Chapter 1

Abdominal pain is a common complaint in pediatric population, often resulting in unscheduled office or emergency room visits. This symptom can be acute, recurrent, or chronic.

Acute abdominal pain generally refers to pain that has been present for <24 hours. When the presentation is acute, the challenge for the evaluating physician is to differentiate potentially life-threatening and serious medical conditions from benign self-limited ones. The frequency of surgical intervention in patients presenting with acute abdominal pain is around 1%,1 but the possibility of overlooking a serious organic etiology is a cause of concern to evaluating physicians and families.

Children are considered to have recurrent or chronic abdominal pain if they have experienced at least three bouts of abdominal pain, severe enough to affect activities, over a period of at least 3 months. Though this definition was initially used by Apley and Nash2 as the entry criteria for their descriptive study, it later became a term to describe all children with abdominal pain without known organic etiology. Recurrent abdominal pain (RAP) should be used as a description rather than as a diagnosis. RAP may occur in functional abdominal pain (FAP; see below), but this pattern of discomfort can also occur with organic disease.3Functional gastrointestinal disorders (FGID) include a combination of chronic and/or recurrent symptoms not explained by known biochemical or structural abnormalities. According to Rome III criteria, symptoms must occur at least once per week for at least 2 months before making a diagnosis of FGID.4 In a study of 227 patients with recurrent and chronic abdominal pain, only 76 (33%) were found to have well-defined organic etiologies.5

Abdominal pain accounts for 2–4% of all pediatric office visits.6 In a study by Hyams et al., 13% of middle-school students and 17% of high-school students experienced weekly abdominal pain. In that study, approximately 8% students saw their physician for abdominal pain evaluation in the previous year.7 In Apley and Nash original study involving 1000 children in primary and secondary schools, 10.8% of children had RAP, with a female preponderance (female to male ratio of 1.3:1).2 In that survey, the age distribution was also examined. Ten to 12% of males aged 5–10 years had RAP, followed by decline in prevalence and a later peak at age 14 years. Females showed a sharp rise in prevalence after age 8 years and by age 9 years 25% of this group experienced RAP. The long-term outcome of patients with FGID is not known, but studies indicate patients with history of chronic abdominal pain that began in childhood and treated by a subspecialist are more likely to have lifelong psychiatric problems and migraine headaches.3 Genetic factors and early life events may have a role in the pathogenesis of chronic abdominal pain.

### Family History

There is a higher prevalence of alcoholism, psychiatric disorders, somatization disorders, migraine, and chronic pain symptoms among family members. Familial clustering is often seen in patients with FGID. Subjects with FGID, in a study by Locke et al., had an increased risk of reporting a first-degree relative with abdominal pain and/or bowel distrurbance.8 Possible explanations ...

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