Chronic abdominal pain in children is defined as any type of pain localized to the abdomen of at least 2 months duration that inhibits normal activity. It is one of the most common presenting complaints to pediatricians. Up to 17% of high school students experience weekly abdominal pain, and chronic abdominal pain accounts for approximately 4% of pediatric office visits.1 The vast majority of these children have functional abdominal pain that, while debilitating, cannot be explained by a clear pathophysiologic mechanism. A minority of patients complaining of chronic abdominal pain has a chronic illness, typically of an infectious, inflammatory, anatomic, or biochemical etiology. These conditions, which will be the focus of this chapter, are often treatable and occasionally curable.
While the differential diagnosis of chronic abdominal pain is broad, a fairly simple approach can be utilized to help determine the etiology of the pain. The first decision point, as depicted in Figure 7–1, concerns the location of the pain. If the patient defines the location, the differential diagnosis becomes more focused, and the etiology is often discernable from organs in the vicinity of the pain. In general, location alone does not allow for clear differentiation of infectious from noninfectious causes. If the patient cannot define the location, either because the pain is diffuse or the patient is too young or is nonverbal, the clinician must rely on other symptoms to identify the problem. This approach is detailed more fully below.
Differential diagnosis of chronic abdominal pain. Letters W, J and F refer to accompanying symptoms.
Pain emanating from the right upper quadrant usually originates from the liver and/or biliary tree. Occasionally, right upper quadrant pain is caused by diseases of the stomach, duodenum, or colon (Figure 7–1). Phrenic pain may also present as right upper quadrant pain.
Pain originating from the liver itself is because of stretching of the liver capsule, as that is the only part of the liver innervated with pain fibers. Thus, liver pain occurs when the liver becomes swollen, such as after trauma or during episodes of severe inflammation and edema. This is not likely to cause chronic abdominal pain, but chronic hepatitis may have periods of more severe inflammation, during which the liver may become edematous, causing the capsule to stretch. A more detailed discussion of hepatitis is found elsewhere in this textbook. Perihepatitis, or inflammation of the capsule itself, will lead to right upper quadrant pain. This is occasionally a component of pelvic inflammatory disease (see Chapter 43).
Cholelithiasis refers to the presence of symptomatic gallstones and may present as intermittent severe right upper quadrant pain, or as milder pain following meals. Most children with cholelithiasis have underlying hemolytic disorders such as sickle cell disease, or have a prolonged history ...