William Spivak, M.D.
Possible Causes for Abdominal Pain
Constipation is usually an easy diagnosis to make. However, an occasional child or adult may present with abdominal pain and have daily bowel movements but incomplete evacuation. Physical exam is usually remarkable for a hard fecal mass in the left lower quadrant or pelvis and firm stool in the rectum. Occasionally, children will present with encopresis because of fecal impaction and overflow diarrhea. It is important to ask when the last bowel movement was before the physical exam, since some patients will have a bowel movement before their Dr.’s appointment and the rectum may therefore be empty. Treatment should be geared not only to "cleaning the patient out" but also toward establishing normal bowel habits.
Less Common (but not rare) Causes of Abdominal Pain
Giardiasis is a parasitic infection of the upper small intestine that can lead to burping, abdominal distension, gas, diarrhea, vomiting and malabsorption. Symptoms may range from nil to life threatening. Stool samples are often negative and occasionally the diagnosis is made by duodenal aspiration at the time of endoscopy. Giardia antigen on fresh stool has a high diagnostic accuracy.
Inflammatory bowel disease (IBD)
IBD should be suspected in patients with chronic GI blood loss, diarrhea, abdominal pain, anorexia, fever and weight loss. In any given patient, some or most of these symptoms may be absent. An occasional child with IBD will have none of these symptoms and may present with growth failure or an extraintestinal manifestation of IBD such as arthritis. Barium enema is rarely indicated since it is neither very sensitive nor specific when compared to colonoscopy. Children with persistent rectal bleeding or guaiac posive stool should have a colonoscopy performed once infectious etiologies and anal fissure have been excluded. Pediatric patients with possible Crohn’s disease should have an upper GEndoscopy performed at the time of their initial Colonoscopy, since about 1 of 3 children with Crohn's disease will have upper intestinal involvement at the time of initial presentation. Occasionally, the colonoscopy will be negative or show non-specific inflammatory changes, but the upper intestinal tract will have granuloma present, confirming the diagnosisType your paragraph here.
Esophagitis, Duodenitis, Gastritis and Ulcer Disease
Frank ulcer disease is uncommon in children. However, children may have peptic related symptoms with inflammation of the upper intestinal tract. These children may have intermittant vomiting, early satiety, poor appetite, difficulty sleeping and supraumbilical or epigastric pain. Occasionally the pain may be periumbilical or in the right or left upper quadrant. Children may not know what heartburn is, but may answer "yes" if asked if they sometimes have the taste of pickle-juice in their throat or chest. H. pylori antibodies in the presence of abdominal are an indication for treatment of abdominal pain with both antibiotics and acid blocking agents. Unlike an upper GI series, endoscopy is very sensitive to mild forms of peptic disease and permits confirmation of H. pylori, a common, treatable bacterial cause of gastritis in adults, although uncommon in children in the United States. Although some patients may be treated empirically for peptic related symptoms, patients with guaiac positive stool, dysphagia, significant weight loss or vomiting should have the diagnosis confirmed endoscopically.
Dietary habits of the older child or adolescent can be a direct cause of abdominal distress. Intestinal gas and abdominal pain can be the result of chewing gum (swallowed air and malabsorbed sugars such as sorbitol), excessive ingestion of soda or apple juice, or gas producing foods such as beans or other legumes. Lactose intolerance may develop in a child or adolescent that previously tolerated milk products, and result in abdominal pain, gas and occasional nausea. Caffeine containing foods such as soda, tea, coffee and chocolate stimulate gastric acid secretion and may cause esophageal reflux. Adolescents may binge eat or eat late at night with resulting abdominal distress. Occasional patients with abdominal pain may unwittingly eat foods that are extremely acidic or spicey and be unaware that these foods cause them to develop indigestion. A careful dietary history is frequently quite revealing in the evaluation of chronic abdominal pain.
Determining the Diagnostic Urgency
Gastrointestinal symptoms are so common in children that extensive diagnostic evaluations are rarely necessary for most self-limited episodes of GI distress that may be viral, bacterial, dietary or stress related. However, certain symptoms or clinical signs may indicate a more pressing need for evaluation. Persistent right lower quadrant pain may indicate Crohn’s disease, chronic append- icitis, or an ovarian problem in a female. Chronic abdominal pain with rash and/or arthritis may represent IBD, or a vasculitic process such as JRA or HSP. Vomiting and weight loss with abdominal pain may indicate peptic disease or Crohn’s disease. Although rectal bleeding occurs in benign bacterial infections and anal fissures, persistent bleeding beyond a week with negative cultures should be a cause for concern and may indicate, for example, a polyp or colitis. Persistent fever, anemia, growth failure, or the presence of visceromegaly or mass would be an indication for prompt work-up. It is important to note that a normal sedimentation rate does not exclude the possibility of IBD.