Chronic And Recurrent Abdominal Pain

Almost all patients with CAP have experienced a medical evaluation, in which neither based on history, physical examination more numerous basal test procedure, a diagnosis could be made.

Chronic abdominal pain (CAP) is defined as for more than 3 months, either in a continuous or in an intermittent shape. Intermittently occurring pain can be described as recurrent abdominal pain (RAP). The acute abdominal pain is discussed elsewhere. The CAP can occur at any point beyond the 5 years of age. More than 10% of all children require clarification with regard to a RAP. About 2% of adults, especially women, CAP (a much higher percentage of adults shows any chronic gastrointestinal symptoms, including dyspepsia nichtulzeröser and various intestinal disorders). Almost all patients with CAP have experienced a medical evaluation, in which neither based on history, physical examination more numerous basal test procedure, a diagnosis could be made. Under the pathophysiology functional abdominal pain syndrome (FAPS) refers to pain that is> 6 months without evidence of a physiological disorder, no relationship to physiological events (z. B. meals, defecation, menses) and interferes with daily body functions. FAPS is causal poorly understood but seems to have something to do with altered pain perception. Sensory neurons in the dorsal horn of the spinal cord are especially excitable and pain hypersensitive from a number of reasons. Cognitive and psychological factors (eg., Depression, stress, culture, secondary gain, coping and support mechanisms) may cause efferent stimulation, pain signals are amplified, so that even a very low pain stimulus is perceived and this long after the end of the stimulus can continue to exist. In addition, the pain may even take over the function of a stress factor and thus maintain a vicious circle. In addition, the menopause enhances gastrointestinal symptoms in several disorders, including irritable bowel syndrome, inflammatory bowel disease, endometriosis and nichtulzeröser dyspepsia. Etiology Approximately 10% of patients have an occult physiological disease (see table: Physiological causes of chronic abdominal pain), the other suffering from functional complaints. The determination of whether certain pathological conditions (eg. As adhesions, ovarian cyst, endometriosis) are the cause of CAP symptoms or an incidental finding, can be difficult. Physiological causes of chronic abdominal pain cause suspicious findings * Diagnostic procedure Urogenital Diseases Congenital anomalies Recurrent UTI Intravenous urography sonography endometriosis symptoms before or during menstruation laparoscopy Ovarian cancer, ovarian cancer Unclear abdominal discomfort, bloating, if necessary palpable pelvic pelvic ultrasound Gynecological examination kidney stones fever, flank pain, dark urine or bloody urine culture Intravenous urography CT episodes of acute pelvic inflammatory disease pelvic discomfort Pelvic inflammatory disease in the history Gynecological examination if necessary Laparoscopy Gastrointestinal diseases Celiac failure to thrive in children bloating, diarrhea and often Steatorrhea symptoms worsen when gluten-containing products are added Serological markers small intestine biopsy Chronic appendicitis Several previous episodes of pain in the RLQ abdominal CT Sonography Chronic cholecystitis recurrent colicky pain RUQ Sonogr aphie HIDA scanning Chronic hepatitis epigastric discomfort, nausea, anorexia, jaundice, acute hepatitis unusual in the history at about one third of patients liver enzymes Viral Hepatitistiter chronic pancreatitis, pancreatic pseudocyst severity of episodes of pain in the stomach, if necessary Malabsorption (eg. As diarrhea, fatty stools) Normally acute pancreatitis in prehistory Serum lipase levels low (often not increased) CT, MRCP colon cancer symptoms, but possibly colicky symptoms, if left colon is partially clogged Often occult or hidden blood in the stool Colonoscopy Crohn’s disease pain episodes with fever, loss of appetite, weight loss, diarrhea Extraintestinal symptoms (joints, eyes, mouth, skin) CT or small bowel barium enema colonoscopy and esophagogastroduodenoscopy with biopsy Stomach cancer dyspepsia or mild pain often fecal occult blood Upper endoscopy granulomatous enterocolitis family history Recurrent infections at other locations (eg. As lung, lymph nodes) BKS barium enema CT hiatal hernia with gastroesophageal reflux heartburn Sometimes cough and / or hoarseness lessening of symptoms when taking antacids Sometimes regurgitation of stomach contents into the mouth barium swallow endoscopy Intestinal tuberculosis chronic nonspecific pain sometimes palpable mass in the RLQ fever, diarrhea, weight loss tuberculin endoscopy for biopsy CT with oral contrast agents lactose intolerance and flatulence Cramps after taking dairy products hydrogen breath test avoiding foods containing lactose pancreatic Severe pain in the upper abdomen, which often radiates late occur in the disease process in the back, when weight loss is often occurred May cause obstructive CT MRCP or ERCP parasites (especially giardiasis) travel or exposure in the history of cramping, bloating, diarrhea stool examination for ova and parasites Stuhlenzymimmunoassay (Giardia) Peptic ulcer disease deterioration of epigastric pain by food and antacids Patients at night wake endoscopy and biopsy on Helicobacter pylori H. pylori breath test evaluation of NSAID-taking faecal occult blood Postoperative adhesions Previous abdominal surgery Colicky complaints with nausea and possibly vomiting Abdomenübersichten , Dünndarmkonstrastaufnahmen or enteroclysis ulcerative colitis Cramping pain Rectal with bloody diarrhea sigmoidoscopy biopsy colonoscope ie systems diseases abdominal epilepsy Very rare Episodic pain No other gastrointestinal symptoms EEG Familial angioedema family history aches, often with peripheral angioedema and fever complement levels (C4) during the attacks Familial Mediterranean Fever family history fever and peritonitis often accompany the pain attacks Beginning in childhood or adolescence Genetic testing food allergy symptoms develop only after eating certain foods (eg. B. Fish) Elimination Diet immunoglobulin-A-associated vasculitis (formerly Henoch-Schonlein purpura) Palpable purpura rash joint pain Fecal occult blood biopsy of skin lesions lead poisoning Cognitive / behavioral problems lead in blood migraine equivalent Rare variant with upper abdominal pain and vomiting ago Usually all family history of migraine in children Clinical investigation Porphyria Recurrent severe abdominal pain, vomiting Benign examination of the abdomen if necessary neurological symptoms (eg. as muscle weakness, seizures, mental disorder) In some cases skin lesions urine porphobilinogen and delta-aminolevulinic acid screening RBC deaminase assay sickle cell anemia Family history Severe episodes of abdominal pain lasting more than one day stop Recurrent pain in nonabdominal sites sickle cell -preparation Hb electrophoresis * findings are not always available and can also exist in other diseases. HIDA = Hydroxyiminodiacetylsäure; MRCP = magnetic resonance cholangiopancreatography; PID = pelvic inflammatory disease; RLQ = right lower quadrant; RUQ = right upper quadrant; SBFT = small bowel enema. Adapted from Barbero GJ: Recurrent abdominal pain. Pediatrics in Review 4:30, 1982 and Greenberger NJ: Sorting through nonsurgical causes of acute abdominal pain. Journal of Critical Illness 7: 1602-1609, 1992. Clarification history The medical history are pain localization, quality, duration, timing and frequency of recurrence and factors that aggravate or alleviate the pain (especially eating or bowel movements) to check. Targeted demand, whether milk or milk products cause abdominal cramps, bloating or a swollen abdomen is required because lactose intolerance is often (v. A. Among blacks). A review of organ systems looks for accompanying gastrointestinal symptoms such as reflux, loss of appetite, bloating or “gas”, nausea, vomiting, jaundice, melena, hematuria, hematemesis, weight loss and mucus or blood in the stool. Intestinal problems such as diarrhea, constipation, and changes in stool consistency and color, or changes in bowel movements are particularly important. In adolescents, a diet history is important because the uptake of large amounts of cola and fruit juices (which contain significant amounts of fructose and sorbitol) can explain otherwise puzzling abdominal pain. The history should include the nature and timing of any abdominal surgery, the findings held gehabter investigations and the results of previous treatment attempts. A detailed drug history includes prescription medications, illegal drug use and alcohol abuse. A family history of recurrent abdominal pain (RAP) and bouts of fever, or both should be implemented like the finding of known cases of sickle cell anemia or disease, familial Mediterranean fever and Porphyrie.Körperliche investigation In a study of vital functions, give special attention to the presence of fever or tachycardia. As part of a general examination is to look for signs of jaundice, rash, and peripheral edema. An examination of the abdomen should pressure sensitive regions Peritonitiszeichen (z. B. guarding, hardened abdominal wall, knocking pain) as well as masses or organomegaly register. A rectal exam and (in women) a pelvic examination are essential to pressure-sensitive areas, masses and bleeding festzustellen.Risikofaktoren The following findings are of particular importance: fever anorexia, weight loss pain that wake the patient’s blood in the stool or urine jaundice edema Abdominal mass or organ enlargement interpretation of results the clinical examination alone allows rarely a reliable diagnosis. It can be difficult to distinguish physiological from a functional cause of CAP. Although the presence of suspicious findings suggesting a high probability of a physical cause, their absence does not exclude such. Physical causes pain call appears to be well localized, v. a. in areas outside the periumbilical. Pains that wake the patient at night, are usually physiological. Some suspicious findings specific diseases are listed in the table Physiological causes of chronic abdominal pain. The pain in functional CAP may correspond with organic cause. However, there is in the former no risk factors and psychological abnormalities are predominant. Physical or sexual abuse in the history or an unhandled loss (z. B. divorce, miscarriage, death of a family member) may be a trigger. The Rome criteria for the diagnosis of irritable bowel syndrome include the presence of abdominal pain or discomfort for at least 3 days / month in the last 3 months along with at least two of the following criteria: (1) improvement of defecation; (2) the beginning of each episode of discomfort with change in stool frequency and (3) changing the Stuhlkonsistenz.Tests General should common tests are carried out (incl. Urinalysis, complete blood count, liver function tests, lipase and BSG). Abnormal values ??in these tests, high suspicious symptoms or specific clinical findings give grounds for further inquiries, even if previous assessments were negative. The indication for specific investigations (see table: Physiological causes of chronic abdominal pain) depends on the collected findings from typically be an ultrasound on ovarian cancer in women over 50 years, a CT of the abdomen and pelvis with contrast, an upper gastrointestinal endoscopy or colonoscopy and perhaps an X-ray examination of the small intestine or stool examination carried out. The benefit to subject patients without abnormal findings such assays remains doubtful. In patients> 50 years, a colonoscopy should be performed; Patients ? 50 years can be observed or a CT scan of the abdomen and pelvis are supplied with a contrast agent, if an imaging examination is desired. Magnetic resonance cholangiopancreatography (MRCP), ERCP and laparoscopy are rare helpful in the absence of specific indications. Between the first investigation and the re-conceptions of the patient (or a child the family) should any pain, incl. His character, intensity and duration as well as its immediate causes, document. The diet, the defecation pattern and each remedies used (including the treatment result) should also be detected. This documentation can unearth inappropriate behavior and exaggerated responses to pain or permit otherwise, any suspected diagnosis. Organic Therapy findings must be treated. If the diagnosis of functional CAP is set, you should avoid frequent examinations and tests because they focus the patient on his physical ailments or enhance them or give the feeling to the patient that the doctor has no confidence in his diagnosis. There is no specific method to cure the functional CAP, but there are helpful ways. They are based on mutual trust, an empathetic relationship between doctor, patient and family. The patient must be made clear that he is not in danger; special problems to be detected and addressed. The physician should explain the laboratory findings and describe the nature of the problem, as the pain comes exactly about and how the patient perceives him (z. B. Pain often occurs in times of particular stress on). It is important to have a permanent manifestation of negative consequences of chronic pain (eg. As permanent absence from school or work, withdrawal from social activities) to avoid and to support independence, participation in social life and self-esteem. These strategies help the patient to control his symptoms and to tolerate while fully participate in daily life. Medications such as aspirin, NSAIDs, H2 receptor blockers, proton pump inhibitors and tricyclic antidepressants may be effective. Opiates should be avoided because they always lead to dependence. Cognitive methods (eg. As relaxation exercises, biofeedback, hypnosis) to support the well-being of the patient. Regular follow ideas should take place depending on the needs weekly, monthly or every two months the patient and should be maintained for some time after the patient’s problem is solved. A psychiatric presentation can be necessary if the patient is depressed or when significant psychological problems in the family are present. The school staff should be involved in the issue of a child who suffers from CAP. Children may be allowed, be sure to stop during the school day in the clinic room with the expectation that they will return after 15-30 minutes in the class. The school nurse can be instructed to administer a mild analgesic (z. B. paracetamol). The nurse can also allow the child to call his parents, who should support the child to stay in school. If parents stop seeing their child as being particularly or ill, the symptoms may worsen before they disappear. Important Points Most cases provide a functional process. Suspicious findings suggest a physical cause and the need for further investigation through. The test is performed based on clinical criteria. After the exclusion of physical causes repeated tests are counterproductive in general.

Health Life Media Team

Leave a Reply