential diagnoses. In general, the clinical approach comprises proper history, including location, onset, character, intensity, and pattern of pain, and associated symptoms, and examination. A quick work up helps in differentiating clinically stable and critically ill patients, who may require immediate surgical consultation. Differential diagnosis of acute abdomen are considered based on the age of the patient.

In infants and toddlers of up to 5 years of age, infantile colic is a frequent observation, which occurs due to lactase deficiency. In India, lactose intolerance prevalence is high and also studies have shown, lactose intolerance to be an important cause in recurrent abdominal pain. Lactase supplements can help children in digesting milk products. Addition of lactase enzyme to the infant feed has shown a reduction in total crying time.

In addition, for abdominal pain associated with spastic and motility disorders, antispasmodics form the mainstay in management of acute abdominal pain along with NSAIDs. Directly acting smooth muscle antispasmodics like drotaverine may be a valuable option, both as initial drug used for pain-killing effect and for maintenance of spasmolysis. It does not have any inhibitory effect on gastrointestinal motility, provides prolonged pain relief, and are devoid of anticholinergic side effects.

References

  1. Iwanczak B, Stawarski A, Czernik J, Bronowickip K, Iwanczak F, Pytrus T, et al. Diagnostic difficulties in pediatric abdominal pain with potential appendicitis. Przegl Lek. 2007;64 Suppl 3:56-60.
  2. Evaluation of abdominal pain in children. Available at: http://us.bestpractice.bmj.com/best-practice/monograph/787.html. Accessed on: 24-10-17.
  3. Berger MY, Gieteling MJ, Benninga MA. Chronic abdominal pain in children. BMJ 2007;334:997.
  4. Leung AK, Sigalet DL. Acute abdominal pain in children. Am Fam Physician. 2003 Jun 1;67(11):2321-6.
  5. Hijaz NM, Friesen CA. Managing acute abdominal pain in pediatric patients: current perspectives. Pediatric Health, Medicine and Therapeutics. 2017:8;83-91.
  6. Macaluso CR, McNamara RM. Evaluation and management of acute abdominal pain in the emergency department. International Journal of General Medicine. 2012;5:789-797.
  7. Sherman R. Abdominal Pain. In: Walker HK, Hall WD, Hurst JW, editors. Clinical Methods: The History, Physical, and Laboratory Examinations. 3rd edition. Boston: Butterworths; 1990. Chapter 86. Available from: https://www.ncbi.nlm.nih.gov/books/NBK412/
  8. Rasquin-Weber A, Hyman P, Cucchiara S, et al. Childhood functional gastrointestinal disorders. Gut. 1999;45(Suppl 2):II60-II68.
  9. Czyzewski DI, Self MM, Williams AE, Weidler EM, Blatz AM, Shulman RJ. Maintenance of Pain in Children with Functional Abdominal Pain. Journal of pediatric gastroenterology and nutrition. 2016;62(3):393-398.
  10. Geitling MJ, Bierma-Zeinstra SMA, Lisman-van Leeuwen Y, et al. Prognostic factors for persistence of chronic abdominal pain in children. J Pediatr Gastroenterol Nutr. 2011;54(2):154–161.
  11. van Tilburg MA, Felix CT. Diet and functional abdominal pain in children and adolescents. J Pediatr Gastroenterol Nutr. 2013 Aug;57(2):141-8.
  12. Zeevenhooven J, Koppen IJN, Benninga MA. The New Rome IV Criteria for Functional Gastrointestinal Disorders in Infants and Toddlers. Pediatric Gastroenterology, Hepatology & Nutrition. 2017;20(1):1-13.
  13. Reust CE, Williams A. Acute Abdominal Pain in Children. Am Fam Physician. 2016 May 15;93(10):830-837.
  14. Yang W-C, Chen C-Y, Wu H-P. Etiology of non-traumatic acute abdomen in pediatric emergency departments. World Journal of Clinical Cases: WJCC. 2013;1(9):276-284.
  15. Di Stefano M, Veneto G, Malservisi S, Strocchi A, Corazza GR. Lactose malabsorption and intolerance in the elderly. Scand J Gastroenterol. 2001 Dec;36(12):1274-8.
  16. Data on File. Walter-Bushnell.
  17. Blumenthal I, Kelleher J, Littlewood JM. Recurrent abdominal pain and lactose intolerance in childhood. British Medical Journal (Clinical research ed). 1981;282(6281):2013-2014.
  18. Sandhu BK, Paul SP. Irritable bowel syndrome in children: Pathogenesis, diagnosis and evidence-based treatment. World Journal of Gastroenterology: WJG. 2014;20(20):6013-6023.
  19. Litschauer-Poursadrollah M, El-Sayad S, Wantke F, Fellinger C, Jarisch R. Abdominal spasms, meteorism, diarrhea: fructose intolerance, lactose intolerance or IBS?. Wien Med Wochenschr. 2012 Dec;162(23-24):506-12.
  20. Zhou H, Chen Y-C, Zhang J-Z. Abdominal pain among children re-evaluation of a diagnostic algorithm. World Journal of Gastroenterology. 2002;8(5):947-951.
  21. Korterink J, Devanarayana NM, Rajindrajith S, Vlieger A, Benninga MA. Childhood functional abdominal pain: mechanisms and management. Nat Rev Gastroenterol Hepatol. 2015 Mar;12(3):159-71.
  22. Joy A. Weydert, Thomas M. Ball, Melinda F. Davis. Systematic Review of Treatments for Recurrent Abdominal Pain. Pediatrics. 2003;111(1):e1-e11.
  23. Miranda A, Sood M. Treatment options for chronic abdominal pain in children and adolescents. Curr Treat Options Gastroenterol. 2006 Sep;9(5):409-15.
  24. Kim MK, Strait RT, Sato TT, Hennes HM. A Randomized Clinical Trial of Analgesia in Children with Acute Abdominal Pain. Academic Emergency Medicine. 2002;9(4):281-287.
  25. Pain Management Handbook. Ministry of Health, Malaysia. 2013.
  26. Poonai N, Paskar D, Konrad SL, Rieder M, Joubert G, Lim R, Golozar A, Uledi S, Worster A, Ali S. Opioid analgesia for acute abdominal pain in children: A systematic review and meta-analysis. Acad Emerg Med. 2014 Nov;21(11):1183-92.
  27. Chiou E, Nurko S. Management of functional abdominal pain and irritable bowel syndrome in children and adolescents. Expert review of gastroenterology & hepatology. 2010;4(3):293-304.
  28. Lacy BE, Weiser K, De Lee R. The Treatment of Irritable Bowel Syndrome. Therapeutic Advances in Gastroenterology. 2009;2(4):221-238.
  29. Blasko G. Pharmacology, mechanism of action and clinical significance of a convenient antispasmodic agent. JAMA India. 2001;4(12):59-66.
  30. Misra SC, Pandey RM. Efficacy of drotaverine in irritable bowel syndrome: a double blind, randomized, placebo-controlled clinical trial. The American Journal of Gastroenterology. 2000;95:2544.
  31. Narang M, Shah D, Akhtar H. Efficacy and Safety of Drotaverine Hydrochloride in Children with Recurrent Abdominal Pain: A Randomized Placebo Controlled Trial. Indian Pediatrics. 2015; 52(10):847-51.
  32. Report on the survey of all paediatric uses of medicinal products in Europe. Available at: http://www.ema.europa.eu/docs/en_GB/document_library/Report/ 2011/01/WC500101006.pdf. Accessed on: 31-10-17.
  33. Huertas-Ceballos AA, Logan S, Bennett C, Macarthur C. Dietary interventions for recurrent abdominal pain (RAP) and irritable bowel syndrome (IBS) in childhood. Cochrane Database Syst Rev. 2009 Jan 21;(1):CD003019.
  34. Tolone C, Pellino V, Piccirillo M, Letizia M, Belfiore I, Tolone S. Recurrent abdominal pain in children: underlying pathologies in the absence of “alarm” symptoms. Minerva Pediatrica. 2017 August;69(4):239-44.
  35. Heyman MB; Committee on Nutrition. Lactose intolerance in infants, children, and adolescents. Pediatrics. 2006 Sep;118(3):1279-86.
  36. Kanabar D, Randhawa M, Clayton P. Improvement of symptoms in infant colic following reduction of lactose load with lactase. J Hum Nutr Diet. 2001 Oct;14(5):359-63.
  37. Trial 1 – A Trial of Lactase in the Management of Infant Colic. Available at: http:// colief-cy.com/trial1/. Accessed on: 31-10-17.
Back to Pedia Flash Vol-4, No-1, 2018