Clinical Consult: Evaluation and management of stomach pain

acheEvery child experiences stomach aches and pains. Identifying its cause is the tricky part.

According to Boston Children’s Hospital’s Lori Zimmerman, MD, a gastroenterologist with the Division of Gastroenterology, Hepatology and Nutrition, abdominal pain accounts for 2-to-4 percent of pediatrician visits, and 25 percent of pediatric GI referrals.

“In most cases, generalized abdominal pain without other red flags, is a manifestation of a other common conditions such as chronic constipationfunctional abdominal pain, or lactose intolerance,” Zimmerman says. “If the pain is chronic, it is also worth evaluating for other chronic gastrointestinal conditions, such as celiac disease.”

Dr. Zimmerman examines these conditions and offers tools to evaluate and manage pediatric stomach pain in the primary care setting.


Constipation and encopresis

If a child develops generalized abdominal pain and is otherwise growing well and gaining weight, has no blood in the stool, and no other concerning symptoms, Zimmerman suggests treating the child for constipation presumptively for a period of time to rule out the condition that affects three percent of children worldwide.

“Childhood constipation is almost always functional and without an organic etiology,” Zimmerman adds. “When treating childhood constipation, the provider should treat fecal impaction before maintenance medications will be efficacious.”

When a child is impacted with stool, they may develop fecal incontinence and any child suffering with fecal soiling needs additional attention. Read more about encopresis and how to treat the condition in the primary care setting.


Functional abdominal pain

The H. pylori myth
Helicobacter pylori (or H. pylori) is a type of bacteria that causes infection in the stomach and is found in about two-thirds of the world’s population. Considered a “silent” infection, H. pylori typically cause no symptoms.
“We don’t recommend screening for H. pylori in a child that has chronic abdominal pain because so many kids can have been exposed to H. pylori and this bacteria is not always the cause of the abdominal pain,” Zimmerman says.

Functional abdominal pain can be triggered by multiple factors such as diet, stress, or the micro-biome or gut bacteria.

“Patients with functional abdominal pain usually require a multidisciplinary approach to care — one that balances medications, dietary and lifestyle changes, and stress reduction techniques to improve a child’s pain and overall quality of life,” Zimmerman says. “But because there is no test for functional abdominal pain, it can be frustrating or difficult for pediatricians to make that diagnosis.”

If a pediatrician suspects a diagnosis of a functional gastrointestinal disorder because of the chronic nature of the pain and lack of other alarm signs, it is helpful to discuss the possibility of this diagnosis with the family in the beginning even while doing more of a workup for other etiologies.

“Having a presumptive diagnosis and explaining the various potential triggers of the pain can reassure families,” she adds.


The lactose/fructose factor

If the child complains of abdominal pain and bloating, it is important to look at the possibility of lactose or fructose being a trigger, Zimmerman suggests.

“If stomach pain occurs in a child after eating ice cream, drinking a glass of milk or eating sweets loaded with high fructose corn syrup, this is an indication of an intolerance,” she says. “So looking carefully at the child’s dietary history can be very helpful.”


Going gluten-free disrupts our ability to effectively screen for celiac disease, an autoimmune enteropathy caused by eating gluten containing foods,” Zimmerman says.

Hold off on the gluten-free diet

Sometimes pediatricians will suggest a child adopt a gluten-free diet to see if it helps with reducing or eliminating stomach pain. Zimmerman recommends holding off on the gluten-free diet introduction until the patient has been screened for celiac disease.

Children with chronic abdominal pain should be screened for celiac disease with a total IgA and Tissue Transglutaminase IgA. If the child has IgA deficiency, the blood test for celiac disease is less sensitive.
“If you make a child who has celiac disease gluten-free before you do the work up, avoidance of gluten can cause intestinal healing and risk false negative celiac testing.  Once patients are feeling better, they are less likely to be willing to add the gluten back into their diet to do the testing.”


Suspect IBD? Follow these steps

If you suspect IBD as a cause for the stomach pain because the pain is chronic, associated with poor weight gain or weight loss, blood in the stool, diarrhea, or the child’s sibling or parent has IBD, you should consider screening for the condition, Zimmerman says. Next steps should include ordering the following tests:

  • blood work to check for anemia, signs of inflammation (ESR, CRP), hypoalbuminemia
  • stool analysis to look for occult blood and lactoferrin or calprotectin (both noninvasive stool tests that are sensitive for intestinal inflammation.)


What are the most common surgical causes of abdominal pain?

The most common surgical causes for stomach aches and pains may be appendicitis, gallbladder disease or intussusception – the most common abdominal emergency affecting children under 2 years old.

“Acquiring a detailed history and careful physical exam is probably the most important way to identify whether surgical intervention is necessary,” Zimmerman adds.


When should a PCP refer to a specialist?

If the pain is persistent or if the patient has any red flags including:

  • weight loss and/or poor growth
  • blood in the stool
  • severe vomiting or diarrhea
  • unexplained fever or focal pain
  • or if the pain is chronic and/or severe, Zimmerman recommends the child be seen by a gastroenterologist for further testing.


Download Boston Children’s “When is a tummy ache not just a tummy ache” e-book and share with your patients.