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Recurrent abdominal pain (RAP), as defined by Apley, consists of paroxysmal abdominal pain in children between the ages of 4 and 16 years that persists for more than 3 months and affects normal activity. RAP is not a diagnosis. It may be the predominant clinical manifestation of a large number of precisely defined organic disorders, but in the majority of cases, RAP is due to a functional bowel disorder. The modifier "functional" is used in
Epidemiology
RAP has been reported to occur in 10% to 15% of children between the ages of 4 and 16 years. At least as many children experience chronic pain but
Apley observed that males and females are affected equally in early childhood up until the age of 9, at which point the incidence decreases in males. The
Clinical Presentations
Children who have RAP tend to exhibit one of three clinical presentations: 1) isolated paroxysmal abdominal pain, 2) abdominal pain associated with symptoms of dyspepsia, and 3) abdominal pain associated with an altered bowel pattern. Symptoms of dyspepsia include: pain associated with eating; epigastric location of pain; and nausea, vomiting, heartburn, oral regurgitation, early satiety, excessive hiccups, and excessive belching. Symptoms of altered bowel pattern include: diarrhea, constipation, or a sense of incomplete evacuation with bowel movements. Functional
Pathophysiology of Functional Abdominal Pain
The etiology and pathogenesis of functional abdominal pain are unknown. It is generally agreed that the pain is genuine and not simply social modeling, imitation of parental pain, or a means to avoid an unwanted experience
Motility disturbances have been described in children by using manometric evaluation, measurements of intestinal transit, and surface electrophysiologic recordings. Studies to date in heterogeneous patients who have functional abdominal pain have described increased intensity of intestinal muscle contraction in both the small bowel and colon and delayed intestinal transit time. A characteristic motility disturbance has yet to be identified for any of the subgroups of functional abdominal pain. The concept of visceral hypersensitivity is derived from studies in adults who have irritable bowel syndrome
The role of inflammation or immunomodulation in the pathogenesis of functional abdominal pain must be considered in view of the frequent finding of nonspecific inflammatory changes in intestinal biopsies at all levels of the GI tract. Inflammatory changes may be the cause or the effect of altered intestinal motility. Immune responses alter neural and
Pain Consequences Affecting Morbidity
The morbidity associated with RAP affects psychosocial function. It interferes with normal school attendance and performance, peer relationships, participation in organizations and sports, and personal and family activities. Studies
providing TV, toys, books, drinks, or food to distract the child; and administrating symptomatic therapy, either tactile (massaging abdomen or applying heating pad) or medication (acetaminophen, dicyclomine). Although the pain usually lasts less than 1 hour, the child is kept home all day from school. Usually the child resumes his or her normal home routine after the pain subsides. School personnel reinforce the pain consequence behavior when they send the child home when he or she complains of pain. The pediatrician may reinforce the pain consequence behavior by prescribing a variety of medications to treat the pain.
Recent studies suggest that patients who have functional abdominal pain and are referred to a subspecialist commonly exhibit "internalizing" behavior characterized by anxiety, mild depression, withdrawal, and low self-esteem. Such a