Preliminary findings on increased muscle tension and tenderness, and recurrent abdominal pain in children. A clinical study

Recurrent abdominal pain of "non-organic origin" is a common pediatric problem. In most instances it is related to psychological factors. The origin of the pain itself, however, is still unknown. In this study, we question whether or not the complaint could have a muscular origin. In this clinical study of recurrent abdominal pain of probable "psychosomatic origin", all 27 children had tense and tender abdominal muscles, which was not the case in a control group. The children with recurrent abdominal pain also had a typical pattern of muscular tension and tenderness in other muscles. These children often have tension headache, "tension" chest pains and also more general symptoms such as loss of appetite and disturbed bowel function.     

A study of 111 children with recurrent abdominal pain

One hundred and eleven children with recurrent abdominal pain were studied to determine the clinical features in a group of unselected children presenting in a general paediatric practice. Organic disease was found in four children and was easy to recognize. There were characteristic clinical features in children with no apparent organic cause for pain which suggest that detailed investigations are inappropriate. A simple psychosomatic approach showed an immediate and sustained improvement in symptoms in 70% of children studied.     

Recurrent abdominal pain.

A long-term follow-up study (minimum of five years) of 161 children with recurrent abdominal pain disclosed that three had organic disease and that was missed--inflammatory bowel disease. Anorexia nervosa developed in one patient. Three fourths of the patients recovered from the initial symptom; most recovered within a few weeks; but some patients continued to have complaints for a number of years. Approximately 20% of patients underwent additional surgical or medical treatments of doubtful necessity. In 18% of patients, other psychosomatic symptoms developed.     

The covariation of common psychosomatic symptoms among children from socio-economically differing residential areas. An epidemiological study

Psychosomatic symptoms among children are believed to be commonplace. In this investigation by questionnaire, 47% of 1333 schoolchildren reported one or several symptoms, such as recurrent abdominal pain, headache, chest pains, loss of appetite and disturbances in bowel function. Coexistence of such symptoms was considerable and if a child had one of these, the probability that it would have one or more other symptoms was significantly increased. This correlation may strengthen both the suspicion that these symptoms are often psychosomatic and the idea that they have common CNS origin. There were appreciable differences in the frequency of the symptoms, between children at the more socially stable schools and schools with social problems. In the latter, the frequencies of symptoms differed between Swedish and immigrant children, which was not the case in the more socially stable schools.     

Elevated cholecystokinin concentrations in plasma in children with recurrent abdominal pain

The objective of the present study was to measure plasma Concentrations of the gastrointestinal hormones gastrin, somatostatin and cholecystokinin in plasma of children with recurrent abdominal pain. since these hormones affect gastrointestinal function. Forty-four children (7–16 years old) with recurrent abdominal pain and 36 control children (matched for age and sex) participated in the study. In a blood sample collected after an overnight fast, gastrin, somatostatin and cholecystokinin concentrations werc measured by radioimmunoassay. The children with recurrent abdominal pain had higher plasma cholecystokinin levels ( p <0.001) than the controls. Whether or not this aberration is related to the clinical symptoms of children with recurrent abdominal pain remains to be established.     

School stressors, psychological complaints and psychosomatic pain

BACKGROUND: The proportion of Scandinavian school children reporting psychosomatic pain and psychological complaints have increased in recent decades. In this study we investigated these symptoms in relation to potential stressors in the school environment. METHODS: A cross-sectional study was conducted based on child interviews linked to nationally representative household surveys in Sweden during 2002-2003 covering a sample of 2588 children aged 10-18 years. The main outcome variable of psychosomatic pain signified suffering from headache as well as recurrent abdominal pain on a weekly basis. RESULTS: School stressors, such as harassment by peers, schoolwork pressure and being treated poorly by teachers, were associated with psychosomatic pain as well as psychological complaints such as sadness, irritability, feeling unsafe and nervous. Harassment was identified as a particularly important determinant with adjusted odds ratios (ORs) ranging from 3.1 to 8.6 for psychosomatic pain. All psychological complaints were associated with psychosomatic pain with adjusted ORs ranging from 2.2 to 3.7, and mediated most of the association of harassment to psychosomatic pain. CONCLUSIONS: School stressors are strongly associated with psychosomatic pain and psychological complaints in school children. Psychological complaints seem to function as mediators in the association of school stressors to psychosomatic pain symptoms to a great extent.     

Diurnal salivary cortisol concentration in school-aged children: increased morning cortisol concentration and total cortisol concentration negatively correlated to body mass index in children with recurrent abdominal pain of psychosomatic origin

INTRODUCTION: The sampling method for salivary cortisol is sensitive, specific and pain-free. Our knowledge about cortisol concentration in saliva and plasma in school-aged children is sparse and contradictory. AIM: To estimate diurnal variation in salivary cortisol concentration in children with and without psychosomatic recurrent abdominal pain (RAP), and to compare groups and relate the concentrations to age, sex, puberty, body mass index (BMI), allergy, headache and ethnicity. CHILDREN AND METHOD: Saliva was collected in 'Salivette' tubes from 159 healthy girls and 147 healthy boys, aged 5-15 years, and from 25 girls and 6 boys, aged 6-18 years, with RAP of psychosomatic origin, at 08.00 h, 13.00 h and 20.00 h. Saliva was analysed using a commercial RIA-cortisol kit. RESULTS: The median concentrations in healthy girls and boys were 8.8/8.3 nmol/l at 08.00 h, 5.5/5.3 nmol/l at 13.00 h, and 2.1/2.3 nmol/l at 20.00 h, respectively. Cortisol concentrations differed between 6-7 year-old and 9 year-old children (higher in the former). Age-matched post-menarcheal girls had higher cortisol concentrations in the evening, 2.2 vs 1.7 nmol/l (p = 0.03). The results were independent of BMI, headache and allergy. In the RAP group, diurnal cortisol concentrations in girls/boys at the different time-points were 14.8/12.9, 5.2/5.8, and 2.4/2.7 nmol/l, respectively, and were negatively correlated to BMI. Total secretion of cortisol was higher than in healthy children. Cortisol concentration was independent of allergy, headache and ethnicity, CONCLUSION: In healthy children, salivary cortisol concentration was dependent on time, age and menarche. In children with RAP of psychosomatic origin, morning and total secretion of cortisol were significantly higher than in healthy children and negatively correlated to BMI.     

One hundred cases of recurrent abdominal pain in children: diagnostic procedures and criteria for a psychosomatic diagnosis

Aims: To highlight the diagnostic difficulties involved in elucidating the aetiology of recurrent abdominal pain and to evaluate the use of special premises and criteria for the diagnosis of psychosomatic pain. Methods: The study included 100 consecutive cases of recurrent abdominal pain in 6 to 15 y-old children who were evaluated at a special paediatric clinic for recurrent abdominal pain and who were followed for at least one year. The investigation included a semi-structured questionnaire, laboratory investigations based on clinical data and diagnoses based on defined criteria. Three premises and seven criteria, based on the assumption that chronic negative stress can cause recurrent pain, were used for the diagnosis of psychosomatic pain. Results: When the presented premises and criteria were employed for the diagnosis of psychosomatic pain, nearly half of the cases (48%) of recurrent abdominal pain could be explained. An organic or possibly organic diagnosis was found in 25% of the cases. Fourteen children had a possible psychosomatic diagnosis and in 9 cases no known diagnosis could be reached. Conclusion. The presented premises and criteria for the diagnosis of psychosomatic pain can be helpful when diagnosing recurrent abdominal pain, but further validation is needed. According to these criteria, a psychosomatic diagnosis was common in this series, accounting for nearly half of the cases. A medical diagnosis was evident in a quarter of the cases.     

A study of 111 children with recurrent abdominal pain

Abstract One hundred and eleven children with recurrent abdominal pain were studied to determine the clinical features in a group of unselected children presenting in a general paediatric practice. Organic disease was found in four children and was easy to recognize. There were characteristic clinical features in children with no apparent organic cause for pain which suggest that detailed investigations are inappropriate. A simple psychosomatic approach showed an immediate and sustained improvement in symptoms in 70% of children studied.     

The use of Lactobacillus GG in irritable bowel syndrome in children: a double-blind randomized control trial

OBJECTIVE: To determine whether oral administration of the probiotic Lactobacillus GG under randomized, double-blinded, placebo-controlled conditions would improve symptoms of irritable bowel syndrome (IBS) in children. STUDY DESIGN: Fifty children fulfilling the Rome II criteria for IBS were given Lactobacillus GG or placebo for 6 weeks. Response to therapy was recorded and collected on a weekly basis using the Gastrointestinal Symptom Rating Scale (GSRS). RESULTS: Lactobacillus GG was not superior to placebo in relieving abdominal pain (40.0% response rate in the placebo group vs 44.0% in the Lactobacillus GG group; P=.774). There was no difference in the other gastrointestinal symptoms, except for a lower incidence of perceived abdominal distention (P=.02 favoring Lactobacillus GG). CONCLUSIONS: Lactobacillus GG was not superior to placebo in the treatment of abdominal pain in children with IBS but may help relieve such symptoms as perceived abdominal distention.     

Recurrent abdominal pain: theories and pragmatics

Although recurrent abdominal pain is a common complaint occurring in approximately 15% of school-age children, 90% of these children do not appear to have disease process that explains the pain. On the other hand, serious and life-threatening pediatric illnesses can present with recurrent abdominal pain as their only symptoms. This article proposes a clinical approach designed to identify those children with active disease processes, and presents a review of the current models proposed to explain the other 90% of children with recurrent abdominal pain. The objective of this review is to help pediatricians to minimize the morbidity associated with and the trauma caused by the evaluation of this common symptom in childhood.     

The pressure pain threshold (PPT) of certain muscles in children suffering from recurrent abdominal pain of non-organic origin. An algometric study

The origin of recurrent abdominal pain of "non-organic origin" is believed to be psychogenic in most cases. But the pathogenesis of the pain itself is unknown. To test the hypothesis that recurrent abdominal pain of non-organic origin is related to increased pain sensitivity in the myofascial elements of the abdominal wall itself, an investigation of pain pressure threshold of the abdominal wall, close to the umbilicus, was carried out. Altogether 140 children in the fourth school grade, approximately 11 years old, were tested for pressure pain threshold. Two groups were constituted: one without pain symptoms (no recurrent abdominal pain, chest pains or headache ( n = 50)) and one with recurrent abdominal pain ( n = 49). The pressure pain threshold differed significantly ( p <0.0001). To support the hypothesis that recurrent abdominal pain is a part phenomenon of a specific pattern of muscular tension and tenderness, the pressure pain threshold was tested in five other muscles, with significant results.     

Depressed concentrations of oxytocin and cortisol in children with recurrent abdominal pain of non-organic origin

The purpose of the present study was to measure plasma concentrations of oxytocin, cortisol and prolactin in children with recurrent abdominal pain of non-organic origin (RAP). Forty children with RAP and 34 controls, matched for age and sex, participated in the study. A blood sample was collected after an overnight fast in association with clinical examinations. Oxytocin, cortisol and prolactin levels were determined by radioimmunoassay (RIA). Oxytocin and cortisol concentrations in the children with RAP were found to be significantly reduced compared with those of the controls (approximately 24 versus 63 pmol/l for oxytocin and 160 versus 300 nmol/l for cortisol, respectively). The low oxytocin and cortisol levels persisted at a second examination 3 months later. No significant differences in the prolactin levels were observed between RAP and controls.     

Challenges in management of irritable bowel syndrome in children

Irritable bowel syndrome (IBS) is a common cause of recurrent abdominal pain (RAP) in children and can be a debilitating experience for both child and family. Organic causes of RAP symptoms such as celiac and inflammatory bowel diseases should be excluded before a diagnosis of IBS is made. Treatment consists of dietary manipulation, drugs, and stress management. Newer therapies may offer better control of symptoms with minimal side-effects. This article discusses the challenges faced by pediatricians in managing IBS and reviews management in the context of children from the Indian subcontinent.     

The prevalence and related symptomatology of Helicobacter pylori in children with recurrent abdominal pain

The aim of the study was to assess and compare the IgG seroprevalence of H. pylori in children with recurrent abdominal pain with healthy children and to investigate the related symptoms. IgG antibodies against low-molecular weight H. pylori antigens were assessed in 438 children with recurrent abdominal pain and in 91 healthy controls. Sera with an ELISA unit-value above the cut-off level were confirmed by Western immunoblot. Only seropositive children with recurrent abdominal pain were examined by an oesophago-gastro-duodenoscopy. Symptomatology was recorded according to the localization of the abdominal pain, presence of pyrosis, nocturnal pain, relation of pain to meals and bowel irregularities. The seroprevalence was 21% (95% CI: 17-25%) in the children with recurrent abdominal pain and 10% (95% CI: 5–18%) in the healthy controls ( p = 0:30). In seropositive children with RAP H. pylori was found in 46/66 by culture and histology. The presence of H. pylori was significantly associated with active or inactive chronic gastritis. The presence of H. pylori was associated with both parents being born in a country with a high prevalence and a low social class. Helicobacter pylori-positive children had more often pain related to meals than the H. pylori- negative children. No differences among the two groups were seen according to the levels of haemoglobin, leucocytes, thrombocytes, weight and height. In conclusion, the seroprevalence of H. pylori is comparable in children with recurrent abdominal pain and healthy children. No specific symptomatology was seen in H. pylori- positive children with RAP.     

Chronic childhood constipation is associated with impaired quality of life: a case-controlled study

OBJECTIVE: The objective of this study was to investigate the effect of chronic constipation on children's quality of life. METHODS: From October 2002 to November 2003, 224 children (140 male, 84 female, aged 10.6 +/- 2.9 years) and 224 parents were evaluated by a health related quality of life tool during initial outpatient consultation. Children with constipation (n = 80) were compared with controls with inflammatory bowel disease (n = 42), controls with gastroesophageal reflux disease (n = 56), and with healthy children (n = 46). RESULTS: Children with constipation had lower quality of life scores than did those with inflammatory bowel disease (70 versus 84; P < 0.05), gastroesophageal reflux disease (70 versus 80; P < 0.05), and healthy children (70 versus 88; P < 0.05). Children with constipation reported lower physical scores than did inflammatory bowel disease patients (75 versus 85; P < 0.02), gastroesophageal reflux disease patients (75 versus 85; P < 0.05), or healthy children (75 versus 87; P < 0.05). Parents of children with constipation reported lower scores than did their children (61 versus 70; P < 0.05). Children with constipation had longer duration of symptoms than did the controls with inflammatory bowel disease and gastroesophageal reflux disease (43.8 months versus 14.2 months; P < 0.001). Prolonged duration of symptoms for children with constipation correlated with lower parent-reported scores (P < 0.002). CONCLUSIONS: At initial evaluation, children with constipation have a lower quality of life than do children with inflammatory bowel disease or gastroesophageal reflux disease. Self-reported lower scores may be a reflection of impaired physical ability. Parental perceptions of low quality of life are probably impacted by the duration of their child's symptoms and by family members with similar complaints. Practitioners should be aware of the high level of parental concern and the relatively low self-reported and parent-reported quality of life in children with chronic constipation as they plan therapy.     

Red Flags of Organic Recurrent Abdominal Pain in Children: Study on 100 Subjects

Objective

A variety of sign, symptoms and laboratory findings are more common in children with organic abdominal pains. This study was performed to evaluate the prevalence of organic and functional abdominal pains and relation of red flags to organic pains in 100 children with recurrent abdominal pain (RAP).

Methods

One hundred consecutive patients with RAP were enrolled in the study. A complete interview and physical examination was made for each patient, accompanied by a series of laboratory, clinical and para-clinical examinations. The data were recorded and analyzed. Logistic regression analysis was used to model and formulize correlations between sign, symptoms, and laboratory findings with organic and functional abdominal pain.

Findings

Among 100 patients (52% male, 48% female, Age: 9.29±3.17) diagnostic works up revealed organic pain for 57 patients. The most common symptoms of the patients included constipation, diarrhea, chest pain, cough, headache, vomiting, hematuria, and dysuria. Fecal incontinence, delayed puberty, organomegaly, jaundice, and family history of inflammatory bowel disease were reported in none of the patients with RAP. Fever, pain not located in periumbilical area, nocturnal pain, elevated erythrocyte sedimentation rate, weight loss, growth disorder, and abdominal tenderness were among the red flags which revealed diagnosis of organic pain in this study.

Conclusion

A series of red flags could increase likelihood of finding organic pain in children with RAP.     

Irritable bowel syndrome: the commonest cause of recurrent abdominal pain in children

Apley, working in Bristol, UK, defined recurrent abdominal pain (RAP) in 1958. After extensive investigations, he found that 8% of children presenting to his clinic with RAP had an organic pathology. The aims of this study were to identify (1) causes of RAP using modern methodology, (2) factors associated with organic RAP and (3) children with none-organic RAP who fulfill the diagnostic criteria for irritable bowel syndrome (IBS). Children, aged over 3 years, presenting with RAP were prospectively recruited to this study. They had a detailed questionnaire completed, a full examination with screening tests (blood for coeliac screen, Helicobacter pylori antibody titre, inflammatory markers, serum amylase, liver function tests, and full blood count, urine and stool analyses and abdominal ultrasonography). Endoscopy and oesophageal pH monitoring were performed if clinically indicated. IBS was diagnosed if the child had no organic pathology and fulfilled the Rome II criteria. Out of 103 children (median age of 10 years, mean 10.04, SD ±3.44,), 31 children (30%) had organic pathologies. Factors associated with organic pain were nocturnal symptoms (P<0. 01) and abdominal tenderness (P<0.005) and with non-organic pain were periumbilical locality (P<0.002), pain alleviation on defaecation (P<0.04) and low fibre diet (P<0.005). Of children with non-organic pain, 37/52 (51%) fulfilled the criteria for IBS (36% of the total). Conclusion:of children presenting with recurrent abdominal pain in a hospital setting, 30% have a diagnosable organic aetiology compared to 8% in Apleys time. Irritable bowel syndrome, however, may be the commonest cause of recurrent abdominal pain and should be considered.Abbreviations CRP C-reactive protein - GORD gastro-oesophageal reflux disease - IBS irritable bowel syndrome - RAP recurrent abdominal pain     

Screening for celiac disease in children with recurrent abdominal pain

BACKGROUND: The clinical presentation of celiac disease--a life-long gluten intolerance--may be characterized by chronic abdominal pain. The objective of this study was to determine if children with recurrent abdominal pain had a higher prevalence of antiendomysial antibodies (a serologic marker of celiac disease) compared with healthy children. METHODS: Children with recurrent abdominal pain and healthy control participants were recruited from the offices of community pediatricians. Serum samples were drawn and antiendomysial antibodies were measured in both groups. Demographic data included age, gender, height, and weight. RESULTS: A total of 200 children were recruited, of whom 173 (87%) had serum samples drawn. Of these, 92 were children with recurrent abdominal pain and 81 were control participants. Only 2 of the 173 samples (1.2%) were positive for antiendomysial antibody. The frequency of antiendomysial antibody positivity in children with recurrent abdominal pain was 1 in 92 (1%; 95% confidence interval, 0-6%) compared with 1 in 81 (1%; 95% confidence interval, 0-7%) in control participants. CONCLUSIONS: This community-based case-control study found no association between recurrent abdominal pain and the prevalence of antiendomysial antibody. Therefore, these data do not support screening for celiac disease in the child with classic recurrent abdominal pain in the primary care setting.     

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??The incidence and prevalence of inflammatory bowel disease ??IBD?? in children are increasing worldwide. Abdominal pain is one of important symptoms of IBD?? and has certain clinical characteristics. The pathogenesis of abdominal pain in IBD is extremely complex?? there are a number of factors and mechanisms involved in the pathogenesis of IBD. Clinically?? the management of abdominal pain in IBD should be individualized.