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Recurrent Pain

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What is unexplained” abdominal pain"?
What is functional recurrent abdominal pain (RAP)?
Why be concerned about RAP?
Are there different types of functional RAP?
What causes functional RAP?
Can stress cause RAP?
Is the source of the problem in the gut or the brain?
Getting Treatment

The problem of “unexplained” abdominal pain.

Without thinking much about it, most of us expect that doctors will be able to “explain” our aches, pains, and complaints by finding some sort of tissue damage or disease that causes our discomfort. Despite such expectations, many of us have learned that not all physical suffering can be neatly explained by a physical examination or by medical tests and procedures. Doctors call physical disorders that are real but not caused by tissue damage “functional” disorders. Children with recurrent abdominal pain (RAP) and their families struggle with this sometimes frustrating and confusing situation every day. The vast majority of children with RAP, probably over 90%, do not have a serious disease that could shorten their life or cause tissue damage to the gut or gastrointestinal system (meaning the esophagus or food tube, the stomach, and the intestines). In the absence of clues to serious disease like blood in bowel movements or vomit, low blood count (anemia), fevers, weight loss or poor growth, persistent vomiting, or pain that repeatedly awakens the child from sleep, children with RAP are especially unlikely to have a serious physical disease.

What is functional recurrent abdominal pain (RAP)?

Functional RAP refers to chronic or recurrent bouts of abdominal pain (i.e., at least three bouts in a three month period) that are bad enough to interfere with a child’s routine activities and daily life, but which are not caused by tissue damage or serious inflammation. RAP is a common problem affecting between 7 and 25 % of school aged children and adolescents, and is one of the most common problems seen by professionals who care for children, including teachers, school nurses, and physicians. Boys and girls are just as likely to be affected before the teenage years, with teenage girls complaining more about RAP than boys. Older children and teenagers complain more often about stomachaches than young children, with one study finding that 8% of middle and high school students reported seeing a doctor for stomachaches during the previous year.

Why be concerned about RAP?

The pain is real. The good news is that the pain suffered by children with functional RAP is not a signal of damage to the stomach or intestines. The bad news is that children with RAP suffer and the pain interferes with their day-to-day life. It hurts.
The problem is real. Though many children with RAP remain excellent students in spite of the pain, children with RAP are more likely to miss school and don’t perform as well as their peers. They can become more withdrawn socially and avoid the kinds of challenges and activities that help children grow into self-assured and productive adults. The overwhelming majority of affected children come from caring families who want to find ways to help, but parents may feel helpless and not know where to turn.
The need for help is real. Children with RAP make more visits to doctors than children without stomachaches, and studies suggest that abdominal pain is the chief complaint for 2 to 4 % of all pediatric office visits. Affected children and their families sometimes feel misunderstood by health care professionals and school officials. What’s more is that the pain can become a big worry, especially for parents, who may be concerned that the child is suffering from a life threatening disease or that each bout of pain is a warning sign that damage is occurring somewhere in the body. Such fears in parents and doctors can put children with RAP at risk to undergo potentially dangerous medical tests, procedures, or treatments (even surgical procedures) that they don’t need.
A clue to other problems. Children with RAP commonly suffer from other physical symptoms, including headaches, other aches and pains, and feelings of dizziness or tiredness. They are also much more likely to be prone to fears and worries than other children their age, and somewhat more likely to appear sad or irritable. A few studies have shown that about 4 of 5 children brought to see a doctor for RAP will have an anxiety disorder and 2 of 5 will suffer from a depressive disorder. While it would be easy to jump to the conclusion that RAP causes the feelings of anxiety and depression, or the reverse, it is probably not that simple. The same sorts of vulnerabilities that could make children prone to RAP might also put them at risk for anxiety, depression, or headaches.
A clue to future problems. Adults with a history of RAP in childhood are more likely to suffer from functional abdominal pain, anxiety and depressive disorders, and worries about illness and physical health than those with no history of RAP.

Are there different types of functional RAP?

Because doctors are trying to learn more about functional RAP, guidelines have been developed for subtypes of functional RAP based on characteristics of the abdominal pain. When the child’s belly pain improves after a bowel movement and/or is associated with a change in bowel habits like diarrhea, constipation, or feeling the need to rush to the bathroom to avoid an accident, a child with RAP is said to suffer from irritable bowel syndrome (IBS). Children with pain above the belly button who do not have bowel complaints consistent with IBS are diagnosed with functional dyspepsia (FD), while those with episodic pain accompanied by symptoms and/or family history characteristic of migraine headaches can be diagnosed with abdominal migraine, and those with continuous or nearly continuous abdominal pain lasting at least 6 months can receive the unfortunate and potentially confusing label of functional abdominal pain (FAP). Unfortunately for physicians and researchers, we still don’t know if there are meaningful differences between children with one or another subtype of RAP. For example, we still don’t know for sure if children with functional RAP who have symptoms of IBS do better or worse over time than those who don’t have bowel related complaints, or if one subtype of RAP responds better to a particular treatment than another subtype. It is also true that many children with functional RAP do not fit neatly into one of the subtypes mentioned above.

What causes functional RAP?

The truth is, we just don’t know for sure. Though the exact cause remains a mystery, some clues are emerging. Some research suggests that children with functional RAP may be oversensitive to sensations or feelings coming from the gut and/or more likely to describe the sensations as painful than other children. Doctors call this extra sensitivity to gut sensations “visceral hyperalgesia”. This tendency may be inborn or could develop later in life, sometimes after an infection or inflammation of the gut that has long since healed. Children who are more sensitive to gut sensations or who are more likely to interpret sensations from the gut as threatening signals that something is wrong with the body would probably be more likely to experience and/or complain about stomachaches.

Can stress cause RAP?

This is not a simple question. In the end, it may turn out that children with RAP are simply more “sensitive” than other children, perhaps both physically and emotionally. Some parents and even some children with RAP notice that stress can sometimes trigger the pain. It may also be true that at least some children with RAP are more likely to react to stress with abdominal pain or have more problems coping with stress than other children. Research has found that many children with RAP are prone to become distressed when faced with unexpected life events and view new experiences as threatening more often than pain-free children. Such emotionally sensitive children with RAP appear to be more likely to experience abdominal pain when dealing with the hassles of everyday than children with more resilient personalities.

Is the source of the problem in the gut or the brain?

The temptation here is to speculate that the answer is simply “yes”, since there is reason to suspect that RAP is a problem involving both the gut and the brain. The gut has its own nervous system that develops from the same cells in the embryo that give rise to the brain. The same parts of the brain process both physical pain and emotions in many instances. Visceral hyperalgesia is likely influenced by body chemicals like serotonin that function as neurotransmitters in both the gut and the brain. Scientists once thought that serotonin was only an important chemical messenger in the brain, but have since learned that over 90% of the body’s serotonin is found in the gut, where it is involved in pain signaling and in the control of intestinal movements. Serotonin is likely to be important in a variety of illnesses such as irritable bowel syndrome (IBS), migraine, anxiety, and depression.