Chronic abdominal pain in children

Chronic abdominal pain (CAP) continues to be a diagnostic and therapeutic challenge. It affects about 10% of school-going children and adolescents. Few Indian studies have reported an organic cause in 30%-40% of children with recurrent abdominal pain. In developing countries, parasitic infestations such as giardiasis and ascariasis are an important cause, of recurrent abdominal pain but their frequency has decreased over time. There is a paucity of data from India on the aetiology, epidemiology and management strategies for CAP, and there is no consensus on the clinical approach to this problem. We present a practical approach to CAP in children. The first step is to elicit a detailed history and do a thorough physical examination so as to categorize CAP according to the site of pain (epigastric, periumbilical or left lower quadrant), the predominant symptom associated with pain (dyspepsia, isolated pain or altered bowel habits) and to differentiate the pain as organic or functional based on the characteristics of pain and presence or absence of alarm signs. The second step is to do appropriate investigations, restricted to simple tests when functional pain is suspected (Level I) and more investigations (Level Ia) if there are alarm signs and pain appears to be organic in nature. Invasive investigations such as gastrointestinal endoscopy (Level II) may be reserved for those with possible organic pain. Level III investigations need to be done in a small percentage of children and include EEG, workup for food allergy and porphyria. The third step is management of organic CAP according to the aetiology, while for functional CAP the pharmacological and, rarely, psychological intervention is more difficult but should be done discreetly and tailored to the needs of the child.