Medical Overview and Epidemiology

Chronic abdominal pain is one of the most common physical symptoms in childhood, affecting approximately 10% of children and adolescents (Chitkara et al. 2005) and being the reason for presentation in approximately 2%-4% of general pediatric office visits (Starfield et al. 1980). The prevalence peaks between ages 4 and 6 years and again in early adolescence, with an equal gender ratio in early child hood and greater female symptom reporting in adolescence. Most children with chronic or recurrent abdominal pain, probably over 90%, do not suffer from explanatory physical disease, such as peptic ulcer or Crohn's disease (American Academy of Pediatrics Subcommittee on Chronic Abdominal Pain 2005), and are considered to suffer generically from functional abdominal pain (FAP). Traditional physical disease, with demonstrable structural, infectious, inflammatory, or biochemical findings, is especially unusual in the absence of red flags such as weight loss, gastrointestinal bleeding, fever, anemia, or persistent vomiting. Helicobacter pylori infection and celiac disease are not etiological in most cases, and despite suspicions about food allergies, lack of dietary fiber, and lactose malabsorption, results of dietary intervention such as fiber supplementation and lactose-free diets have been disappointing (Huertas-Ceballos et al. 2008a).

A common clinical presentation of FAP involves a child whose abdominal pain began with an apparent bout of gastroenteritis or other inflammatory process but then persisted following the apparent resolution of gut inflammation. Prior gut inflammation may be one pathway to the heightened gut sensitivity (i.e., visceral hypersensitivity) often observed in youth with FAP, perhaps lowering the threshold for particular sensations to be experienced as painful or distressing; the mechanism may involve the neurotrans-mitter serotonin, which is distributed throughout the gut and the central nervous system (Spiller 2007).

A detailed discussion of the medical assessment of chronic abdominal pain is beyond the scope of this chapter, but some basic principles warrant attention. Assessment should be individualized and should ideally incorporate multiple sources of information beyond the patient, including parents, other professionals, teachers, and school nurses. The presence of red flags that may signal undiagnosed physical disease (e.g., evidence of gastrointestinal bleeding, persistent vomiting, weight loss, fever, other signs of systemic illness) should prompt the clinician to consider additional medical assessment.

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