Symptom sorter on recurrent abdominal pain in children

GPs Dr Keith Hopcroft and Dr Vincent Forte continue their series on making sense of common but often tricky symptoms

Recurrent abdominal pain in childhood can be a calling card for a myriad hidden agendas. More than 85 causes have been listed, and as in most areas of general practice, the trick is to sift through the morass of information to find the keys to the diagnosis. The underlying cause in the most persistent cases is usually non-organic.

Differential diagnosis

Common

• Recurrent viral illnesses

• Anxiety and depression – sometimes known as periodic syndrome or abdominal migraine

• Recurrent UTI

• Constipation

• Gastritis and GORD.

Occasional

• Crohn's and coeliac disease

• Duodenal ulcer

• Irritable bowel syndrome

• Diabetes

• Henoch-Schonlein purpura

• Hydronephrosis, renal stones and ureteric reflux

• Meckel's diverticulum.

Rare

• Parasitic infestation of the gut

• Food allergy

• Sickle-cell disease

• Tuberculosis

• Hirschsprung's disease

• Temporal lobe epilepsy

• Pica.

Possible investigations

Likely

• Urinalysis and mid-stream specimen of urine (MSU): urinalysis will reveal evidence of a UTI, which an MSU for microscopy and culture will confirm. Urinalysis will also reveal glucose in diabetes and possible haematuria in Henoch–Schonlein purpura.

Possible

• FBC: Hb may be reduced in any chronic disorder, leucocytosis in bacterial infection, eosinophilia in parasitic infestation or genuine food allergy.

• Blood film: may show sickling.

• ESR/CRP: raised ESR/CRP suggests organic disease.

Rare

• Plain abdominal X-ray.

• Ultrasound: non-invasive first-line investigation of renal tract. Other investigation for confirmed UTI will be arranged by the paediatrician.

• Further hospital-based investigations if there is a high suspicion of organic disease.
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Top tips

• The majority of children with recurrent abdominal pain will not have organic pathology – take the problem seriously and assess carefully, but avoid reinforcing worries with unnecessary investigation.

• Explore the parents' concerns – a child's anxiety may be fed by parents unnecessarily worrying about sinister and unlikely diagnoses.

• Talk to children alone – this may reveal relevant problems at home or school which they would not have been able to admit in front of parents.

• If recurrent UTI is a possibility, provide the parents with the necessary bottle and lab form so that an MSU can be taken during the next episode of pain.

Red flags

• Organic disease is suggested by pain distant from the umbilicus which wakes the child and which is associated with loss of appetite or weight, or a change in bowel habit.

• Beware the unlikely event of an acute cause for the pain supervening, such as appendicitis or torsion of the testis – ensure that parents know that a different, acute pain should not be dismissed, but should be presented urgently.

• Children proven to have a UTI should be managed according to NICE guidelines.

• Avoid colluding in parental somatisation and overlooking the existence of family dysfunction or other causes of unhappiness.

• Don't forget the rare possibility of sickling in the appropriate ethnic groups.