THE SUBACUTE,CHRONIC AND RECURENT ABDOMINAL PAIN



THE SUBACUTE, CHRONIC AND RECURENT ABDOMINAL PAIN

The abdominal pain is one of the most frequently encountered symptoms in suckling and children. It is often hard to evaluate because its causes are extremely variable.

In suckling, crying usually suggests hunger. If crying continues after feeding pain is to be considered.

About 10% of the schoolchildren experience recurent abdominal pain, although only 10% of this children have organic lesions. The "so" called, "functional" abdominal pain, a frequent finding in preadolescent youth, is a reality for the patient whatever the cause may be.

Phisiopatho1ogy:

Generally speaking, the pain is the response to a stimulus that's harmful for the body. Its utility results in the fact that it signals to the cortex the changes that such stimuli determine.

The internal organs have highly specialized receptors for: pain (algoreceptors), temperature (thermoreceptors), pressure (baroreceptors) and chemical composition of the body fluids (chomoreceptors).

There are two types of nervous fibres inside the abdomen:

-the A fibres from the skin and the abdominal wall muscles, that transmit acute and well localized pain;

-the C fibres from the perithoneum, abdominal organs and inner muscles that transmit low intensity and diffuse pain.

The main mechanisms for the abdominal pain are :

1 )The elongation of the mesentery

2)Variations of the blood flow. A low blood flow leads to ischemia,

hypotony and acid accumulation ( thromboses, volvulation, invagination,

strangulated hernia).

3)Prolonged and intense muscular contraction- explaines the pain that occurs in case of ulcer, renal colic, biliary duct colic and hunger.

4)Wall distension of the stomach, intestines and gall-bladder associates vomiting, nausea, low blood pressure, palpitations, increased heart rate and subjective sensation of not getting enough air.

5)Inflamation of any organ or perithoneum tissue increases the sensitivity of the algoreceptors.

6)Capsule distension :acute hepatosplenomegaly.

The visceral abdominal pain(AP) tends to localize along the middle line of the abdomen, so that stimuli from liver, pancreas, stomach and upper small intestine are felt as epigastric pain, stimuli from the end of the small intestine, caecum, apendix and the ascendent part of the large intestine are felt as periumbilicus pain and stimuli from the rest of the large intestine, urinary tract and pelvic organs are felt as suprapubic pain. When the stimulus is very intense the pain may extend to the aria whose sensitivity is conduced by the same spinal nerve.

The recurent AP is one of the most frequent symptoms that determine medical examination. There are three reasons that make the diagnosis difficult :

l)The high diversity of the diseases that may determine recurent AP

2)The organic and stress determined AP may occur simultaneously for example the stress determined gastric ulcerus.

3)The small child is unable to describe and localize the pain. The pain that has no organic cause is usually diffuse, changes place frequently and has strange spread areas. The connection with a stress situation and the fact that the pain never disturbs the sleep suggest emotional pain.

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No abdominal distension or muscle contraction are found through palpation. Some authors situate this kind of pain between 4 and 13 years of age, others between 8 and 15 years old. Between the ages of 3 and 5 the AP is more likely to have organic causes.

In order to find out the cause a complete examination will be performed :

The inquiery :

l)The age of onset, the frequency of pain (daily, weekly, monthly)

2)The localisation : usually diffuse in young children. The most frequent areas are around the umbilicus and in the epigastrum.

3)The iradiation

4)The evolution :short, prolonged or persistent with paroxism. It may end suddenly or slowly.

5)Τhe character :

a)Burning : determined by the irritation of the digestive mucosae in case of oesophageal reflux and excesive gastric acidity;

b)Tension : excesive gas or incomplete evacuation of the stomach, small and large intestines ;

c)Colics :paroxistic pain due to smooth muscles spastic contraction

d)Penetrating pain :whenever the perithoneum is involved : perforation of acute ulcer, acute pancreatitis

6)The rate ( permanent, recurent ) and the situation that is followed by AP ( meals, phisical activity, defecation and spontaneous )

7)Associated symptoms :

-general : fever, headache, paleness, migraine ;

-digestive : anorexia, nausea, vomiting, bitter taste, flatulence, diarrhoea, constipation ;

-urinary :amount, frequency, character, urine aspect ;

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8)Social data : quarrels, lack of affection, compulsion towards eating, school dependent pain ;

9)Family histοry : the same symptom during childhood, migraine and ulcer.

THE CLINICAL EXAMINATION

Inspection :

the volume of the abdomen (normal,distension,excavation)

the superficial vein aspects

the movements of the abdomen

scars due to surgery

Palpation :begins with the unaffected areas and slowly reaches the painful region. The palpation is performed very slowly, with warm hands, paying attention to the child's face and keeping the child's attention focused on something else. Are to be determined through palpation : the localisation, the tonus of the abdominal wall muscles, the size of the parenchimal organs : liver, spleen, kidneys, the presence of tumours and fake tumours :distension of the bladder, accumulation of worms, pregnancy. The palpation ends with the checking up of the herniation points plus rectal and genital exam.

Laboratory findings :

-haemoglobin levels, blood cell counting

-ESR

-transaminase levels

-blood urea

-complete urine examination

-coproparasitologic exam.

-Adler test for faeces

-barium X ray exam of stomach, duodenum and rectum

-urographic exam, sonography, CT scan , MRI

-EEG

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CLASIFICATION OF THE ABDOMINAL PAIN

Organic AP

Functional AP

Organic ΑP

I.Abdominal causes (organic, inflamatory, noninflamatory ) :

a) Stomach:

1)Air inside the stomach

2)Unproper diet (hard to digest food)

3)Ulcer-mostly of the duodenum,is a rare finding in children. The pain may be situated arround the umbilicus, epigastric or diffuse, it lasts for minutes to hours end occurs more often during nights than days. Milk provides with temporary relief but the pain becomes more intense after some time after meals. Positive Adler test. Gastroduodenal barium X ray exam and fibroscopic exam are diagnostic.

4)Zollinger-Sllison disease : high acidity levels in the gastric secretion, ulceration on the stomach, duodenum or small intestine. The disease has been reported in children over 7 years old.

b)Small and large intestine :

1)Duodenitis

2)Subacute and chronic apendicitis : pain occurs 4 to 5 hours after meals, being localized in the apendicular region and sometimes arround the umbilicus, in the right hipocondrium or in the epigastrum. It associates nausea, vomiting and colitis that show no answer to correct diet.

3)Terminal ileitis (Crohn's disease) -recurent strokes of AP, cramps, anorexia, vomiting, diarrhoea, fever and loss of weight. The symptoms may simulate apendicitis.

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4)Meckel diverticule: acute diverticulitis (similar to appendicitis ) or diverticular ulcerus (acute or prolonged intestinal haemorrhage )

5)Colitis and enterocolitis (Salmonella enteritis, disentery )

6)Ulerative colitis : abdominal pain, diarrhoea.

7) Intestinal tuberculosis

8)Aerocolia

9)Chronic constipation : may determine mild abdominal disconfort and even AP.

10)Malrotation of the small intestine : common mesentery, mobile caecum, volvulation of the sigmoid colone.

11)Megacolone.

12)Intestinal polipous disease ( rare cause for AP )

13)Intestinal tract duplications : intermitent AP, vomiting.

14)Subacute recurent bowel invagination

15)Intestinal tumours

16)Intestinal wall oedema (with no abdominal wall skin oedema)

17)Lactase deficiency (profuse watery diarrhoea)

18)Cystic fibrosis

19.Food allergy

c)Intestinal parasitic disease :

1)Giardiasis

2)Ascaridiasis

3)Oxiurosis : rare cause for apendicitis

4)Teniasis

d)Perithoneum disease

1)Primitive streptococal or pneumococal peritonitis ( rare nowadays) induces low intensity diffuse abdominal pain.

2)Perithoneum tuberculosis determines abdominal disconfort.

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3)Adherential developments after surgery

4)Common mesentery

5)Mesentery chists

6)Mesentery lymphadenitis -simulates apendicitis. In most of the cases the diagnose is established during surgery. The pain occurs during a rinopharingitis, tonsilitis or other infections disease (measles, scarlett fever, rubella, mononucleosis), although it may also be primitive. The pain is more diffuse and closer to the middle abdomen line, has an acute character and associates fever, paleness and flatulence. The abdominal palpation does not find any painful point or abdominal muscle contraction. The blood leukocyte levels are far more increased than the clinical findings would suggest. When the abdominal sensitivity remains stable apendicitis is excluded, otherwise exploratory laparotomy could be recomanded.

e)Liver and bile tract disease:

1)Viral epidemic hepatitis : may be cause for abdominal disconfort and right hipocondrium pain. In case of chronic hepatitis the pain is due to liver enlargement and abnormal biliary tract motility.

2)Angiocolitis and cholecystitis (biliary tract and gall bladder inflamation) are rare findings during childhood. Associates fever, painful hepatomegaly, mild jaundice and pain that extends to the right shoulder. Bile examination is recommended in such cases.

3)Liver tumours (benign, malignant ) may cause abdominal disconfort.

4)Chistic dilatation of the biliary tract and gall bladder : pain, jaundice and positive palpation of the right hipocondrium.

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5)Cholelithiasis determines recurent pain in the right hipocondrium, nausea, sensitivity during palpation and ocasionally jaundice. In children cholelitiasis can result from chronic haemolitic anaemia, Wilson disease, chistic fibrosis.

6)Erythrocyte sludgeing inside the sinusoid capilaries determined by sikle-cell anaemia crises: determine jaundice, hepatomegaly, abdominal pain, fever, increased alcaline phosphatas blood levels, high leukocyte levels.

7) Passive liver congestion in case of heart failure.

f)Pancreatic disease :

-chronic pancreatitis-recurent abdominal disconfort and ρain, greasy faeces, diabetes mellitus and pancreatic calcium deposits.

-chists and tumours of the pancreas

g)Spleen diseases:

-large sρlenomegaly-due to passive congestion in case of portal hypertension and to cell sequestration in case of blood disease, may determine abdominal disconfort in both situations.

-perisplenic tissue inflamation (perisplenitis)

h)Reno-urinary diseases :

-Urinary tract obstruction (UTO) with or without any UTI may case AP in the hypogastrum, lombar region and on the sides of the abdomen. Causes:

-urinary tract malformations

-lithiasis

-kidney tumours

-renal tuberculosis

i) Genital disease:

1) ovarian torsion, chist, tumour (right ovary tumour may be hard to be differenciated from apendicitis )

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2)rupture of an ovarian folicle during the ovulation determines

AP 2 weeks before menstruation (AP is a frequent finding during menstruations). 3)dysmenorrhoea determines lower abdomen and sacrum region pain, sometimes associating headache, nausea and vomiting.

4)haematocolpos in teenage girls may be cause for intermitent or permanent AP.

5)ovarian and uterine inflamation that acompanies the gonococal vulvo-vaginitis.

j)Abdominal and retroperitoneal tumours.

k)Mesentery vein trombosys and superior mesentery artery syndrome: constant or ocasional duodenum obstruction that causes AP,exagerated peristaltic movements, nausea, vomiting and growth retardation.

II.Abdominal wall disease :

-hernia of the middle abdomen line

-diaphragm hiatus hernias

-inguinal hernias

-haematomas

III.Extraabdominal diseases :

A.Pulmonary disease: pmeumonia: mostly of the right lobe with associated diaphragmatic pleuresia.

B.Heart disease :

-hepatomegaly due to congestive heart failure

-pericarditis may determine epigastric pain

-endocardum fibroelastosys -cause for intermitent AP in suckling.

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S and spinal chord disease :

-Abdominal epilepsy: AP may represent the aura. Sudden onset with epigastrum or periumbilicus pain that lasts for some minutes.

During the seizure a partial loss of conscience and state of confusion have been noticed. The EEG abnormalities are diagnostic.

-Cerebral tumours ( mostly in the posterior lobes) occasionally determine AP

-The abdominal migraine : vomiting and diffuse abdominal pain that associate no contraction of the abdominal wall muscles. Personal or family history of migraine with one sided headache, nausea and photophobia.

-Hysteria- 12-14 years old girls, spoiled by the family, pretend to experience AP in order to focus the attention on them.

D.Haematho1ogy :

-Acute haemolisis-in case of chronic hereditary haemolitic anaemia (microspherocitosis, drepanocitosis)

-Spleen thrombosys -left hypocondrium pain

-Leukaemia

-Hennoch-Schönlein disease : pain and digestive bleeding that occurs either before or after the skin lesions become manifest.

-The haemophily- may cause retroperithoneal haemorrhage.

-Acute infectious lymphocitisis

E.Metabolism disorders:

-Tetany: phosphorus and calcium metabolism disorder that leads to painful spastic contraction of the abdominal smooth muscles.

Calcium administration determines relaxation.

-Hypoglicemy: in case of pancreatic adenoma or exces of insulin may determine AP, cold sweating, headache, convulsions and coma.

-Diabetic acidosis.

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-Essential hyperlipidemia : violent AP that occurs after a high lipid meal. Low fat diet and heparine administration provide with relief.

-Phenilkaetonury -diffuse AP

-Addison disease: abdominal pain, vomiting and diarhoea

-Cyclic aketonaemic vomiting

F.Other causes:

-Acute rheumatic fever: diffuse or epigastric AP, fever, vomiting, high leukocyte levels.

-Diseases that determine high blood pressure (Polyarteritis nodosa, Pheocromocitoma, Aortic coarctation, Abnormalities of the renal arteries).

THE FUNCTIONAL ABDOMINAL PAIN

a) The abdominal colics of the suckling : occur in about 10% of the children and are considered as benign manifestations. They develop during the first three months of life and manifest through prolonged and violent crying that repeats daily or every night at the same hour. Holding the child provides with relief. These children seem to have a good general state of health and the appetite is normal. The only one gastro-intestinal symptom that can be found is the flatulence. After 9 to 12 weeks the crises disappear. Some authors recommend antispastic therapy.

b) The morning abdominal pain of the schoolchildren associate anxiety, headache, fatigue, sleeping disturbances and various unpleasant sensations. The onset is obviously connected to going to school, conflicts and emotional difficulties. Such diagnosis is established only after any other cause for AP has been thought and eliminated.

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