Abdominal Pain, Chronic

Also known as recurring abdomincal pain

We have selected the following expert medical opinion based on its clarity, reliability and accuracy. Credits: Sourced from the MSD Manual, Consumer Version, authored by Norton J. Greenberger, MD (see below). Please refer to your own medical practitioner for a final perspective, assessment or evaluation.

Overview

Chronic abdominal pain is pain that is present for more than 3 months. It may be present all the time or come and go (recurring). About 10 to 15% of children aged 5 to 16 years, particularly those aged 8 to 12 years, have chronic or recurring abdominal pain. It is somewhat more common among girls. About 2% of adults, mainly women, have chronic abdominal pain.

People with chronic abdominal pain may also have other symptoms, depending on the cause.

Causes

Usually by the time abdominal pain has been present for 3 months or more, people have been evaluated by a doctor, and typical disorders that cause abdominal pain have already been identified. If people have been evaluated and the cause has not been identified by this time, only about 10% of them have a specific physical disorder. The remaining 90% have what is called functional abdominal pain.

Functional pain is real pain that exists for more than 6 months and occurs with no evidence of a specific physical disorder (such as peptic ulcer disease). It is also not related to body functions (such as menstrual periods, bowel movements, or eating), a drug, or a toxin. Functional pain can be severe and typically interferes with the person's life. Exactly what causes the pain is unknown. But the nerves of the digestive tract may become oversensitive to sensations (such as normal movements of the digestive tract), which do not bother most people. Genetic factors, life stresses, personality, social situations, and underlying mental disorders (such as depression or anxiety) may all contribute to functional pain. Chronic abdominal pain in children may be related to a need for attention (as when a sibling is born or the family moves), the stress of starting school, lactose intolerance, or sometimes child abuse.

Common physical causes

Many physical disorders cause chronic abdominal pain. The most common causes vary by age.

In children, the most common causes are:                         

• Lactose intolerance (lactose is a sugar in dairy products)
• Constipation
• Gastroesophageal reflux disease

(See section on Abdominal Pain, Recurrent in Children)

 In young adults, common causes include:

• Indigestion (dyspepsia) due to peptic ulcer or drugs such as aspirin or nonsteroidal anti-inflammatory drugs (NSAIDs)
• Stomach irritation (caused by aspirin or NSAIDs, acidic beverages, and spicy foods)
• Liver disorders, such as hepatitis
• Gallbladder disorders, such as cholecystitis
• Pancreatic disorders, such as pancreatitis
• Parasitic infections, such as giardiasis
• Inflammatory bowel disease, such as Crohn disease
• Irritable bowel syndrome

 In older adults,

• Cancer (such as stomach, pancreatic, colon, or ovarian cancer) becomes more common
• Irritable bowel syndrome, inflammatory bowel disease, and endometriosis (Menopause increases abdominal symptoms in women who have these disorders)

Evaluation

Doctors first focus on whether the pain is functional or has a physical cause. Making this distinction may be difficult. However, if warning signs are present, functional pain is unlikely (but not impossible).

Warning signs

The following symptoms are cause for concern:

• Fever
• Loss of appetite and weight
• Pain that wakes the person during the night
• Blood in vomit, stool, or urine
• Severe or frequent vomiting or diarrhoea
• Jaundice
• Swelling of the abdomen and/or legs
• Difficulty swallowing

When to see a doctor

If people with chronic abdominal pain develop warning signs, they should usually see a doctor as soon as possible. When these warning signs are present, a physical cause is very likely. People without warning signs should see a doctor at some point, but a delay of a few days or so is not harmful.

What the doctor does

Doctors first ask questions about the person's symptoms and medical history. Doctors then do a physical examination. What they find during the history and physical examination often suggests a cause of the pain and the tests that may need to be done.

Doctors ask particularly about activities (such as eating, urinating, or having a bowel movement) that relieve or worsen the pain. Whether the pain or other digestive upset occurs after eating or drinking dairy products is important because lactose intolerance is common, especially among blacks. Doctors also ask about other symptoms (such as vomiting, diarrhoea, or constipation), about diet, and about any surgery involving the abdomen, drugs used, and previous tests and treatments for the pain. Whether any family members have disorders that cause abdominal pain is also important.

The physical examination focuses particularly on the abdomen to identify any tender areas, masses, or enlarged organs. Usually, a rectal examination is done, and the doctor tests the stool for blood. A pelvic examination is done in women. Doctors note whether the skin looks yellow (jaundice) and whether people have a rash or swelling in the legs.

Between the initial visit and follow-up visits, people are often asked to record information about the pain, bowel movements, diet, any activities that seem to trigger pain, any remedies tried, and the effects of the remedies.

Testing

Doctors may feel that it is necessary to do certain tests. These tests include urinalysis, a complete blood cell count, blood tests to evaluate how the liver and pancreas are functioning, and a blood test to measure the erythrocyte sedimentation rate (ESR). The ESR is a general test to check for inflammation somewhere in the body. Usually if people are over 50, a colonoscopy is also recommended. Some doctors recommend computed tomography (CT) of the abdomen if people are under 50, but other doctors wait for specific symptoms to develop. Other tests are done depending on results of the history and physical examination.

Additional tests are done if any test results are abnormal, if people develop new symptoms, or if new abnormalities are detected during the examination.

Treatment

Treatment depends on the cause. For example, if people have lactose intolerance, a lactose-free diet (eliminating milk and other dairy products) can help. If people are constipated, using a laxative for a few days plus adding fibre to the diet can help.

Functional pain

Treatment focuses on helping people return to normal daily activities and lessening the discomfort. Usually, treatment involves a combination of strategies. Several visits to the doctor may be needed to develop the best combination. Doctors often arrange follow-up visits every week, month, or 2 months, depending on people's needs. Visits are continued until well after the problem has resolved.

After functional pain is diagnosed, doctors emphasize that the pain, although real, does not have a serious cause and that stress and other psychologic factors can affect the body. Doctors try to avoid repeating tests after thorough testing has failed to show a physical cause of the symptoms.

Although there are no treatments to cure functional chronic abdominal pain, many helpful measures are available. These measures depend on a trusting, empathic relationship between the doctor, person, and person's family members. Doctors explain how the laboratory and other test results show that the person is not in danger. The doctor also explains how functional abdominal pain develops and how people perceive it. For example, they tend to feel pain when they are under stress. Doctors encourage people to participate in work, school, and social activities. Such participation does not worsen the condition but instead encourages independence and self-reliance. People who withdraw from their daily activities risk having their symptoms control their life rather than having their life control their symptoms.

Doctors recommend acetaminophen or other mild pain relievers to relieve the pain. A high-fibre diet and fibre supplements can also help. Many drugs have been tried with varying success. They include drugs that reduce or stop muscle spasms in the digestive tract (antispasmodics), peppermint oil, cyproheptadine (an antihistamine), and drugs that suppress acid production in the stomach.

Sources of stress or anxiety are minimized as much as possible. Parents and other family members should avoid reinforcing the pain by giving it too much attention. If people continue to feel anxious, doctors may prescribe antidepressants or drugs to reduce anxiety. Therapies that help people modify their behaviour, such as relaxation training, biofeedback, and hypnosis, may also help reduce anxiety and help people better tolerate their pain.

About the author

Norton J. Greenberger, MD

Clinical Professor of Medicine, Harvard Medical School.

Senior Physician, Brigham and Women's Hospital.

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