Indian J Pediatr DOI 10.1007/s12098-015-2029-3
SCIENTIFIC LETTER
A Child with Recurrent Abdominal Pain: A Cross-road between Pediatrics, Neurology and Psychiatry Nakka Nagarajitha 1 & Monica Nakka 2 & Sandeep Krishna Murthy Kosaraju 1 & Tilak Chandra Pal Adusumalli 2
Received: 9 September 2015 / Accepted: 28 December 2015 # Dr. K C Chaudhuri Foundation 2016
To the Editor: Recurrent abdominal pain is a common problem among children. Many a times, in spite of a battery of diagnostic tests, the cause seems elusive. This can lead to these children being deemed to be suffering from ‘psychogenic pain’. Abdominal epilepsy is one such disease with a rare presentation which is easily treatable, but rarely recognizable. It is found that on an average this diagnosis does escape clinician’s attention [1–3]. While suicide is one of the major causes of death in adolescence [4, 5] recurrent idiopathic pain, in particular, primary headache and abdominal pain, is one of the leading somatic health issues among this age group. A 12-y-old boy was brought to the pediatric outpatient clinic with complaints of abdominal pain since 4 mo. Abdominal pain was diffuse, more on the epigastrium, right hypochondrium, left iliac fossa and around the umbilicus. The frequency, intensity and duration had been steady for the past 4 mo and he was having several such attacks a week. His physical examination and a number of investigations were normal. Despite trying, he did not respond to analgesics or antispasmodics. He was thought to have functional pain and was referred to the child guidance clinic. Here he was examined by a psychiatrist and on detailed evaluation it was revealed that the child had paroxysms of severe pain. There were no undue stress factors or secondary gains, no convulsions could be elicited from the history. A diagnosis of
abdominal epilepsy was therefore suggested, based on the episodic nature of the condition and relatively symptom free periods in between and also no attention seeking was noted, despite the child being a precious one (only child after three miscarriages). An electroencephalogram (EEG) was done in order to investigate for epileptic phenomenon and it found to be abnormal, indicating epilepsy. Neurologist opinion was taken and the child was put on carbamazepine 100 mg twice daily after preliminary investigations to which he showed a remarkable response. He has been symptom-free from the time of the medication change for the past one year. The criteria laid down for its diagnosis [3] are (i) paroxysmal abdominal pain, (ii) exclusion of abdominal visceral pathology, (iii) alteration of mental status during some of the attacks, (iv) definite abnormal electro-encephalographic tracing and (v) response to anticonvulsant therapy. Not all the criteria need be present in each case to confirm the diagnosis. A similar picture may also be seen in abdominal migraine. However, in that condition, the pain is usually gradual in onset, a family history of migraine is often present, and the EEG is normal or shows only minor abnormalities. Compliance with Ethical Standards Conflict of Interest None. Source of Funding None.
* Nakka Nagarajitha [email protected]
References 1
2
Department of Psychiatry, Bhaskar Medical College, Hyderabad, Telangana 500075, India Department of Pediatrics, Bhaskar Medical College, Hyderabad, Telangana 500075, India
1.
Zarling EJ. Abdominal epilepsy: an unusual cause of recurrent abdominal pain. Am J Gastroenterol. 1984;79:687–8. 2. Schade GH, Gofman H. Abdominal epilepsy in childhood. Pediatrics. 1960;25:151–4.
Indian J Pediatr 3. 4.
Douglas EF, White PT. Abdominal epilepsy - a reappraisal. J Pediatr. 1971;78:59–67. Kessler RC, Borges G, Walters EE. Prevalence of and risk factors for lifetime suicide attempts in the national comorbidity survey. Arch Gen Psychiatry. 1999;56:617–26.
5.
Hankin BL, Abramson LY. Development of gender differences in depression: an elaborated cognitive vulnerability-transactional stress theory. Psychol Bull. 2001;127:773–96.
SCIENTIFIC LETTER
A Child with Recurrent Abdominal Pain: A Cross-road between Pediatrics, Neurology and Psychiatry Nakka Nagarajitha 1 & Monica Nakka 2 & Sandeep Krishna Murthy Kosaraju 1 & Tilak Chandra Pal Adusumalli 2
Received: 9 September 2015 / Accepted: 28 December 2015 # Dr. K C Chaudhuri Foundation 2016
To the Editor: Recurrent abdominal pain is a common problem among children. Many a times, in spite of a battery of diagnostic tests, the cause seems elusive. This can lead to these children being deemed to be suffering from ‘psychogenic pain’. Abdominal epilepsy is one such disease with a rare presentation which is easily treatable, but rarely recognizable. It is found that on an average this diagnosis does escape clinician’s attention [1–3]. While suicide is one of the major causes of death in adolescence [4, 5] recurrent idiopathic pain, in particular, primary headache and abdominal pain, is one of the leading somatic health issues among this age group. A 12-y-old boy was brought to the pediatric outpatient clinic with complaints of abdominal pain since 4 mo. Abdominal pain was diffuse, more on the epigastrium, right hypochondrium, left iliac fossa and around the umbilicus. The frequency, intensity and duration had been steady for the past 4 mo and he was having several such attacks a week. His physical examination and a number of investigations were normal. Despite trying, he did not respond to analgesics or antispasmodics. He was thought to have functional pain and was referred to the child guidance clinic. Here he was examined by a psychiatrist and on detailed evaluation it was revealed that the child had paroxysms of severe pain. There were no undue stress factors or secondary gains, no convulsions could be elicited from the history. A diagnosis of
abdominal epilepsy was therefore suggested, based on the episodic nature of the condition and relatively symptom free periods in between and also no attention seeking was noted, despite the child being a precious one (only child after three miscarriages). An electroencephalogram (EEG) was done in order to investigate for epileptic phenomenon and it found to be abnormal, indicating epilepsy. Neurologist opinion was taken and the child was put on carbamazepine 100 mg twice daily after preliminary investigations to which he showed a remarkable response. He has been symptom-free from the time of the medication change for the past one year. The criteria laid down for its diagnosis [3] are (i) paroxysmal abdominal pain, (ii) exclusion of abdominal visceral pathology, (iii) alteration of mental status during some of the attacks, (iv) definite abnormal electro-encephalographic tracing and (v) response to anticonvulsant therapy. Not all the criteria need be present in each case to confirm the diagnosis. A similar picture may also be seen in abdominal migraine. However, in that condition, the pain is usually gradual in onset, a family history of migraine is often present, and the EEG is normal or shows only minor abnormalities. Compliance with Ethical Standards Conflict of Interest None. Source of Funding None.
* Nakka Nagarajitha [email protected]
References 1
2
Department of Psychiatry, Bhaskar Medical College, Hyderabad, Telangana 500075, India Department of Pediatrics, Bhaskar Medical College, Hyderabad, Telangana 500075, India
1.
Zarling EJ. Abdominal epilepsy: an unusual cause of recurrent abdominal pain. Am J Gastroenterol. 1984;79:687–8. 2. Schade GH, Gofman H. Abdominal epilepsy in childhood. Pediatrics. 1960;25:151–4.
Indian J Pediatr 3. 4.
Douglas EF, White PT. Abdominal epilepsy - a reappraisal. J Pediatr. 1971;78:59–67. Kessler RC, Borges G, Walters EE. Prevalence of and risk factors for lifetime suicide attempts in the national comorbidity survey. Arch Gen Psychiatry. 1999;56:617–26.
5.
Hankin BL, Abramson LY. Development of gender differences in depression: an elaborated cognitive vulnerability-transactional stress theory. Psychol Bull. 2001;127:773–96.
