Overview
Definition:
Functional abdominal pain (FAP) in children is defined as recurrent or continuous abdominal pain for at least 2 months, not explained by an underlying organic disease, and associated with functional symptoms or limitations in daily activities
When accompanied by anxiety, it highlights a significant psychosomatic component where emotional distress exacerbates or perpetuates the pain experience.
Epidemiology:
FAP is highly prevalent in pediatric populations, affecting 10-20% of school-aged children
Anxiety is a common comorbidity, reported in 30-60% of children with FAP
It is more common in females and tends to persist into adolescence and adulthood, significantly impacting quality of life and school attendance.
Clinical Significance:
Understanding FAP with anxiety is crucial for pediatricians as it represents a significant burden on patients and healthcare systems
Early recognition and integrated management can prevent unnecessary investigations, reduce healthcare utilization, improve patient well-being, and mitigate long-term functional impairments
This condition requires a multidisciplinary approach beyond purely pharmacological interventions.
Clinical Presentation
Symptoms:
Recurrent or chronic abdominal pain, often periumbilical, epigastric, or diffuse
Pain may be variable in intensity and timing, often related to school days or stressful events
Associated symptoms can include nausea, vomiting, early satiety, bloating, constipation, or diarrhea
Children may also exhibit symptoms of anxiety such as worry, irritability, sleep disturbances, social avoidance, and somatic complaints like headaches or muscle tension.
Signs:
Physical examination is typically normal, with no signs of acute distress or specific organ tenderness
Vital signs are usually stable
Signs of anxiety may be evident in the child's demeanor or reported by parents, including restlessness, apprehension, or withdrawal
Growth parameters are usually normal, ruling out significant chronic illness.
Diagnostic Criteria:
Diagnosis is primarily based on Rome IV criteria for Functional Abdominal Pain-Related Functional Gastrointestinal Disorders (FAP-FGIDs)
Key criteria include sufficient Rome IV criteria for FAP, symptom duration of at least 2 months, and symptoms causing significant functional impairment
Exclusion of organic pathology through thorough history and targeted investigations is essential
Presence of anxiety symptoms further supports the diagnosis of FAP with a strong psychosomatic link.
Diagnostic Approach
History Taking:
A detailed history should focus on pain characteristics (location, duration, frequency, triggers, alleviating factors)
Inquire about associated gastrointestinal symptoms, bowel habits, diet, and any patterns related to school or emotional stressors
Crucially, assess for symptoms of anxiety and mood disorders, including family history of anxiety, depression, or functional disorders
Red flags to identify include weight loss, persistent vomiting, nocturnal symptoms waking the child, fever, blood in stool or vomit, family history of gastrointestinal malignancy, and recent onset of symptoms after age 6.
Physical Examination:
Perform a comprehensive physical examination, paying attention to abdominal tenderness (localized vs
diffuse), masses, organomegaly, and signs of dehydration
Assess growth parameters (height, weight, BMI) to rule out failure to thrive
Observe the child's general appearance, behavior, and signs of distress or anxiety
A thorough neurological and general systemic examination may also be warranted to rule out other potential etiologies.
Investigations:
Investigations are primarily aimed at excluding organic pathology
A complete blood count (CBC) to check for anemia or infection
Erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) for inflammation
Stool studies for occult blood, ova, and parasites
Urinalysis to rule out urinary tract infections
Depending on the clinical suspicion, further tests might include abdominal ultrasound, celiac serology (anti-TTG IgA), and if red flags are present, endoscopy or other imaging
For anxiety, no specific lab tests are needed
diagnosis is clinical.
Differential Diagnosis:
Differential diagnoses include organic causes such as inflammatory bowel disease (Crohn's disease, ulcerative colitis), peptic ulcer disease, celiac disease, lactose intolerance, parasitic infections, urinary tract infections, appendicitis, and rare abdominal malignancies
Functional disorders like Irritable Bowel Syndrome (IBS), functional dyspepsia, and functional constipation can overlap, but the diagnosis of FAP with anxiety is made when a clear organic cause is absent and psychological factors are prominent.
Management
Initial Management:
The cornerstone of management is reassurance and education for both the child and parents
Emphasize that the pain is real but not due to a serious organic disease
Develop a collaborative treatment plan
Re-establish normal routines, including school attendance and physical activity, as much as possible
Avoid unnecessary investigations and treatments.
Medical Management:
While there are no specific medications for FAP itself, treatment focuses on symptom management and addressing the anxiety component
For constipation, consider osmotic laxatives like polyethylene glycol (PEG) with doses adjusted based on response
For pain, short-term, low-dose tricyclic antidepressants (TCAs) like amitriptyline or nortriptyline (e.g., 0.25-0.5 mg/kg/day, slowly titrated up) can be effective due to their analgesic and anxiolytic properties
Selective serotonin reuptake inhibitors (SSRIs) may be used for significant anxiety or comorbid depression, with careful monitoring.
Psychological Therapies:
Cognitive Behavioral Therapy (CBT) is highly effective in managing FAP with anxiety
It helps children develop coping mechanisms, reframe negative thoughts about pain, and manage anxiety
Other therapies include relaxation techniques, mindfulness, biofeedback, and family therapy to address family dynamics that may exacerbate stress
A multidisciplinary approach involving pediatricians, gastroenterologists, child psychologists, and psychiatrists is often ideal.
Lifestyle Modifications:
Encourage regular physical activity and exercise, which can help reduce stress and improve mood
Promote healthy dietary habits, ensuring adequate fiber intake to prevent constipation
Advise against restrictive diets unless specific intolerances are proven
Ensure adequate sleep hygiene
Education on stress management techniques and identifying emotional triggers is vital.
Complications
Early Complications:
School absenteeism and academic decline
Social withdrawal and isolation
Increased reliance on healthcare services for recurrent consultations and investigations
Development of avoidance behaviors related to activities that trigger pain or anxiety.
Late Complications:
Development of chronic pain syndromes in adulthood
Increased risk of developing other functional gastrointestinal disorders (FGIDs) or anxiety disorders
Potential for depression and impaired quality of life into adulthood
Healthcare utilization costs may remain high if not managed effectively.
Prevention Strategies:
Early and accurate diagnosis
Prompt initiation of an integrated, multidisciplinary treatment plan
Thorough patient and family education
Empowering children with coping strategies
Addressing parental anxiety and enabling supportive parenting
Regular follow-up to monitor progress and adjust management.
Prognosis
Factors Affecting Prognosis:
Early diagnosis and intervention
Positive family support
Effective management of anxiety
Child's engagement in therapy and coping strategies
Presence of comorbid conditions (e.g., depression) can affect prognosis.
Outcomes:
With appropriate integrated treatment, most children experience significant improvement in pain frequency and intensity, reduction in anxiety symptoms, improved school attendance, and enhanced quality of life
Complete remission is achievable for many, though some may experience intermittent symptoms
Long-term follow-up is essential.
Follow Up:
Regular follow-up appointments with the primary pediatrician and/or a specialist (gastroenterologist, psychologist) are crucial
Frequency depends on severity and response to treatment, ranging from monthly to quarterly
Monitoring for symptom recurrence, treatment adherence, and psychological well-being is key
Transition of care to adult services should be planned when appropriate.
Key Points
Exam Focus:
Remember Rome IV criteria for FAP-FGIDs
Key differentials include organic causes and other functional disorders
Integrated management requires addressing both pain and anxiety
TCAs and CBT are mainstays of treatment
Red flags necessitate urgent investigation
High prevalence in pediatric practice.
Clinical Pearls:
Believe the child's pain is real, but the cause may be functional
Build rapport and a trusting relationship
Educate parents about the mind-gut connection
Gradual reintroduction to school and activities is vital
Consider low-dose TCAs for pain and anxiety, starting low and titrating slowly
Collaborate with mental health professionals.
Common Mistakes:
Over-investigating without clear indications, leading to iatrogenic anxiety and increased costs
Dismissing symptoms as "all in the head." Inadequate management of the anxiety component
Failing to involve parents or family in the treatment plan
Not establishing clear follow-up protocols.