Chronic abdominal pain

To chronic abdominal pain include abdominal pain, persisting for more than 3 months and proceeding as a permanent or intermittent pain syndrome. Intermittent pain can be considered as a recurrent pain in the abdomen. Chronic abdominal pain occurs after the age of 5 years. At 10% of children, there is a need to evaluate recurrent abdominal pain. Approximately 2% of adults, mostly women, have chronic abdominal pain.

Almost all patients with chronic abdominal pain have previously undergone examination, but despite a thorough medical history, a physical and complete examination of the diagnosis was not established. Perhaps 10% of these patients have an unidentified somatic disease, but many of them may have functional disorders. Confirmation of whether specific disorders (eg, adhesions, ovarian cyst, endometriosis) cause symptoms or an accidental finding can be quite complex.

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Causes and pathophysiology of chronic abdominal pain

The causes of chronic abdominal pain can be physical illness or functional disorders.

Functional abdominal pain syndrome (FABS) is characterized by abdominal pain that persists for more than 6 months without evidence of a physical illness, is not associated with physiological factors (eg, food intake, defecation, menstruation) and causes disability. Functional abdominal pain syndrome is poorly understood, but is probably associated with a change in pain sensitivity. Sensory neurons in the posterior horn of the spinal cord can become pathologically excitable or easily excitable from a combination of various factors. Emotional and psychological factors (eg depression, stress, cultural peculiarities, mechanisms of psychological adaptation and support) can cause efferent stimulation, which strengthens pain signals, leading to the perception of pain with a low pain threshold and the maintenance of the pain syndrome after the end of the stimulating effect. In addition, the pain itself can act as a stress factor, while maintaining a positive feedback.

[5], [6]

Diagnosis of chronic abdominal pain

Differential diagnosis between physiological and functional HAB can be quite difficult.

Anamnesis and physical examination. Pain caused by physiological causes is usually well localized, mainly by anatomical areas, except the periumbilical area. Pain can be irradiated in the back, the patient often wakes up. The results of the examination, indicating a high risk of somatic pathology, include anorexia; persistent or recurrent fever; jaundice; anemia; hematuria; general symptoms; edema; weight loss; blood in the stool; hematomesis; changes in palpation of the intestine, color or characteristic discharge; bloating, volumetric education, or hepatomegaly. Intermittent pain caused by structural changes, as a rule, manifests itself by specific signs or is associated with the nature and intake of food or defecation.

Functional chronic abdominal pain can be similar to the pain of somatic origin. However, there are no common signs indicating high risk and psychosocial features. The appearance of symptoms during physical exertion or sexual abuse may suggest functional chronic abdominal pain. The key to the diagnosis may be the establishment of a history of psychological trauma, such as a divorce, spontaneous abortion or death of a family member. Patients often experience psychological disorders or personality changes that can affect interpersonal relationships at work, school, family, and social relationships. Pain is often the main feature of a patient's life, leading to a "pain cult". Characteristic is the presence in the family history of chronic somatic complaints or pains, peptic ulcer, headaches, "nerves" or depression.

Somatic causes of chronic abdominal pain

Causes	Diagnostics
Genitourinary disorders
Congenital disorders	Intravenous urography, ultrasound
Urinary tract infection	Bacteriological culture of urine
Inflammatory pelvic disease	X-ray and ultrasound examination of the pelvis, CT
Ovarian cyst, endometriosis	Consultation of a gynecologist
Gastrointestinal disorders
Hernia of the esophageal opening of the diaphragm	Study with barium
Hepatitis	Functional liver tests
Cholecystitis	Ultrasound
Pancreatitis	Levels of amylase and serum lipase, CT
Peptic Ulcer	Endoscopy, Helicobacter pylori test , occult blood stool study
Parasitic infestation (eg, lambliasis)	Study of a stool on eggs of worms or parasites
Meckel's diverticulum	Instrumental examination
Granulomatous enterocolitis	ESR, irrigography
Tuberculosis of the intestine	Tuberculin test
Ulcerative colitis	Sigmoscopy, rectal biopsy
Crohn's disease	Endoscopy, X-ray, biopsy of the large and small intestine
Postoperative adhesions	Consecutive investigation of the upper gastrointestinal tract, passage of barium through the intestine, irrigoscopy
Pancreatic pseudocyst	Ultrasound
Chronic appendicitis	X-ray examination of the abdominal cavity, ultrasound
Systemic disorders
Signs of intoxication	Blood test, levels of protoporphyrin erythrocytes
Purple Shenlaine-Genocha	Anamnesis, urinalysis
Sickle-cell anemia	Identification of cells, hemoglobin electrophoresis
Food allergy	Exclusion of food products
Abdominal Epilepsy	EEG
Porphyria	Porphyrins in the urine
Familial large thalassemia, familial angioneurotic edema, migraine equivalent	Family history

Children with functional chronic abdominal pain may experience underdevelopment, unusual dependence on parents, anxiety or depression, a sense of fear, tension and the doctrine of moral improvement. Often parents perceive the child inadequately because of family relationships (eg, an only child, the youngest child, only a boy or girl in the family) or because of a medical problem (eg, colic, eating problems). Parents are often too concerned about child protection.

Examination

In general, routine studies (including urinalysis, a general blood test, functional liver tests, ESR, amylase and lipase levels) should be performed. Changes in these tests or the presence of suspicious symptoms and signs require further investigation, even if the previous results of the study were negative. The use of specific studies depends on the data obtained previously, but usually CT scans of the abdominal cavity and pelvis with contrast, endoscopy of the upper gastrointestinal tract and colonoscopy and, if necessary, X-ray examination of the small intestine.

The informativeness of studies without the presence of pathognomonic symptoms and signs is extremely small. Thus, more than 50% of patients should undergo colonoscopy; less than 50% may be monitored or CT scans of the abdominal cavity and pelvis with contrasting should be performed if this study is appropriate. ERCP and laparoscopy are usually uninformative in the absence of specific symptoms.

In the interval between the initial examination and subsequent follow-up, the patient (or the family, if the patient is a child) should note the occurrence of any pain, including its nature, intensity, duration, and note the provoking and pain-intensifying factors. The nature of food, stool, as well as all the means taken (and the results obtained) should be fixed. This report may show a discrepancy between the form of behavior and the increased reaction to pain or, otherwise, assume a diagnosis. An individual survey is required as to whether milk or dairy products cause abdominal pain, flatulence, or bloating, since lactose intolerance is often seen, especially in black people.

[7], [8], [9], [10]

Prognosis and treatment of chronic abdominal pain

Somatic causes of pain are treatable. If a diagnosis of functional chronic abdominal pain is established, frequent examination and examination should be avoided, as the patient can constantly focus on this, which will lead to an increase in complaints or a suspicion of a doctor's uncertainty in the diagnosis.

Currently, there are no methods to cure functional chronic pain in the abdomen; however, there are many palliative measures. These activities are based on the element of trust, empathy of the doctor with the patient and family. The patient must be sure that he is not in danger; certain patient problems must be clarified and resolved. The doctor should explain the results of laboratory tests, the nature of the complaints and the mechanism of the appearance of pain, and also why the patient experiences pain (i.e., constitutional features of the perception of pain as a function of time and load). It is important to avoid the persistence of negative psychosocial consequences of chronic pain (eg, long absences of school or work, refusal of public activities) and promote the development of a sense of independence, participation in public life and self-reliance. This strategy helps the patient to control and not to take symptoms, fully participating in daily activities.

With the exception of the rare use of non-steroidal anti-inflammatory drugs and sometimes tricyclic antidepressants, other medications are ineffective. Opiates should be avoided because they invariably lead to addiction.

Cognitive methods (eg, relaxation training, biofeedback, hypnosis) can be effective, contributing to a patient's understanding of comfort and control. Subsequent regular follow-up visits should be conducted weekly, monthly or bi-monthly depending on the needs of the patient and should continue until the problem is resolved. You may need psychiatric help if symptoms persist, especially if the patient is depressed or if there are significant psychological problems in the family.

The school staff should be involved in solving the problem of the child with chronic abdominal pain. The child should be able to relax a little in the nurse's office during the school day with the expectation that he will return to class in 15-30 minutes. A school nurse may be authorized to prescribe a weak analgesic (eg, acetaminophen). A nurse can sometimes allow a child to call parents who must support a child remaining in school. However, in the case when parents do not consider their child as a patient, the symptoms may not weaken, but intensify.