Recurrent Abdominal Pain Gunnar B. Stickler, MD, Dennis B.
\s=b\ A
Murphy,
long-term follow-up study (mini-
of five years) of 161 children with recurrent abdominal pain disclosed that three had organic disease that was missed\p=m-\inflammatorybowel disease. Anorexia nervosa developed in one patient. Three fourths of the patients recovered from the initial symptom; most recovered within a few weeks; but some patients continued to have complaints for a number of years. Approximately 20% of patients underwent additional surgical or medical treatments of doubtful necessity. In 18% of patients, other psychosomatic mum
symptoms developed. (Am J Dis Child 133:486-489, 1979) children in England, that one of every nine children of school age had at least three episodes of abdominal pain affecting normal activities during a period of longer than three months. In contrast, one of seven children com¬ plained of headaches, and one of 25 complained of recurrent pain in the limbs. Apley and MacKeith1 found an organic cause in only one of 20 chil¬ dren complaining of abdominal pain. The list of organic causes for abdomi¬ nal pain is long, but approximately half are related to diseases of the urinary tract. Gastrointestinal (GI) causes include inflammatory bowel
of In Apley1 found a
survey
-
disease, Meckel's diverticulum, recur¬ rent intestinal intussusception, peptic ulcers, and tumors.2 Several "causes" mentioned in the literature, such as
the presence of worms, nonspecific mesenteric lymphadenitis, chronic ap¬ pendicitis, abdominal epilepsy, mi¬ graine, linea alba hernia, and food allergy, are not bona fide causes,
according to Apley.1 Patients who
are seen
because of
vague, subjective symptoms such as abdominal pain pose a great chal¬
lenge, particularly to the inexperi¬ enced physician. Many children are seen in a major referral center because of various nonorganic comFrom the Mayo Clinic and Mayo Foundation, Rochester, Minn. Reprints not available.
MD
plaints, such as stomach pains, leading to prolonged absences from school. In
many instances, such children have had multiple consultations and inves¬ tigations, and either the parents were unable to accept the diagnosis of psychosomatic illness or the physi¬ cians could not convince themselves that there was no evidence of organic illness. Perhaps one of the major reasons for this reluctance to accept abdominal pain as a psychosomatic disorder stems from the fear of over¬ looking serious progressive organic illness or the mistaken belief that a definite emotional cause has to be found to explain the illness. To alle¬ viate this fear and to find out how successful we were in counseling these children and their parents, we evalu¬ ated the outcome of patients with disease processes classified as recur¬ rent psychosomatic abdominal pain. SUBJECTS AND METHODS The records of all patients younger than 15 years of age who had been seen at the Mayo Clinic from 1962 to 1967 were selected on the basis of the following diag¬ functional abdominal pain, psycho¬ somatic abdominal pain, recurrent abdomi¬ nal pain of undetermined etiology, abdom¬ inal pain, separation anxiety, and school phobia. Patients were included only if they had symptoms for at least one month. A total of 170 patients were identified. Twen¬ ty-two patients had been followed up at our clinic for many years because of their place of residence but the majority of patients were self-referred. A group of patients was referred by their family physician, but a distinction as to whether the patient was truly referred or whether the parents decided on their own to come could not be made. A questionnaire was sent to the parents in 1973 to ensure a minimum follow-up of five years. Some patients were difficult to trace, and replies to our ques¬ tionnaire after a second mailing to nonresponders came in as late as the summer of 1977. Twenty-nine parents or patients were interviewed by telephone. The ques¬ tions asked were identical to those used on the questionnaire. No evidence could be found that the phone interview was inferi¬ or to a completed questionnaire. noses:
RESULTS
Complete follow-up was obtained on 161 of the 170 patients; 61 were boys and 100 were girls. There were patients in each age group, but the numbers seemed to peak in both sexes at 11 and 12 years of age. The duration of symptoms varied, but many pa¬ tients had symptoms for less than one year. Specific findings in 161 children with recurrent abdominal pain in¬ cluded the following: There were five girls and three boys aged 5 years and younger, seven girls and four boys aged 5 to 6 years, 18 girls and 16 boys aged 7 to 8 years, 22 girls and seven boys aged 9 to 10 years, 22 girls and 20 boys aged 11 to 12 years, and 23 girls and 11 boys aged 13 to 14 years. In 72 patients the duration of the complaint was less than one year, in 48 patients it was one to three years, and in 41 patients it was three years or longer. Associated symptoms consisted of nausea in 72 patients, vomiting in 56 patients, diarrhea in 34 patients, lowgrade fever in 24 patients, and consti¬ pation in 11 patients. There were normal roentgenographic findings of the stomach and duodenum in 97 patients, of barium enema examina¬ tion in 56 patients, of the small bowel in 37 patients, of excretory urograms in 32 patients, and of the gallbladder in 14 patients. Other findings included normal results of proctoscopic exami¬ nations in 19 patients, normal leuko¬ cyte counts in 151 patients, and normal urine in 153 patients. Sedi¬ mentation rate (in millimeters per hour) was less than 20 in 91 patients, 20 to 30 in 11 patients, and more than 30 in seven patients. In addition, there were normal EEG findings in 16 patients. Findings of stool guaiac were negative in 61 patients and posi¬ tive in six patients. Many of the patients had been suspected of having no evidence of organic disease, but others had received diagnoses elsewhere of duo¬ denal ulcer, abdominal epilepsy, ab¬ dominal migraine, spastic colon, mesenteric cysts, and kidney stones. Eight patients had previous appendecto¬ mies, and another eight had abdomi¬ nal exploratory surgery. One child had an
appendectomy,
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a
herniorrhaphy,
and two abdominal explorations done elsewhere. Among associated symptoms, nau¬ sea was mentioned by almost one half of the patients, with vomiting or loose stools being mentioned less frequent¬ ly. That school was missed was stated specifically by the parents of 35 patients, and a history of sleeping with one parent or the other was noted in the records of eight patients. This was considered to be a sign of
separation anxiety. Results of our physical
examina¬ tions were normal, with the exception of rather vague abdominal tenderness that was mentioned frequently. Many patients located the pain in the umbil¬ ical area. Almost all patients were tested for hemoglobin level, leukocyte count, and urinalysis; results of all of these were normal. Because these patients were seen by a number of pediatrie consul¬ tants on our staff, the number of addi¬ tional roentgenographic examinations or other evaluations varied. The has been impression gained from this review that the more experienced physician ordered fewer additional tests, and perhaps the less-anxious parent was more easily satisfied with fewer investigations. Many of the additional tests were ordered as a part of the psychotherapeutic regimen to alleviate anxiety. No minimal diag¬ nostic workup had been defined, but this had been left to the individual
physician. Thirty-three patients underwent psychiatric consultations, and psycho¬ therapy was recommended for 31 patients. None of these patients had abdominal explorations while under
The management varied but consisted in most instances of the following:'(l) having a detailed consul¬ tation with the parents and the child; (2) recommending a return to school and (3) having some "face-saving' device available for the children—in other words, an explanation of a possi¬ ble mechanism for the abdominal pain that would be understood and ac¬ cepted by the child's peers. The major¬ ity of patients returned to their fami¬ ly physician, or when they lived close our care.
enough to our clinic, they were encour¬ aged to return if there were continued
difficulties. No data were obtained in this study to ascertain the type of follow-up recommended for each pa¬ tient. OUTCOME
information was avail¬ 161 of 170 patients. Nine patients could not be traced, but their symptoms and clinical findings on the initial examination did not differ substantially from those of the other 161 patients. The outcome is described in terms of several "adjustments" or "solutions" to the problem. Some of the patients could be placed in more than one adjustment category. With a minimum follow-up of five years, adjustment of the 161 children was as follows: There was rapid reso¬ lution in 92 patients and later resolu¬ tion in 31 patients. Of the 31 patients, six had surgery elsewhere, with relief of pain (two patients had an appen¬ dectomy and one each had a laparotomy for adhesions, surgery for rup¬ tured ovarian cysts, tonsillectomy and adenoidectomy, and laminectomy); seven had other psychosomatic symp¬ toms, but no further abdominal pain; eight displaced the abdominal pain complaint with other complaints, and ten experienced a prolonged recovery phase. Of the total 161 children, 38 failed to resolve their abdominal pain. Of those patients, 14 had surgery else¬ where but continued to have abdomi¬ nal pain or they had other psychoso¬ matic complaints (surgery was done for ovarian cysts in five patients, and five patients had an appendectomy, one patient had a dilation and curettage, one patient had a subtotal gas¬ tric resection, and two patients had bowel resection for Crohn's disease). Twenty-two of the 38 patients contin¬ ued to have abdominal pain and hypochondriasis. Another three patients had organic disease (Crohn's disease) (two of the three were among the 14 patients who had had surgery), and one patient had anorexia nervosa in addition to continued abdominal pain and other psychosomatic symptoms.
Follow-up
able
on
COMMENT 'The Cure' A
typical comment was, "We fol¬ physician's diagnosis and
lowed the
our child no longer has abdominal pain." Ninety-two patients were in this category. These patients had their symptoms disappear within a short time, they were completely reha¬ bilitated, and they returned to
school.
'The Continued Problem'
Sixty-nine patients continued to have symptoms. However, the abdom¬ inal pain of 31 patients improved eventually over a period of one to nine years, averaging 3Vé years; again there was some variation in the type of adjustment. Together with the 92 patients whose conditions improved immediately, there were 123 patients who were eventually free of symp¬ toms (three fourths of all patients followed up for five years or longer). The symptoms were worse in seven patients. In 15 patients, the symptoms had not changed, and 16 patients failed to indicate the severity of symptoms at the time of the follow-up inquiry.
Various
adjustments occurred patients who did not respond promptly to reassurance and counseling. For instance, some of the 14 patients who had had surgery with questionable indication were cured of the abdominal pain but other psycho¬ somatic symptoms developed, or eight patients who had additional diagnoses displaced the abdominal pain com¬ plaint with other complaints. Patients with psychiatric consultations did no better or did worse in their adjust¬ among the 69
ment than
did those who had not received such consultation. There was no trend detected in which patients were selected for psychiatric interven¬ tion in the first place. Only one patient died. This was a boy in his late teens who died of an accidental gunshot wound. Nothing in his parents' reply to our inquiry would allow the conclusion that this was a suicide, yet this possibility cannot be ruled out. He had had prompt resolu¬ tion of his abdominal pain. Three patients had definite organic disease (Crohn's disease) that was not recognized at the initial examination. The diagnosis had been suspected in two cases, but roentgenographic stud¬ ies of the small bowel in both failed to
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confirm the diagnosis. One patient had a normal sedimentation rate, and the other had a rate of 24 mm in one hour. A definite warning signal was the fact that one patient had a recent
weight loss of 4.1 kg, and the other patient had lost 2.7 kg. In the third patient, the diagnosis had not been suspected, but she had had a barium
examination, the results of which were normal. The diagnosis was made six to seven years after these patients were initially seen. None of them had returned to our clinic for a follow-up visit. One set of parents was resentful that, during the initial eval¬ uation, a psychiatric examination had been scheduled, and they canceled this enema
appointment. Eight patients were under psychiat¬ ric care at the time of the inquiry. No
indication was given that any of these patients had been psychotic at any time.
Surgical Procedures A typical comment was, "With the removal of the second cyst (ovarian) and also the right ovary, it was found in the biopsy specimen of the cyst that if she had waited any longer than when she did have the surgery, the cyst would have been cancerous." Twenty patients had surgical proce¬ dures done elsewhere after we had seen them. In considering the type of surgery that these patients had, followed by relief of symptoms, it became apparent that six of the 20 had experienced a placebo effect. Fourteen patients continued to have abdominal pain or had other psychoso¬ matic complaints at the time of the inquiry. Two of the patients were found to have Crohn's disease and had bowel resection. Other procedures included appendectomy in seven pa¬ tients and removal of ovarian cysts in six patients. Of the remaining five patients in this group, one patient had a laparotomy to "remove adhesions"; one patient had a tonsillectomy and adenoidectomy; one patient had a dila¬ tion and curettage, a laminectomy, and a subtotal gastric resection; and one patient had removal of an ovarian cyst and an appendectomy. The lastmentioned patient had a cyst removed from the ovary, yet she continued to
complain of nausea, headaches, leg pains, shortness of breath, and blurred vision. She lost her job as a factory worker because of frequent absences. Another patient had surgery on a "ruptured ovarian cyst" ten days after she was seen at our clinic, and it is impossible to state whether the abdominal pain was related to this cyst or not. The patients who had surgical procedures done before exam¬
ination at our clinic had outcomes similar to those of the general group. It was disconcerting that one of five children (20%) had surgical procedures before or after we had seen them.
Displacing Diagnosis' A typical comment was, "The prob¬ lem at Mayo Clinic was approached from an emotional standpoint. The osteopath said that she had a severe 'The
abdominal obstruction. She worked on this for about five treatments and has no further difficulties." This adjust¬ ment could be called adjustment by a "displacing diagnosis." Fifteen pa¬ tients were in this category. The patient went to another physician or in some instances to a chiropractor. A diagnosis was made, the patient's
symptoms were explained on an organic basis, and treatment was given. A different diagnosis may have been the proper one. However, it would be difficult to accept such diag¬ noses as "milk allergy outgrown in
early teens," diaphragmatic hernia, dysmenorrhea, intestinal virus, and
sinus infection as true causes of the patient's symptoms of recurrent abdominal pain. Yet, most of these patients seemed to be helped. One patient was considered to have a "spastic" colon, a diagnosis not infre¬ quently made by internists. even
'Learned to Live With It'
A typical comment was, "However, I have learned to relax under tense situations, so I very rarely have recur¬ rence of the pain." Twenty patients or
their parents reported that they recognized, in some fashion, the rela¬ tionship between tension or stress and pain. All of these patients had learned to live with the problem and reported no further absences from school or work.
'The
Hypochondriac'
A typical comment was, "I have thought for some time my son was a hypochondriac. It always is the same thing. Most times he is tired. Really not up to par or doesn't feel just right." Twenty-nine patients were in
this category. Patients whose reports indicated that they had one or more of the following symptoms, with or without further abdominal pain, were consid¬ ered to have a "hypochondriacal adjustment": nausea, headache, dizzi¬ ness, weakness, leg aches, shortness of breath, blurred vision, and pain in the arms or legs. Seven of the 29 patients reported having no further abdominal pains. The other 22 had continued abdominal pains. A total of five patients had surgery, with questiona¬ ble indications. One patient suffered anorexia nervosa. Eight patients had gained good insight into their prob¬ lem, whereas five had not. Five of the 29 patients had been seen by a psychiatrist, and, again, there was no evidence that the initial symptoms or the psychiatric consultation had had any influence on the outcome. CONCLUSIONS This study did not include all of the children who were seen with chronic abdominal pain. The study was lim¬ ited to children who were thought to have nonorganic disease, based on their clinical history, physical find¬ ings, and normal results of laboratory and roentgenographic examinations. The major questions were: Was sig¬ nificant organic illness missed? Was serious psychiatric disease missed? What was the later adjustment of these children? Only three instances of organic disease were missed. (Three patients had a later diagnosis of inflammatory bowel disease.) In two of the patients, the disease had been suspected, but it was not confirmed by the roentgeno¬ graphic examination. Warning signs such as loss of weight in two patients and anemia were noted retrospective¬ ly. In one other patient, the diagnosis of an ovarian cyst, which supposedly ruptured ten days after the examina¬ tion, may have been missed, but there was no
confirmation by
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a
pathologist.
Whether some of the other diagnoses made later were indeed explanations for the initial symptoms remains an open question. Only the patient who later had the diagnosis of anorexia nervosa may have had abdominal pain as an
early symptom.
In diagnosing and treating psycho¬ somatic illness, the dilemma of decid¬ ing on the magnitude of additional roentgenographic and laboratory ex¬ aminations remains. We could not establish the absolute minimum num¬ ber of examinations necessary to exclude organic disease, and it is doubtful that this would be possible. Too many factors influence the need or lack of need for extensive investi¬ gations. Weiss' has stated it very well:
Psychosomatic diagnosis means more than diagnosis by exclusion. It means the utili¬ zation of physiological and psychological technics simultaneously in preparation for comprehensive medical care.... Diagnosis by exclusion is dangerous in these cases and leads to greater invalidism. The physi¬ cian becomes a pathogenic agent in perpet¬ uating the illness by his well meaning but mistaken and never-ending efforts to find a "physical cause." This statement reflects
our
feelings
accurately, yet we have seen anxiety among some physicians, lead¬ ing to numerous and even harmful investigations. However, when pa¬ most
tients with three
or more
roentgeno¬
graphic investigations were compared with patients who had only one such examination, we found no significant
difference in relation to continuance of symptoms (18% vs 19%), perhaps minimizing the risk that Weiss men¬ tioned. Three long-term follow-up studies of children who had psychosomatic abdominal pain were available in the literature. These involved 60,"' 34," and 1197 patients. The first two studies suggested that about one third of patients continue to have symptoms of abdominal pain but that other
psychosomatic symptoms also may develop. In Liebman's7 study, on a telephone follow-up, 24% of patients were found to have relapses. Very few instances of organic disease were missed in Apley and Hale's5 series of 60 patients: one patient had a duode-
nal ulcer
diagnosed
late and another considered to have a dermoid cyst of both ovaries, causing abdominal pain. Christensen and Mortensen's study" of 34 patients, compar¬ ing them with a control group, showed that 18 patients continued to have abdominal pain. They attributed these symptoms in 11 patients to "irritable colon," in five patients to "irritable colon plus peptic ulcer-gastritis," and in two patients to duodenal ulcers. In reviewing this last study, the question arose as to the evidence for such "or¬ ganic" diagnoses. A shorter follow-up study of 18 months maximum was reported by Berger and co-workers* with better results, but associated
patient
new
was
psychosomatic symptoms
were
not studied. However, in their study, continued contact may have pre¬
vented these
exposed
to
patients from being
less-effective medical
or
surgical procedures. A follow-up study of roentgenographic findings was reported by Heinild et al."
Less reassuring in our study was the persistence of symptoms in a siza¬ ble percentage of patients and the failure to keep these patients from
exposure to
diagnoses
or
new and questionable surgical procedures. In
way can we state that these proce¬ dures were not indicated, nor can we be convinced that the effect of addi¬ tional medical or surgical procedures was not a placebo effect. Yet, it would have been desirable to avoid unneces¬ sary procedures and further tests and interpretations. Perhaps the develop¬ ment of more psychosomatic disease and the emergence of true hypochondriasis cannot be avoided. Yet, one wonders whether continued psycho¬ therapy or at least contact with a physician could have avoided such an unfortunate adjustment, or as Chris¬ and Mortensen" consid¬ tensen ered, "... whether more intense psy¬ chiatric treatment might prevent some little bellyachers from growing up to become big bellyachers." The lessons learned from the study include the following: (1) The diagno¬ sis of psychosomatic pain is correct in most instances, and organic disease is missed but rarely. (2) Loss of weight and anemia are signs of organic disease in patients with abdominal no
pain. (3) Roentgenographic and labo¬ ratory studies should be kept to a minimum. (4) Patients who are consid¬ ered to have nonorganic abdominal pain must be followed up to avoid unnecessary additional procedures,
and psychotherapy should be insti¬ tuted if necessary. For most patients with abdominal pain who are often absent from school, the recommendations made so ably by Schmitt1" follow and some are added: (1) Give the patient an unequivocal clean bill of health. (2) Persuade the parents that immediate return to school is mandatory. (3) Review with the mother what to do if the child is "sick" or late on school mornings. (4) Designate the adult responsible for taking the child to school if he refuses to go. (5) Contact the school principal and nurse. We would like to add the following: (6) Perhaps the child should be provided with a "face-saving" device, that is, an excuse that she or he can give to explain the symptoms and prolonged absences to peers. An example would be "nonspecific flu," a prolonged viral syndrome. (7) Berger and co-workers* have stressed the importance of a family conference. Both parents and the patient should be counseled carefully and an appro¬ priate follow-up should be arranged. References 1. Apley J: The Child With Abdominal Pain, ed 2. Oxford, Blackwell Scientific Publications, 1975. 2. Apley J, MacKeith R: The Child and His Symptoms: A Psychosomatic Approach. Philadelphia, FA Davis Co, 1962, pp 40-46. 3. Apley J: The child with recurrent abdominal pain. Pediatr Clin North Am 14:63-72, 1967. 4. Weiss E: Psychogenic rheumatism. Ann Intern Med 26:890-900, 1947. 5. Apley J, Hale B: Children with recurrent abdominal pain: How do they grow up? Br Med J 3:7-9, 1973. 6. Christensen MF, Mortensen 0: Long-term prognosis in children with recurrent abdominal pain. Arch Dis Child 50:110-114, 1975. 7. Liebman WH: Recurrent abdominal pain in children: A retrospective survey of 119 patients. Clin Pediatr 17:149-153, 1978. 8. Berger HG, Honig PJ, Liebman R: Recurrent abdominal pain: Gaining control of the symptom. Am J Dis Child 131:1340-1344, 1977. 9. Heinild S, Malver E, Roelsgaard G, et al: A psychosomatic approach to recurrent abdominal pain in childhood: With particular reference to the x-ray appearances of the stomach. Acta Paediatr 48:361-370, 1959. 10. Schmitt BD: School phobia\p=n-\thegreat imitator: A pediatrician's viewpoint. Pediatrics 48:433-441, 1971.
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\s=b\ A
Murphy,
long-term follow-up study (mini-
of five years) of 161 children with recurrent abdominal pain disclosed that three had organic disease that was missed\p=m-\inflammatorybowel disease. Anorexia nervosa developed in one patient. Three fourths of the patients recovered from the initial symptom; most recovered within a few weeks; but some patients continued to have complaints for a number of years. Approximately 20% of patients underwent additional surgical or medical treatments of doubtful necessity. In 18% of patients, other psychosomatic mum
symptoms developed. (Am J Dis Child 133:486-489, 1979) children in England, that one of every nine children of school age had at least three episodes of abdominal pain affecting normal activities during a period of longer than three months. In contrast, one of seven children com¬ plained of headaches, and one of 25 complained of recurrent pain in the limbs. Apley and MacKeith1 found an organic cause in only one of 20 chil¬ dren complaining of abdominal pain. The list of organic causes for abdomi¬ nal pain is long, but approximately half are related to diseases of the urinary tract. Gastrointestinal (GI) causes include inflammatory bowel
of In Apley1 found a
survey
-
disease, Meckel's diverticulum, recur¬ rent intestinal intussusception, peptic ulcers, and tumors.2 Several "causes" mentioned in the literature, such as
the presence of worms, nonspecific mesenteric lymphadenitis, chronic ap¬ pendicitis, abdominal epilepsy, mi¬ graine, linea alba hernia, and food allergy, are not bona fide causes,
according to Apley.1 Patients who
are seen
because of
vague, subjective symptoms such as abdominal pain pose a great chal¬
lenge, particularly to the inexperi¬ enced physician. Many children are seen in a major referral center because of various nonorganic comFrom the Mayo Clinic and Mayo Foundation, Rochester, Minn. Reprints not available.
MD
plaints, such as stomach pains, leading to prolonged absences from school. In
many instances, such children have had multiple consultations and inves¬ tigations, and either the parents were unable to accept the diagnosis of psychosomatic illness or the physi¬ cians could not convince themselves that there was no evidence of organic illness. Perhaps one of the major reasons for this reluctance to accept abdominal pain as a psychosomatic disorder stems from the fear of over¬ looking serious progressive organic illness or the mistaken belief that a definite emotional cause has to be found to explain the illness. To alle¬ viate this fear and to find out how successful we were in counseling these children and their parents, we evalu¬ ated the outcome of patients with disease processes classified as recur¬ rent psychosomatic abdominal pain. SUBJECTS AND METHODS The records of all patients younger than 15 years of age who had been seen at the Mayo Clinic from 1962 to 1967 were selected on the basis of the following diag¬ functional abdominal pain, psycho¬ somatic abdominal pain, recurrent abdomi¬ nal pain of undetermined etiology, abdom¬ inal pain, separation anxiety, and school phobia. Patients were included only if they had symptoms for at least one month. A total of 170 patients were identified. Twen¬ ty-two patients had been followed up at our clinic for many years because of their place of residence but the majority of patients were self-referred. A group of patients was referred by their family physician, but a distinction as to whether the patient was truly referred or whether the parents decided on their own to come could not be made. A questionnaire was sent to the parents in 1973 to ensure a minimum follow-up of five years. Some patients were difficult to trace, and replies to our ques¬ tionnaire after a second mailing to nonresponders came in as late as the summer of 1977. Twenty-nine parents or patients were interviewed by telephone. The ques¬ tions asked were identical to those used on the questionnaire. No evidence could be found that the phone interview was inferi¬ or to a completed questionnaire. noses:
RESULTS
Complete follow-up was obtained on 161 of the 170 patients; 61 were boys and 100 were girls. There were patients in each age group, but the numbers seemed to peak in both sexes at 11 and 12 years of age. The duration of symptoms varied, but many pa¬ tients had symptoms for less than one year. Specific findings in 161 children with recurrent abdominal pain in¬ cluded the following: There were five girls and three boys aged 5 years and younger, seven girls and four boys aged 5 to 6 years, 18 girls and 16 boys aged 7 to 8 years, 22 girls and seven boys aged 9 to 10 years, 22 girls and 20 boys aged 11 to 12 years, and 23 girls and 11 boys aged 13 to 14 years. In 72 patients the duration of the complaint was less than one year, in 48 patients it was one to three years, and in 41 patients it was three years or longer. Associated symptoms consisted of nausea in 72 patients, vomiting in 56 patients, diarrhea in 34 patients, lowgrade fever in 24 patients, and consti¬ pation in 11 patients. There were normal roentgenographic findings of the stomach and duodenum in 97 patients, of barium enema examina¬ tion in 56 patients, of the small bowel in 37 patients, of excretory urograms in 32 patients, and of the gallbladder in 14 patients. Other findings included normal results of proctoscopic exami¬ nations in 19 patients, normal leuko¬ cyte counts in 151 patients, and normal urine in 153 patients. Sedi¬ mentation rate (in millimeters per hour) was less than 20 in 91 patients, 20 to 30 in 11 patients, and more than 30 in seven patients. In addition, there were normal EEG findings in 16 patients. Findings of stool guaiac were negative in 61 patients and posi¬ tive in six patients. Many of the patients had been suspected of having no evidence of organic disease, but others had received diagnoses elsewhere of duo¬ denal ulcer, abdominal epilepsy, ab¬ dominal migraine, spastic colon, mesenteric cysts, and kidney stones. Eight patients had previous appendecto¬ mies, and another eight had abdomi¬ nal exploratory surgery. One child had an
appendectomy,
Downloaded From: http://archpedi.jamanetwork.com/ by a Karolinska Institutet University Library User on 05/22/2015
a
herniorrhaphy,
and two abdominal explorations done elsewhere. Among associated symptoms, nau¬ sea was mentioned by almost one half of the patients, with vomiting or loose stools being mentioned less frequent¬ ly. That school was missed was stated specifically by the parents of 35 patients, and a history of sleeping with one parent or the other was noted in the records of eight patients. This was considered to be a sign of
separation anxiety. Results of our physical
examina¬ tions were normal, with the exception of rather vague abdominal tenderness that was mentioned frequently. Many patients located the pain in the umbil¬ ical area. Almost all patients were tested for hemoglobin level, leukocyte count, and urinalysis; results of all of these were normal. Because these patients were seen by a number of pediatrie consul¬ tants on our staff, the number of addi¬ tional roentgenographic examinations or other evaluations varied. The has been impression gained from this review that the more experienced physician ordered fewer additional tests, and perhaps the less-anxious parent was more easily satisfied with fewer investigations. Many of the additional tests were ordered as a part of the psychotherapeutic regimen to alleviate anxiety. No minimal diag¬ nostic workup had been defined, but this had been left to the individual
physician. Thirty-three patients underwent psychiatric consultations, and psycho¬ therapy was recommended for 31 patients. None of these patients had abdominal explorations while under
The management varied but consisted in most instances of the following:'(l) having a detailed consul¬ tation with the parents and the child; (2) recommending a return to school and (3) having some "face-saving' device available for the children—in other words, an explanation of a possi¬ ble mechanism for the abdominal pain that would be understood and ac¬ cepted by the child's peers. The major¬ ity of patients returned to their fami¬ ly physician, or when they lived close our care.
enough to our clinic, they were encour¬ aged to return if there were continued
difficulties. No data were obtained in this study to ascertain the type of follow-up recommended for each pa¬ tient. OUTCOME
information was avail¬ 161 of 170 patients. Nine patients could not be traced, but their symptoms and clinical findings on the initial examination did not differ substantially from those of the other 161 patients. The outcome is described in terms of several "adjustments" or "solutions" to the problem. Some of the patients could be placed in more than one adjustment category. With a minimum follow-up of five years, adjustment of the 161 children was as follows: There was rapid reso¬ lution in 92 patients and later resolu¬ tion in 31 patients. Of the 31 patients, six had surgery elsewhere, with relief of pain (two patients had an appen¬ dectomy and one each had a laparotomy for adhesions, surgery for rup¬ tured ovarian cysts, tonsillectomy and adenoidectomy, and laminectomy); seven had other psychosomatic symp¬ toms, but no further abdominal pain; eight displaced the abdominal pain complaint with other complaints, and ten experienced a prolonged recovery phase. Of the total 161 children, 38 failed to resolve their abdominal pain. Of those patients, 14 had surgery else¬ where but continued to have abdomi¬ nal pain or they had other psychoso¬ matic complaints (surgery was done for ovarian cysts in five patients, and five patients had an appendectomy, one patient had a dilation and curettage, one patient had a subtotal gas¬ tric resection, and two patients had bowel resection for Crohn's disease). Twenty-two of the 38 patients contin¬ ued to have abdominal pain and hypochondriasis. Another three patients had organic disease (Crohn's disease) (two of the three were among the 14 patients who had had surgery), and one patient had anorexia nervosa in addition to continued abdominal pain and other psychosomatic symptoms.
Follow-up
able
on
COMMENT 'The Cure' A
typical comment was, "We fol¬ physician's diagnosis and
lowed the
our child no longer has abdominal pain." Ninety-two patients were in this category. These patients had their symptoms disappear within a short time, they were completely reha¬ bilitated, and they returned to
school.
'The Continued Problem'
Sixty-nine patients continued to have symptoms. However, the abdom¬ inal pain of 31 patients improved eventually over a period of one to nine years, averaging 3Vé years; again there was some variation in the type of adjustment. Together with the 92 patients whose conditions improved immediately, there were 123 patients who were eventually free of symp¬ toms (three fourths of all patients followed up for five years or longer). The symptoms were worse in seven patients. In 15 patients, the symptoms had not changed, and 16 patients failed to indicate the severity of symptoms at the time of the follow-up inquiry.
Various
adjustments occurred patients who did not respond promptly to reassurance and counseling. For instance, some of the 14 patients who had had surgery with questionable indication were cured of the abdominal pain but other psycho¬ somatic symptoms developed, or eight patients who had additional diagnoses displaced the abdominal pain com¬ plaint with other complaints. Patients with psychiatric consultations did no better or did worse in their adjust¬ among the 69
ment than
did those who had not received such consultation. There was no trend detected in which patients were selected for psychiatric interven¬ tion in the first place. Only one patient died. This was a boy in his late teens who died of an accidental gunshot wound. Nothing in his parents' reply to our inquiry would allow the conclusion that this was a suicide, yet this possibility cannot be ruled out. He had had prompt resolu¬ tion of his abdominal pain. Three patients had definite organic disease (Crohn's disease) that was not recognized at the initial examination. The diagnosis had been suspected in two cases, but roentgenographic stud¬ ies of the small bowel in both failed to
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confirm the diagnosis. One patient had a normal sedimentation rate, and the other had a rate of 24 mm in one hour. A definite warning signal was the fact that one patient had a recent
weight loss of 4.1 kg, and the other patient had lost 2.7 kg. In the third patient, the diagnosis had not been suspected, but she had had a barium
examination, the results of which were normal. The diagnosis was made six to seven years after these patients were initially seen. None of them had returned to our clinic for a follow-up visit. One set of parents was resentful that, during the initial eval¬ uation, a psychiatric examination had been scheduled, and they canceled this enema
appointment. Eight patients were under psychiat¬ ric care at the time of the inquiry. No
indication was given that any of these patients had been psychotic at any time.
Surgical Procedures A typical comment was, "With the removal of the second cyst (ovarian) and also the right ovary, it was found in the biopsy specimen of the cyst that if she had waited any longer than when she did have the surgery, the cyst would have been cancerous." Twenty patients had surgical proce¬ dures done elsewhere after we had seen them. In considering the type of surgery that these patients had, followed by relief of symptoms, it became apparent that six of the 20 had experienced a placebo effect. Fourteen patients continued to have abdominal pain or had other psychoso¬ matic complaints at the time of the inquiry. Two of the patients were found to have Crohn's disease and had bowel resection. Other procedures included appendectomy in seven pa¬ tients and removal of ovarian cysts in six patients. Of the remaining five patients in this group, one patient had a laparotomy to "remove adhesions"; one patient had a tonsillectomy and adenoidectomy; one patient had a dila¬ tion and curettage, a laminectomy, and a subtotal gastric resection; and one patient had removal of an ovarian cyst and an appendectomy. The lastmentioned patient had a cyst removed from the ovary, yet she continued to
complain of nausea, headaches, leg pains, shortness of breath, and blurred vision. She lost her job as a factory worker because of frequent absences. Another patient had surgery on a "ruptured ovarian cyst" ten days after she was seen at our clinic, and it is impossible to state whether the abdominal pain was related to this cyst or not. The patients who had surgical procedures done before exam¬
ination at our clinic had outcomes similar to those of the general group. It was disconcerting that one of five children (20%) had surgical procedures before or after we had seen them.
Displacing Diagnosis' A typical comment was, "The prob¬ lem at Mayo Clinic was approached from an emotional standpoint. The osteopath said that she had a severe 'The
abdominal obstruction. She worked on this for about five treatments and has no further difficulties." This adjust¬ ment could be called adjustment by a "displacing diagnosis." Fifteen pa¬ tients were in this category. The patient went to another physician or in some instances to a chiropractor. A diagnosis was made, the patient's
symptoms were explained on an organic basis, and treatment was given. A different diagnosis may have been the proper one. However, it would be difficult to accept such diag¬ noses as "milk allergy outgrown in
early teens," diaphragmatic hernia, dysmenorrhea, intestinal virus, and
sinus infection as true causes of the patient's symptoms of recurrent abdominal pain. Yet, most of these patients seemed to be helped. One patient was considered to have a "spastic" colon, a diagnosis not infre¬ quently made by internists. even
'Learned to Live With It'
A typical comment was, "However, I have learned to relax under tense situations, so I very rarely have recur¬ rence of the pain." Twenty patients or
their parents reported that they recognized, in some fashion, the rela¬ tionship between tension or stress and pain. All of these patients had learned to live with the problem and reported no further absences from school or work.
'The
Hypochondriac'
A typical comment was, "I have thought for some time my son was a hypochondriac. It always is the same thing. Most times he is tired. Really not up to par or doesn't feel just right." Twenty-nine patients were in
this category. Patients whose reports indicated that they had one or more of the following symptoms, with or without further abdominal pain, were consid¬ ered to have a "hypochondriacal adjustment": nausea, headache, dizzi¬ ness, weakness, leg aches, shortness of breath, blurred vision, and pain in the arms or legs. Seven of the 29 patients reported having no further abdominal pains. The other 22 had continued abdominal pains. A total of five patients had surgery, with questiona¬ ble indications. One patient suffered anorexia nervosa. Eight patients had gained good insight into their prob¬ lem, whereas five had not. Five of the 29 patients had been seen by a psychiatrist, and, again, there was no evidence that the initial symptoms or the psychiatric consultation had had any influence on the outcome. CONCLUSIONS This study did not include all of the children who were seen with chronic abdominal pain. The study was lim¬ ited to children who were thought to have nonorganic disease, based on their clinical history, physical find¬ ings, and normal results of laboratory and roentgenographic examinations. The major questions were: Was sig¬ nificant organic illness missed? Was serious psychiatric disease missed? What was the later adjustment of these children? Only three instances of organic disease were missed. (Three patients had a later diagnosis of inflammatory bowel disease.) In two of the patients, the disease had been suspected, but it was not confirmed by the roentgeno¬ graphic examination. Warning signs such as loss of weight in two patients and anemia were noted retrospective¬ ly. In one other patient, the diagnosis of an ovarian cyst, which supposedly ruptured ten days after the examina¬ tion, may have been missed, but there was no
confirmation by
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a
pathologist.
Whether some of the other diagnoses made later were indeed explanations for the initial symptoms remains an open question. Only the patient who later had the diagnosis of anorexia nervosa may have had abdominal pain as an
early symptom.
In diagnosing and treating psycho¬ somatic illness, the dilemma of decid¬ ing on the magnitude of additional roentgenographic and laboratory ex¬ aminations remains. We could not establish the absolute minimum num¬ ber of examinations necessary to exclude organic disease, and it is doubtful that this would be possible. Too many factors influence the need or lack of need for extensive investi¬ gations. Weiss' has stated it very well:
Psychosomatic diagnosis means more than diagnosis by exclusion. It means the utili¬ zation of physiological and psychological technics simultaneously in preparation for comprehensive medical care.... Diagnosis by exclusion is dangerous in these cases and leads to greater invalidism. The physi¬ cian becomes a pathogenic agent in perpet¬ uating the illness by his well meaning but mistaken and never-ending efforts to find a "physical cause." This statement reflects
our
feelings
accurately, yet we have seen anxiety among some physicians, lead¬ ing to numerous and even harmful investigations. However, when pa¬ most
tients with three
or more
roentgeno¬
graphic investigations were compared with patients who had only one such examination, we found no significant
difference in relation to continuance of symptoms (18% vs 19%), perhaps minimizing the risk that Weiss men¬ tioned. Three long-term follow-up studies of children who had psychosomatic abdominal pain were available in the literature. These involved 60,"' 34," and 1197 patients. The first two studies suggested that about one third of patients continue to have symptoms of abdominal pain but that other
psychosomatic symptoms also may develop. In Liebman's7 study, on a telephone follow-up, 24% of patients were found to have relapses. Very few instances of organic disease were missed in Apley and Hale's5 series of 60 patients: one patient had a duode-
nal ulcer
diagnosed
late and another considered to have a dermoid cyst of both ovaries, causing abdominal pain. Christensen and Mortensen's study" of 34 patients, compar¬ ing them with a control group, showed that 18 patients continued to have abdominal pain. They attributed these symptoms in 11 patients to "irritable colon," in five patients to "irritable colon plus peptic ulcer-gastritis," and in two patients to duodenal ulcers. In reviewing this last study, the question arose as to the evidence for such "or¬ ganic" diagnoses. A shorter follow-up study of 18 months maximum was reported by Berger and co-workers* with better results, but associated
patient
new
was
psychosomatic symptoms
were
not studied. However, in their study, continued contact may have pre¬
vented these
exposed
to
patients from being
less-effective medical
or
surgical procedures. A follow-up study of roentgenographic findings was reported by Heinild et al."
Less reassuring in our study was the persistence of symptoms in a siza¬ ble percentage of patients and the failure to keep these patients from
exposure to
diagnoses
or
new and questionable surgical procedures. In
way can we state that these proce¬ dures were not indicated, nor can we be convinced that the effect of addi¬ tional medical or surgical procedures was not a placebo effect. Yet, it would have been desirable to avoid unneces¬ sary procedures and further tests and interpretations. Perhaps the develop¬ ment of more psychosomatic disease and the emergence of true hypochondriasis cannot be avoided. Yet, one wonders whether continued psycho¬ therapy or at least contact with a physician could have avoided such an unfortunate adjustment, or as Chris¬ and Mortensen" consid¬ tensen ered, "... whether more intense psy¬ chiatric treatment might prevent some little bellyachers from growing up to become big bellyachers." The lessons learned from the study include the following: (1) The diagno¬ sis of psychosomatic pain is correct in most instances, and organic disease is missed but rarely. (2) Loss of weight and anemia are signs of organic disease in patients with abdominal no
pain. (3) Roentgenographic and labo¬ ratory studies should be kept to a minimum. (4) Patients who are consid¬ ered to have nonorganic abdominal pain must be followed up to avoid unnecessary additional procedures,
and psychotherapy should be insti¬ tuted if necessary. For most patients with abdominal pain who are often absent from school, the recommendations made so ably by Schmitt1" follow and some are added: (1) Give the patient an unequivocal clean bill of health. (2) Persuade the parents that immediate return to school is mandatory. (3) Review with the mother what to do if the child is "sick" or late on school mornings. (4) Designate the adult responsible for taking the child to school if he refuses to go. (5) Contact the school principal and nurse. We would like to add the following: (6) Perhaps the child should be provided with a "face-saving" device, that is, an excuse that she or he can give to explain the symptoms and prolonged absences to peers. An example would be "nonspecific flu," a prolonged viral syndrome. (7) Berger and co-workers* have stressed the importance of a family conference. Both parents and the patient should be counseled carefully and an appro¬ priate follow-up should be arranged. References 1. Apley J: The Child With Abdominal Pain, ed 2. Oxford, Blackwell Scientific Publications, 1975. 2. Apley J, MacKeith R: The Child and His Symptoms: A Psychosomatic Approach. Philadelphia, FA Davis Co, 1962, pp 40-46. 3. Apley J: The child with recurrent abdominal pain. Pediatr Clin North Am 14:63-72, 1967. 4. Weiss E: Psychogenic rheumatism. Ann Intern Med 26:890-900, 1947. 5. Apley J, Hale B: Children with recurrent abdominal pain: How do they grow up? Br Med J 3:7-9, 1973. 6. Christensen MF, Mortensen 0: Long-term prognosis in children with recurrent abdominal pain. Arch Dis Child 50:110-114, 1975. 7. Liebman WH: Recurrent abdominal pain in children: A retrospective survey of 119 patients. Clin Pediatr 17:149-153, 1978. 8. Berger HG, Honig PJ, Liebman R: Recurrent abdominal pain: Gaining control of the symptom. Am J Dis Child 131:1340-1344, 1977. 9. Heinild S, Malver E, Roelsgaard G, et al: A psychosomatic approach to recurrent abdominal pain in childhood: With particular reference to the x-ray appearances of the stomach. Acta Paediatr 48:361-370, 1959. 10. Schmitt BD: School phobia\p=n-\thegreat imitator: A pediatrician's viewpoint. Pediatrics 48:433-441, 1971.
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