Chronic abdominal pain is pain that is present for more than 3 months. It may be present all the time (chronic) or come and go (recurring). Chronic abdominal pain usually occurs in children beginning after age 5 years. 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. Chronic abdominal pain is also common among adults, affecting women more often than men.
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 ( see Acute 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 ( see Table: Physical Causes and Features of Chronic Abdominal Pain). The remaining 90% have what is called centrally mediated abdominal pain syndrome (previously known as functional abdominal pain).
Centrally mediated abdominal pain syndrome causes real pain that exists for more than 6 months and occurs with no evidence of a specific physical disorder or other gastrointestinal problem (for example, peptic ulcer disease). It is also not related to a drug or a toxin and does not alter bowel habits (such as constipation or diarrhea). When abdominal pain occurs in people who have altered bowel habits, it is called irritable bowel syndrome (IBS). The 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 and brain-gut axis 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 the 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 ( see Table: Physical Causes and Features of 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)
In young adults, common causes include
Liver disorders, such as hepatitis
Gallbladder disorders, such as cholecystitis
Parasitic infections, such as giardiasis
Inflammatory bowel disease, such as Crohn disease
In older adults, cancer (such as stomach, pancreatic, colon, or ovarian cancer) becomes more common.
Evaluation
Doctors first focus on whether the pain is functional pain or is caused by a disorder, drug, or toxin. 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 awakens the person during the night
Blood in vomit, stool, or urine
Severe or frequent vomiting or diarrhea
Jaundice (yellowing of the skin and whites of the eyes)
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 see a doctor right away unless the only warning signs are loss of appetite, jaundice, and/or swelling. People with loss of appetite, jaundice, and/or swelling or with steady, worsening pain should see a doctor within a few days. When 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 ( see Table: Physical Causes and Features of Chronic Abdominal Pain).
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 Black, Hispanic, Asian (particularly East Asian countries), and American Indian people. Doctors also ask about other symptoms (such as vomiting, diarrhea, 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 also 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
Usually, doctors do certain tests. These tests include urinalysis, a complete blood cell count, and blood tests to evaluate how the liver, kidneys, and pancreas are functioning. Usually if people are over 50 or have risk factors for colon cancer (such as a family history of the disease), 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 ( see Table: Physical Causes and Features of Chronic Abdominal Pain).
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 of abdominal pain depends on the cause and the symptoms. 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 fiber to the diet can help.
Functional abdominal pain
Treatment of functional pain depends on the symptoms and is focused 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, 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, usually does not have a serious cause and that emotional factors (for example, stress, anxiety, depression) may trigger or worsen an episode of pain. 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 and understanding 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. 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.
Changing the diet and consuming a high-fiber diet or fiber supplements helps some people. People may need to avoid foods that trigger their pain. For example, some people should avoid eating large amounts of foods that are difficult to digest and produce a lot of gas and avoid drinks that are high in sugar.
Many drugs have been tried with varying success. They include drugs that reduce or stop muscle spasms in the digestive tract (antispasmodics) and peppermint oil.
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 or depressed and this seems to be related to the pain, doctors may prescribe antidepressants or drugs to reduce anxiety. Therapies that help people modify their behavior, such as relaxation training, biofeedback, and hypnosis, may also help reduce anxiety and help people better tolerate their pain.
For children, help from parents is essential. Parents are advised to encourage the child to become independent and to fulfill the child’s normal responsibilities, particularly attending school. Allowing the child to avoid activities may actually increase the child’s anxiety. Parents can help the child manage pain during daily activities by praising and rewarding the child’s independent and responsible behaviors. For example, parents could reward the child by scheduling special time with the child or a special outing. Involving school personnel can help. Arrangements can be made to let the child rest briefly in the nurse's office during the school day, then return to class after 15 to 30 minutes. The nurse can sometimes allow the child to call a parent, who should encourage the child to stay in school.
Key Points
Usually, chronic or recurring abdominal pain is centrally mediated (that is, people have pain but no specific physical disorder and no other gastrointestinal problem).
Symptoms that require a doctor’s immediate attention include a high fever, loss of appetite or weight, pain that awakens the person, blood in stool or urine, jaundice, severe nausea and vomiting, difficulty swallowing, and swelling of the legs and/or abdomen.
Blood and urine tests are usually done to check for disorders that may cause the pain.
Additional tests are needed only if people have abnormal test results, warning signs, or symptoms of a specific disorder.
For centrally mediated pain, treatment involves learning to minimize stress or anxiety, participating in normal daily activities, a trial of fiber supplements and/or high-fiber foods, drugs that reduce or stop muscle spasms in the digestive tract, and sometimes taking drugs or using behavioral modification therapies to relieve anxiety, and/or altering the diet.
