What Is Meant By Chronic Abdominal Pain
When pain in the abdomen has been present for a period of three months or more, it is termed as chronic abdominal pain. The pain may be almost continuous or it may be intermittent. It is more frequently encountered in children between the ages five to sixteen and most often in 8-12 year olds. It is more common in girls and women compared to boys and men respectively. Incidence is found to be10 to 15% in children of susceptible age and 2% in adults.
Depending on the underlying condition, several other symptoms may be present along with chronic abdominal pain.
Causes Of Chronic abdominal Pain
The causes of abdominal pain may have been investigated from the time it appeared and appropriate treatments initiated. However, if no particular reason could be identified in spite of tests, the condition is classified as functional abdominal pain. Around 90% of patients having chronic abdominal pain is found to be having functional pain.
When there are no specific disorders such as peptic ulcer present, and if the pain is not due to particular situations such as bowel movements, gas formation after meals or menstrual cramps, it is probably a functional pain. The exact cause of functional pain is not known but it is assumed that the oversensitivity of the nerves of the abdominal tract to normal motions of the stomach and intestines is the reason. Emotional and physical stresses, mental problems, genetic predisposition are all factors known to trigger or worsen functional abdominal pain. Children going through stressful situations such as starting or changing school, birth of a sibling, separation of parents, moving houses etc., may develop chronic abdominal pain which is considered as a need for extra attention. Child abuse in the family or outside may trigger chronic abdominal pain. Functional pain is as real as any other pain and it may be often quite severe.
The other causes of chronic abdominal pain may differ depending on the age of the patient.
In children, the usual causes are gastro esophageal reflux, constipation and an allergic reaction to the lactose sugar in milk, called lactose intolerance.
In younger adults, any of the following may cause chronic abdominal pain.
- Disorders of the stomach such as peptic ulcer, dyspepsia etc.
- Allergic reactions to certain drugs including NSAIDs and aspirin and food and food additives such as MSG.
- Disorders of the liver including hepatitis.
- Cholecystitis or other disorders of the gall bladder.
- Pancreatitis or other pancreatic problems.
- Crohn’s disease and other inflammatory bowel diseases or irritable bowel syndrome.
- Infestations of parasites and infections by microorganisms such as amoebiasis and giardiasis
In older adults, chronic pain may be due o the development of cancer of the pancreas or stomach. Ovarian cysts, fibroids, uterine and colon cancers also may cause chronic pain.
Evaluation
Since chronic stomach pain is common and it may occur due to minor causes or even no identifiable cause, it is advisable to self evaluate the condition before seeking medical help. Some of the causes may progress to life threatening conditions which require immediate medical help. The following list of warning signs may help in seeking timely medical care.
Warning signs: these are additional symptoms to watch out for:-
- Presence of diarrhea, nausea and vomiting
- Traces of blood found in urine, stool or vomiting blood.
- High temperature or continuous low grade fever.
- Problems with swallowing food.
- Recent weight loss for no apparent reason.
- Severe pain which disturbs sleep at night.
- Signs of jaundice like yellowing of eyes and nails.
- Swollen abdomen with or without swelling in the legs.
- Lack of appetite.
When any of the above additional symptoms, except the last two, appear in people who have chronic abdominal pain, immediate medical attention should be sought. Those who have lack of appetite and swelling of abdomen or legs should also consult a doctor, but in a few days time. When chronic abdominal pain is accompanied by additional symptoms, the chance of it being functional pain is very slim. Hence it is always advisable to get the advice of a doctor and undergo the required tests to rule out serious complications.
Diagnosis and Treatment
Physical examination of the abdominal region is done to check for specific areas of tenderness or pain and to detect enlargement of organs or presence of masses. Rectal examination and pelvic examination for women are done to check for anorectal fissures, abscesses, hemorrhoids and bleeding from rectum or vagina. Signs of jaundice and presence of swellings or rashes are also examined.
Medical history is also very important in reaching a diagnosis. Doctor may particularly ask questions regarding the eating habits and bowel habits of the patient, to see if any connection exists between those and the abdominal pain. If pain is associated with the intake of dairy products, there is a high probability of lactose intolerance which is an allergic reaction to the lactose sugar in the milk. It is very common among blacks. Details of the drugs used regularly as well as any drugs used recently are noted as well as any abdominal surgery undergone by the patient. Family history of abdominal disorders is also taken into account. Presence of other symptoms such as diarrhea, constipation and blood in urine, stool or in the vomit may point to specific causes which can be investigated further. The aim of preliminary examination is not only to detect the cause of the condition but also to determine the diagnostic tests which may be required.
Doctors often ask the patients to keep a record of bowel movements, different types of food eaten and any relation perceived between those and the occurrence pain in the abdomen. Any particular activity or drug triggering the pain should also be recorded. Any remedy which had brought relief also can be included.
Testing: General tests to check for infections and inflammations include blood test with ESR, urinalysis and stool tests. Depending on the impressions got from physical examination, doctor may prescribe other diagnostic tests such as ultrasound or other imaging tests. CT scan of the abdomen and colonoscopy may also be done for older adults. When any abnormality is found in the tests, further testing is done to pinpoint the exact cause.
Treatment
Once the cause of the chronic abdominal pain is established through physical examination and tests, treatment is initiated to resolve the issue. If constipation is found to be the cause, a diet rich in fiber may help. Laxatives or stool softeners may be given to make the movements easier. People detected to be having lactose intolerance are advised to avoid dairy products.
Functional pain: Since the cause of the functional pain cannot be determined; treatment to cure the condition is also not available. However, various measures can be taken to help the patient take control of the situation using relaxation techniques and mild pain killers such as acetaminophen, when necessary. Patients are reassured that they are not in any physical danger due to their condition and that they can indulge in any normal physical activity without fear of harm. In fact, patients should be encouraged to be active, especially children who may be reluctant to take part in school activities due to the pain.
After a number of tests have clearly established the absence of any disorder, further testing may be unnecessary, but doctors encourage patients to visit the clinic at regular intervals. Continuous monitoring will reassure the patient and will have a positive psychological effect. Trust and rapport between the doctor and the patient is a very important in successful management of the condition. It may have to be explained to the family members of the patient that even though functional pain can be aggravated by emotional stress and it may have a psychosomatic factor in it, the pain is real and not imagined. And often it is as severe as any other abdominal pain which may be caused by a definite disorder.
Certain drugs which prevent muscle spasms are found to be effective in reducing functional pain. They are called antispasmodic drugs. Antihistamines and drugs that reduce the production of stomach acids have also been tried with some success. Peppermint oil is also helpful. People with anxiety problems may benefit from antidepressants. Several relaxation techniques and self-help measures such as yoga, hypnosis and biofeedback are helpful in managing the pain. A diet rich in fiber or taking supplemental fiber also may be helpful.
Children need the help and support from the doctors as well as the members of the family. The focus should be on helping the child lead a normal, independent life, in spite of the painful condition. Their pain should be treated as real and not imagined, but at the same time, too much attention and sympathy should be avoided. The child should be encouraged to attend school and take part in all physical activities. When the child has an episode in the school, help should be available at the nurse’s office. A short period of rest or a dose of acetaminophen should help the child to return to normal activities. If the child is allowed to call the parents, they should speak to the child over the phone and reassure him and encourage him to stay in school. The child should be rewarded for responsible behavior and independence shown. The child who has functional abdominal pain may need extra attention to sort out his/her stressful situations in life. The required extra attention should definitely be given to the child, but not because the child has stomach pain. Spending quality time with the child and taking him out or enrolling him in extracurricular activities may help remove the focus from stomach pain. More often than not, the functional pain may resolve by itself after a while.
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Yasser Elnahas
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Acute abdomen can be defined as severe, persistent abdominal pain of sudden onset that is likely to require surgical intervention to treat its cause. The pain may frequently be associated with nausea and vomiting, abdominal distention, fever and signs of shock. One of the most common conditions associated with acute abdominal pain is acute appendicitis.