Recurrent abdominal pain in children

　　First, the cause of the disease

　　There are many causes of abdominal pain, and it is necessary to distinguish between symptomatic, gastrointestinal functional, and organic causes.

　　1. Symptomatic

　　Mostly caused by extraintestinal diseases, such as upper respiratory tract infection, purulent tonsillitis, liver and gallbladder diseases, urinary system diseases, and intestinal parasitic diseases can all cause abdominal pain. Intestinal parasitic diseases were once the most common cause of abdominal pain, but in recent years, due to the improvement of dietary hygiene, the incidence of intestinal parasitic diseases has decreased significantly, especially in urban areas.

　　2. Organic diseases in the abdominal cavity

　　Such as peptic ulcer disease, appendicitis, intestinal obstruction, acute abdomen, and other conditions.

　　3. Functional

　　The most common causes of abdominal pain are improper diet, eating snacks at will, excessive consumption of cold drinks, constipation, and disordered digestive function (also known as functional dyspepsia).

　　4. Psychogenic

　　There are also reports from abroad that it is related to psychological factors in children, such as tension and depression.

　　5. Chronic gastritis and Helicobacter pylori infection

　　Recent research believes that recurrent abdominal pain is related to chronic gastritis and Helicobacter pylori infection. For example, Beijing Fengxinhospital found 47 cases of gastrointestinal mucosal lesions (25 cases of superficial gastritis, 2 cases of reflux gastritis, 2 cases of erosive gastritis, 3 cases of gastric mucosal prolapse, 10 cases of duodenitis, 1 case of esophagitis, 4 cases of superficial gastritis with duodenitis) in 76 cases of recurrent abdominal pain through fiberoptic gastroscopy, accounting for 61.84%. There were 13 cases of ulcer disease, accounting for 17.1%. Helicobacter pylori was positive in 33 cases, accounting for 43.4%; Shanghai Ruijin Hospital found 25 cases of superficial gastritis and 1 case of superficial atrophic gastritis in 26 cases of non-ulcer dyspepsia through gastroscopy and pathological examination.

　　2. Pathogenesis

　　The abdominal organs themselves are not sensitive to pain. The occurrence of abdominal pain can generally be in three forms:

　　1. Colic

　　It is often caused by muscle spasm or obstruction (accompanied by spasm) in tubular organs, such as intestinal, biliary, and ureteral spasm or obstruction, which often manifests as paroxysmal colic pain.

　　2. Dull pain

　　It is caused by traction of the organ capsule, such as the traction of the capsule due to inflammation and swelling of the liver, kidney, appendix, and peritoneum, which often manifests as persistent dull pain. The location of the pain is often consistent with the location of the organ lesion.

　　3. Migratory pain

　　Visceral pain is transmitted through visceral sensory nerves to the corresponding spinal segments, causing the somatic nerve支配部位 of the same segment to feel pain, such as the pain of liver and gallbladder diseases, which sometimes can radiate to the right shoulder. In addition, pain from organs outside the abdomen can sometimes radiate to the abdomen, such as in large lobe pneumonia and herpes zoster affecting the abdominal spinal nerves, which can cause severe abdominal pain. The muscular spasm of the abdominal muscles in tetanus can also cause severe abdominal pain.

　　The mechanism of intestinal spasm caused by dyspepsia is the fermentation and gas production of undigested food in the intestinal lumen, stimulating the intestinal wall, or sympathetic nerve excitation, causing transient muscular spasm of the intestinal wall, temporarily blocking the passage of intestinal contents. Subsequently, the proximal intestinal tube undergoes strong contractions and disordered peristalsis. As the peristalsis intensifies, abdominal pain becomes more severe in a paroxysmal manner. Tympany is pronounced, and in severe cases, vomiting may occur simultaneously. After a certain period of spasm, the intestinal muscle naturally relaxes, and abdominal pain temporarily relieves, only to recur later. In typical cases, intestinal spasm often occurs in the small intestine, with the pain mainly located around the umbilicus. Spasm of the distal large intestine and ileum often radiates to the lower right abdomen. Spasm of the descending colon or sigmoid colon often causes severe pain before defecation. In a few older children, spasm may occur at the hepatic flexure or splenic flexure of the colon, with pain mainly in the costal region, often on one side. According to the author's observation, recurrent abdominal pain in children is mainly reported to occur around the umbilicus in 4/5 cases, and in the upper abdomen in 1/5 cases. Short-term acute attacks are mostly due to intestinal spasm, while long-term chronic recurrent attacks are often found to have gastric lesions, with superficial gastritis being the most common, followed by duodenitis, and a few cases of ulcer disease. Abdominal pain localization in children, especially infants, is very inaccurate.

　　1, Disorder of the body's autonomic nervous system function

　　It is manifested by the strengthening of sympathetic nervous function activity, increased respiration, increased heartbeat, increased gastrointestinal motility, ugly complexion, cold extremities, cold sweat, and so on.

　　2, Strengthening of the body's metabolism

　　Long-term abdominal pain can lead to hyperactivity of endocrine activity, such as increased secretion of adrenaline, adrenal cortical hormones, antidiuretic hormone, insulin, and so on, which can cause hypertension, hyperglycemia, and increased basal metabolic rate in clinical practice.

　　3, Emotional reaction

　　Abdominal pain can cause a series of emotional reactions, including tension, restlessness, and so on. When abdominal pain reaches a certain degree, patients usually find it difficult to bear, and even dizziness may occur.

　　4, Inhibition of the activity center of vascular activity

　　Severe and persistent abdominal pain can cause the activity center of vascular activity to shift from excitation to high inhibition, thereby causing disorders in the activity of the body's fine blood vessels, a decrease in vascular tension, dilatation of fine blood vessels, continuous and large amounts of stasis in the fine blood vessels, a decrease in cardiac output, a decrease in blood pressure, tissue hypoxia, and ultimately leading to the occurrence of painful shock.

　　The location and nature of abdominal pain in clinical manifestations mainly rely on the child's report. During physical examination, it is necessary to make the child cooperative to check for tenderness, muscle tension, or swelling. Older children usually have no problems and can cooperate, while younger children often cannot cooperate. In this case, it is necessary to rely on the sudden onset of abnormal crying, pale complexion, sweating, poor spirit, and special posture to judge. For non-cooperative children, it is best to use the contrast method for abdominal examination. The mother can distract the child so that the child does not cry, or the mother can hold the child to breastfeed, and the doctor can gently and slowly touch the abdomen from the side or back, making the child accustomed to this examination. Then, compare the reactions of various parts repeatedly. If the child still cries and does not cooperate, 1 dose of chloral hydrate can be given orally, with a dose of 30-50mg/kg (10% solution, 0.3-0.5ml/kg per dose), taken orally or enema. When enema, the water should be diluted twice, and then check after the child falls asleep.

　　It is necessary to understand the child's dietary habits, vomiting, and bowel movement conditions, as well as digestive system symptoms, which are helpful in determining the cause of the disease. If the intestinal spasm is caused by improper diet and disordered digestive function, the child may exhibit sudden onset of paroxysmal abdominal pain, with each attack lasting not long, from several minutes to several tens of minutes, with intermittent pain, occurring daily or every few days, most abdominal pain is mild, often occurring during meals and disappearing shortly afterwards. After the attack, the child can play normally, while severe cases may show crying, restlessness, rolling, sweating, and even pale complexion and cold extremities. During the attack, most children have no positive signs in the abdomen, a few may show mild tenderness in the abdomen, or it may seem like there is muscle tension, but after the attack, the abdomen is soft during the interval period, without tenderness, no intestinal pattern, no swelling, and occasionally, a cord-like spasmed intestinal tract can be felt. There is often abdominal distension and hyperactive bowel sounds.

　　Since there are often psychological or physiological factors involved, and influenced by environmental, family, and genetic factors, the focus of prevention includes eliminating worries, avoiding simple symptomatic medication, preventing constipation, forming a regular defecation habit, avoiding mental stress, etc., to effectively prevent functional RAP. The prevention and treatment of peptic ulcer disease, gastrointestinal inflammation, parasitic infection, and other diseases can prevent and treat RAP.

　　1. Stool routine

　　Examine for undigested food, parasitic eggs, and occult blood test.

　　2. Peripheral blood

　　White blood cell count and classification may be necessary to exclude inflammation and infection.

　　3. X-ray examination

　　An abdominal X-ray is used to observe intestinal distension and free gas. If necessary, barium meal or barium enema is performed to observe for ulcers, gastritis, duodenitis, intestinal adhesions, intestinal obstruction, or diverticula.

　　4. Gastroscopy

　　Gastroscopy is helpful in detecting gastric lesions such as gastritis, duodenitis, and ulcer disease in children with chronic recurrent abdominal pain.

　　5. Gastric electrogastrography

　　As it is non-invasive, it is easy for children to accept, but the specificity of the results is not strong, and it can only be used as a reference.

　　6. Helicobacter pylori examination

　　It is closely related to chronic recurrent abdominal pain. If Helicobacter pylori is found, treatment should be given.

　　7. Gastric motility examination

　　Esophageal and duodenal manometry, real-time ultrasound, and gastric emptying test are helpful in detecting gastrointestinal motility disorders.

　　Dietary adjustment is very important for the cure of recurrent abdominal pain in children. The general principle is that food should be 'fine, soft, tender, and well-cooked'. Children are individuals in growth and development, so the food should also be rich in nutrition, such as milk, poached eggs, fish, dairy products, noodles, congee, fresh vegetables, and fruits. In addition
　　Children's abdominal pain examination
　　External foods that can help with stomach digestion can be eaten, such as yam, mung bean, lotus seeds, gizzard, stomach, and rice kernel. Foods that should not be eaten too much include celery, bamboo shoots, fatty meat, and various fried foods. The following dietary therapies are suitable for children:
　　1. 500 grams of white radish, 150 grams of honey. Cut the radish into pieces, cook in boiling water, remove and dry for half a day, then add honey to the pot and simmer over low heat, mix well, cool, and store in a bottle. Take 3 tablespoons a day. Suitable for children with stomach distension, belching, and acid regurgitation.
　　2. 220 ml of milk, 30 grams of honey, and 1 quail egg. Boil the milk first, then beat the quail egg into it, cook for a few minutes, and add honey before serving. Take in the morning. Suitable for children with stomachache, thirst, poor appetite, and constipation.
　　3. Dissolve 20 grams of molasses in 250 milliliters of soy milk, bring to a boil, and drink on an empty stomach. Suitable for children with hidden stomach pain, cold hands and feet, and aversion to cold.
　　4. Take 50 grams of lotus seeds, glutinous rice, and rice kernel, and 15 grams of brown sugar. Soak the lotus seeds in boiling water to expand, peel and remove the core, then cook them in a pot with water for 30 minutes, add glutinous rice and rice kernel and bring to a boil, then simmer over low heat until soft, add brown sugar and eat. Suitable for children with upper and middle abdominal pain, emaciation, loss of appetite, and greasy tongue.

　　I. Treatment

　　1. Symptomatic Abdominal Pain

　　For symptomatic abdominal pain, the primary treatment is to actively treat the primary disease. Symptomatic treatment can be given for abdominal pain.

　　2. Organic RAP

　　For recurrent abdominal pain caused by organic lesions, surgery or drug treatment should be given in a timely manner according to the methods proposed in the special chapters of surgery or internal medicine. It should be avoided to use drug treatment for common causes of organic RAP, but appropriate use of antispasmodics, promotility drugs, and drugs that regulate autonomic nerve function, such as belladonna, domperidone (Motilium), cimetidine, and oryzanol, can be helpful. For constipated patients, fiber-rich foods should be gradually added, and the habit of defecating at regular times should be cultivated. Children with functional RAP should be followed up and observed regularly in the outpatient department.

　　3. Functional Recurrent Abdominal Pain

　　It accounts for about 95% of recurrent abdominal pain, and its treatment is the focus of this introduction:

　　(1) Rational Feeding: Infants under 4 months should be breastfed as much as possible, as pure breastfeeding rarely causes indigestion and abdominal pain. After meals, fruits can be eaten; after waking up from a nap, pastries and candies can be eaten together; when eating, staple and supplementary foods should be matched, and vegetables should be eaten in moderation without preference.

　　(2) Digestive Aids: If there is indigestion, infants can be given pepsin mixture.

　　(3) Indigestion: Acute intestinal spasm caused by indigestion is a common emergency in pediatrics. The child often has a sudden onset, crying and restlessness, abdominal distension, and hyperactive bowel sounds. After excluding organic acute abdominal disease, glycerin/sodium chloride (Gua Shen Lotion) is given for defecation, which is both a diagnostic measure to exclude intestinal obstruction and a treatment measure. After the child defecates and passes gas, the abdominal pain can stop immediately.

　　(4) Physical Therapy: Use warm hand massage on the abdomen, or place a hot water bag on the abdomen to temporarily relieve abdominal pain.

　　(5) Antispasmodics: belladonna 4-8mg, taken orally. Anisodamine (654-2) 1mg/kg, taken orally, or intramuscularly for severe cases.

　　(6) Acupuncture Therapy: Immediate pain relief is better. For infants and young children who are not cooperative, moxibustion is safer; children can be treated with needles or moxibustion. Acupoints: Hegu, Zusanli, and Sanyinjiao. For pain above the navel, add Zhongwan; for pain below the navel, add Guanyuan and Zhongji. For pain around the navel, add Tianchedu and Qihai; for side abdominal pain, add Yanglingquan.

　　4. Gastritis and Gastric Ulcer

　　If gastritis, ulcer disease, and Helicobacter pylori infection are found, appropriate treatment should be given.

　　5. Gastrointestinal Motility Drugs

　　If gastrointestinal motility disorders are found, promotility drugs can be given, such as domperidone (Motilium) at a dose of 0.3mg/kg, 3 times a day, taken orally.

　　6. Psychological Therapy

　　If there is a mental disorder found, psychological therapy should be provided.

　　7. Traditional Chinese Medicine Treatment

　　Abdominal pain is a symptom with a wide range. Clinical differentiation should be based on the cause, location, and nature of the pain, considering comprehensively. In terms of location, upper abdominal pain is mostly related to the spleen and stomach; right upper abdominal pain is mostly related to the liver and gallbladder; middle abdominal pain is mostly considered between the intestines and stomach; pain around the navel is mostly seen in worm infestation; pain in the lower abdomen on both sides should pay attention to cold hernia and Qi pain. In terms of the nature of the pain, continuous walking and distending pain is mostly in the Qi channel; pain that prefers heat is mostly cold; pain that prefers coolness is mostly hot.

　　Treat according to syndrome differentiation and treatment.

　　(1) Cold conglomeration abdominal pain:

　　Main symptoms: Sudden abdominal pain, severe pain, pain is relieved by heat, worsens by cold, no thirst, clear urine, pale tongue, white tongue coating, deep and tight pulse.

　　Treatment principle: Warm the middle to dispel cold, regulate Qi and relieve pain. Formula: Liangfu Pill modified.

　　Commonly used drugs: Dahuang, Xiangfu, Qingpi, Angelica sinensis, Acorus tatarinowii, Mosla, Dry ginger, Yuanhuan, Licorice.

　　(2) Gastrointestinal real heat abdominal pain:

　　Main symptoms: Fever, abdominal heat, abdominal pain, abdominal distension, or vomiting, dry stools, yellow and涩urine, restless, restless sleep, red tongue, yellow tongue coating, rapid and strong pulse.

　　Treatment principle: Clear heat and purgation. Formula: Dachengqi Decoction modified.

　　Commonly used drugs: Rhei, Magnolia officinalis, Zhizi, Natrium sulfide, Mosla, Bai Shao.

　　(3) Worm infestation abdominal pain:

　　Main symptoms: Abdominal pain that stops and starts, severe and unbearable when it starts, often around the navel, or left or right, in severe cases, vomiting ascaris, facial spots of worms.

　　Treatment principle: Expel worms and harmonize the stomach. Formula: Wu梅 Pill modified.

　　Commonly used drugs: Areca nut, Quisqualis, Pericarpium Meliae, Prunus mume, Mosla, Zhike, Sichuan pepper, Asarum, Dry ginger, Yuanming powder.

　　(4) Food retention abdominal pain: According to observation, this type is the most common.

　　Main symptoms: Epigastric and abdominal pain, loss of appetite, acid regurgitation, pain worsens after eating, pain decreases after defecation, thin and greasy yellow tongue coating, slippery and rapid pulse.

　　Treatment principle: Eliminate food retention and relieve pain by promoting the flow of Qi. Formula: Baohuo Pill modified.

　　Commonly used drugs: Hoelen, Chen Pi, Jiuxian, Radish Seed, Amomum villosum, Coptis, Poria, Mosla, Bai Shao,甘草.

　　Second, Prognosis

　　After being diagnosed with functional RAP, 30% to 50% of the children have relief of abdominal pain within 2 to 6 weeks or the pain naturally disappears during growth. However, a small number of children still have abdominal pain attacks into adulthood or develop chronic pain in other parts. Some scholars believe that the prognosis is not ideal for the following conditions:

　　1. From a family with a history of pain, one or both of whose parents have recurrent attacks of abdominal pain.

　　2. Male.

　　3. First attack before the age of 6.

　　4. History of abdominal pain for more than 6 months before treatment.