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Chronic abdominal complaints are a frequent concern or complaint of adolescents and young adults. One definition is three or more separate episodes of pain that occur over a 3 - month period. In most cases of recurrent abdominal pain in adolescents, no specific organic problem is found. The prevalence is as high as 5-10% or more of all adolescents.
Differential Diagnosis includes:
- Functional abdominal pain often related to stress and eating habits. The pain tends to be periumbilical, crampy and nonspecific without radiation. It usually does not wake adolescents. There may be associated nausea and vomiting, headaches, fatigue, dizziness and diarrhea. It does not usually cause weight loss or other systemic symptoms. It distinction organic abdominal pain usually includes more localized pain and may awake the teen from sleep.
- Irritable Bowel Syndrome : Pain is usually colicky in nature and is usually more common in older adolescents and more common in females.
- Lactose intolerance which is associated with crampy abdominal pain, diarrhea, flatulence and belching
- Gynecologic conditions such as ectopic pregnancy, mittleschmerz, ruptured ovarian cysts and pelvic inflammatory disease.
- Musculoskeletal conditions like costochondritis or muscle wall strain
- Hepatitis and pancreatitis
- Gastrointestinal infections such as giardiasis
- Referred pain from lower lungs such as pneumonia or spinal cord tumor
- Gastrointestinal disease such as peptic ulcer disease, inflammatory bowel disease or obstructed bowel.
- Systemic conditions : Occasionally systemic conditions in adolescents may lead to abdominal pain such as diabetic ketoacidosis, sickle cell crisis,
An organic disease is usually suggested by the history, physical examination and results of screening laboratory tests. The history should include pain description, family history, current stresses and relationship to pain. It may be helpful to have teen keep a pain and dietary diary. The examination should include height and weight and growth charts, careful examination of abdomen for tenderness, rebound, hepatosplenomegaly or masses. Signs of systemic diseases should be looked for and a pelvic examination if indicated. Screening laboratory tests include CBC, sedimentation rate, urinalysis, basic chemistry panel and liver enzymes. In addition, stool samples for occult blood, ova and parasite may be needed. Other helpful tests might include stool alpha-antitrypsin test as screen for IBD or protein losing enteropathy as well as plain film of abdomen and H.pylori antibody titer. More complicated or invasive tests might be needed depending on initial evaluation.
If the diagnosis of functional abdominal pain is made, the clinician will need to explain to the need the meaning of this disorder. In addition, the clinician needs to explain that the symptoms are real but can result from emotions and feelings. The clinician can use the example of blushing, a physiological response to the feeling of embarrassment. The teen should be reassured that they can return to their activities and school.
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As many as 5% of adolescents in medical clinics complain about chest pain. In contrast to adults, acute chest pain in adolescents is rarely of cardiac origin. However, many teens fear having a heart attach or having cancer. The common causes of chest pain in adolescents includes:
- Musculoskeletal including precordial "stitch", muscle strain, costochrondritis, Tietze's syndrome and much less commonly slipping rib syndrome, fibromyalgia, thoracic outlet obstruction and metatstatic bone disease.
- Psychogenic including stress, hyperventilation and depression
- Pulmonary causes including cough, asthma, pneumonia, pleural effusion, pleurodynia, pneumothorax, acute chest syndrome with sickle cell disease and acute pulmonary embolism.
- Gastrointestinal including reflux, peptic ulcer disease, gastritis, cholecystitis
- Trauma to ribs
- Breast lesions or mastitis
- Cardiac conditions such as mitral valve prolapse, pericarditis, myocarditis and rare congenital problems
- Less common problems also include herpes zoster
The diagnosis is usually based on history and physical examination. Important historical items include characterization of pain, precipitating and alleviating factors, recent activity, trauma, recent infections, associated symptoms and recent stress. Physical examination includes vital signs, chest wall palpation, cardiopulmonary examination, breast examination and abdominal examination. Most adolescents will not require any further laboratory tests and usually an electrocardiogram and chest radiograph are normal. Symptoms that should be of particular concern to the clinician include acute chest pain precipitated by exercise, pain that interferes with sleep or associated with dyspnea, palpitations, dizziness or syncope.
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Another common complaint among teens is fatigue. This may be a common complaint from parents who may be concerned that their teens seem to not be doing enough. It is less common to have teens complain of severe fatigue. The most common cause of fatigue in teens is nonorganic representing a reaction to stress, anxiety or depression. Causes include psychosocial causes (stress, anxiety, depression), inadequate sleep, dieting, pregnancy, medications, infections, allergies, systemic diseases (renal, anemia, malignancy, collagen vascular diseases, thyroid dysfunction, diabetes mellitus, IBD) and chronic fatigue syndrome.
The evaluation should include careful review of systems, medical history, psychosocial history including alcohol and substance use and sleep history. History suggestive of organic causes include fatigue that increases during the day, that decreases with rest, history of fever, weight loss, night sweats, arthritis or lymphadenopathy. The physical examination may point to an organic problem. Many teens will not require any laboratory tests but if there is any questions, a screening evaluation might include, CBC with differential, urinalysis, mononucleosis test, sedimentation rate and perhaps a screening chemistry panel. Other tests would be based on the history and examination.
Chronic fatigue syndrome
Chronic fatigue syndrome (CFS) is a clinically defined syndrome for adults that is characterized by new onset, severe, disabling fatigue and a combination of symptoms highlighted by self-reported impairments in concentration and short-term memory, musculoskeletal or joint pains, sleep disturbances, headaches, sore throat, tender lymph nodes and post exertional malaise. Diagnosis excludes uncontrolled chronic illness, past or current mental illnesses like depression, bipolar affective disorder or anorexia nervosa. The criteria for adults can be found at the CDC web site at http://www.cdc.gov/ncidod/diseases/cfs and then going to the CFS definition. However, there are no accepted criteria for CFS in adolescents. The etiology and pathophysiology is controversial and unknown. It has been linked to various viruses and may be associated with various immunological abnormalities. The evaluation is similar to that discussed for general fatigue. Treatment has involved reassurance, low-dose antidepressants, psychotherapy and physical therapy.
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Recurrent headaches are also a frequent problem in adolescents and young adults. Almost 75% of teens by age 15 have experienced headaches. Most recurrent headaches in adolescents and young adults are not associated with severe organic pathology. However, they may be signs of stress, anxiety, or depression. This is in contrast to a isolated single very severe acute headache that may be a sign of organic disease. Most headaches are a result of either vascular dilation, muscular contraction, traction of structures or local inflammation.
By age 12 about 66% of adolescents have had headaches and this increases to 75% by age 15. About 25% of migraine headaches begin during childhood and adolescence. After age 12 headaches become more common in females.
- With acute severe headache
- Febrile patients: meningitis, brain abscess, sinusitis, other infections
- Afebrile patient: Subarachnoid hemorrhage, intracerebral hemorrhage, post-seizure headache, severe hypertension, acute dental disease, or acute orbital disease
- With episodic, recurrent headaches and complete recovery between episodes
- Muscle tension type headaches - Associated with bandlike, bilateral, steady pain and usually lack nausea, vomiting, photophobia or neurologic symptoms
- Classic Migraine: Classic migraine is associated with aura, unilateral throbbing headache and also nausea and/or vomiting. Photophobia, family history and history of motion sickness are common.
- Common migraine is similar to classic but lacks aura and may be bilateral.
- Migraine variants include hemiplegic migraine, confusional migraine, abdominal migraine and ophthalmoplegic migraine.
- Cluster headaches - Associated with burning or pain behind one eye with sudden onset also rhinorrhea, lacrimation and conjunctival injection on same side.
- Chronic headaches but continuous or increasing in intensity after onset
- Intracranial mass lesions, hydorcephalus, post-lumbar puncture headaches, pseudotumor cerebri, depressive headaches, post-trauma, local extracranial disease, pregnancy, chronic meningitis, substance abuse, obstructive sleep apnea.
In diagnosing the cause of headaches, the history is the primary diagnostic tool with examination being also key. The history should include onset, pattern and chronology of the pain, associated symptoms, preceding symptoms or visual symptoms, precipitants including stress, illnesses, foods, medication and caffeine. Medications can be important including analgesics, birth control pills and tetracycline. Substance abuse history and stress history is important as well as history of migraines in the family. The physical examination includes a good general examination with a careful neurological examination. In general, teens with recurrent headaches and separated by periods of complete recovery rarely need further laboratory evaluation. Neuroimaging is indicated in the acute severe headache or increasing constant headache or teens with abnormal neurological examination.
It is generally better to take medications sooner in the onset of the headache than later. Reassurance in most teens and families is a key issue. A headache diary can be helpful in eliminating triggering events or foods. Helpful interventions in tension headaches include relaxation exercises, simple analgesics or combined analgesics with both acetaminophen and nonsteroidal anti-inflammatory medications. Migraine headaches may respond to elimination of certain triggering items as well as stabilizing caffeine intake. Medications include simple analgesics, antiemetics, sedative-analgesic combinations, ergot derivatives, and the triptan medications for acute severe migraine headaches. Prophylactic treatment can include beta-blockers, antidepressant medications, low dose non-steroidal medications, anticonvulsants (valproic acid and phenytoin), calcium channel blockers and clonidine.
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Sleep problems can be a common problem in teens as either a major complaint or on the review of systems. Problems can include insomnia, hypersomnia (narcolepsy and excessive daytime sleepiness) and parasomnias (nightmares, night terrors, sleepwalking and nocturnal enuresis). Adolescents require about 8 1/2 to 9 1/2 hours of sleep per night but actually get far less. Early teens sleep about 9 hours, mid adolescents about 7 1/2 hours and late adolescents about 7 hours. Teens with sleep problems should be asked about the type of problem, frequency, duration, daytime symptoms, family history, age of onset, bedtime habits, prior treatment, psychosocial history and medications and drug history.
The most frequent problem in teens is insomnia involving either trouble falling asleep, staying asleep or awakening too early. Treatment involves identifying any organic problems and psychosocial stresses. Important interventions include counseling, regularizing bedtime hours, relaxation techniques, daily exercise, curtailing caffeine and alcohol and avoid daytime naps.
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What is the most common cause of recurrent abdominal pain in adolescents?
Functional abdominal pain
Name 5 other relatively common causes of recurrent abdominal pain in adolescents?
- Irritable bowel syndrome
- Lactose intolerance
- Muscle wall inflammation or trauma
- Gynecologic infections
- Rupture ovarian cysts
- Inflammatory bowel disease
What are the most common causes of chest pain in adolescents?
- Chest wall musculoskeletal strain or trauma
A teen presents with 3 months of fatigue. What would be important findings on history and examination that would suggest this is organic?
- History of systemic symptoms
- Fatigue increases throughout the day
- Weight loss
- Focal examination findings such as arthritis, lymphadenopathy, hepatospenomegaly
What are important history and physical findings that would suggest a serious cause of headaches?
- Acute onset of severe headache
- Headache that is constant, persistent is increasing in intensity
- Focal neurologic symptoms such as weakness, motor changes or seizures
- Focal neurologic signs on examination
- Abnormal fundoscopic examination
- Absence of findings suggestive of migraines such as aura, photophobia
- Persistent vomiting
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A 16 year old female complains of about 5 months of occasional abdominal pain. The pain is crampy in nature. What would be key history questions in this teen?
- Nature of pain including severity, radiation and precipitating or alleviating factors
The pain occurs in lower abdomen about once or twice a month. There is no radiation. It is not increased or decreased with food, bowel movements or exercise. The pain does not wake her up at night.
- Associated symptoms including nausea, vomiting, diarrhea or constipation
There is not history of any of these symptoms
- Menstrual history and sexual history
Confidentiality should be discussed before taking the sexual history. She has a boyfriend and they have been having sexual intercourse for six months with occasional use of condoms. Her menses started at age 12 and has regular for several years. Her last menstrual period was about 4-5 weeks ago and her last sexual intercourse was two weeks ago. She denies any vaginal discharge or genital lesions. The pain appears to probably come most months in mid cycle.
- Review of systems
She denies any other systemic complaints and review of systems is negative.
- Psychosocial history
She lives with her parents and they get along well. She denies any use of drugs and she denies and mental health issues.
What would be important parts of her physical examination?
- Vitals signs:
BP 110/76, Respirations 12, Temperature 37, Her weight and height are 45 th percentile
- Abnormalities on skin, joint, cardiopulmonary exam to suggest chronic disease:
These are all normal
- Abdominal examination
There is no tenderness, no organomegaly and bowel sounds are normal
- Pelvic examination
Because the adolescent is sexually active, she is not contracepting well, and because she has abdominal complaints, a pelvic examination should be performed. It could either be performed at that time or in the very near future. Because she has no acute symptoms and because she has no vaginal complaints and she has no abdominal tenderness, if it could not be performed at that time, it could be rescheduled for near future. This would also depend on the ease of having the teen return.
The pelvic examination shows no external genital lesions, no discharge, no cervical motion tenderness, uterine or adnexal tenderness or masses.
What would you do at this point in time?
There are several issues at the present time. First, she has the history of abdominal pain, second she is sexually active without contraception and is at risk for both STIs and pregnancy, third is the issue of a possibility of delayed menses and pregnancy.
In regards to her abdominal pain, one possibility would be mittleschmerz. The pain seems to come mainly at the time of mid-cycle, although the history is not entirely clear. A menstrual calendar with a diary of her pain might help diagnosis this or establish if there are other correlations to her pain. There would appear to be no history to suggest serious organic disease or systemic disease.
In regards to her reproductive issues, it would be important to discuss with her the potential issues of pregnancy and STIs and explore what options she would like to go in. It would be important to explore the nature of her relationship including age of partner, consensuality of the intercourse. It would be important to test for chlamydia and gonorrhea during the pelvic examination. A pap smear could be done at this point although, recommendations are moving into possibly waiting until three years after the onset of sexual activity to perform first pelvic exam.
This adolescent has only occasionally used contraception and may be late with her menses. It would also be important to discuss the possibility of pregnancy and to obtain a pregnancy test. It would also be important to discuss more reliable forms of contraception and other options including hormonal contraceptive options and more consistent use of condoms.
A 15 year old male complains of about 6 months of recurrent abdominal pain. The pain is crampy in nature. On history you find that:
Nature of pain: The pain occurs in lower abdomen and midabdomen several times a month. It may last from hours to on and off for several days. There is no radiation. It sometimes is worse with food intake but is not associated with exercise. Bowel movements sometimes help. The pain does not wake her up at night.
Associated symptoms : There is no history of nausea, vomiting. There is occasional history of constipation.
- Sexual history: Confidentiality is discussed. The teen is not sexually active and has no sexual relationships.
- Review of systems : Occasionally has headaches and occasional trouble getting to sleep.
- Psychosocial history : The teen lives with his mother has mom is divorced. He states he fights with her all the time as she does not let him "live his own life". He feels she is watching over him all the time. He has been doing poorly in school with a below average grades that have worsen in past year. He admits to drinking heavily on the weekends and occasionally using other drugs. He has tried marijuana. He occasionally get very depressed and has once or twice thought of taking a bottle of the pills his mother keeps in her cabinet.
- Vitals signs: BP 120/80 Respiration 16, Temperature 37, His weight and height are 55 th percentile
- There are no abnormalities on skin, joint, cardiopulmonary exam to suggest a chronic disease:
- Abdominal examination: There is minimal tenderness in midabdomen and no organomegaly and bowel sounds are normal. There are no masses. There is no rebound tenderness.
What would be your next steps?
There are several issues significant issues at this point. First is the abdominal pain that the teen is concerned about. In addition, there appears to be some significant conflict between the teen and his mother. The teen is also doing poorly in school and this has worsen. In addition, he appears to be drinking heavily and has a history of depression and perhaps suicidal ideation.
Regarding the abdominal pain. There is nothing on the history to suggest an organic etiology and there is much to suggest that the pain may be functional and stress related. However, some basic screening laboratory might be in order including a CBC, sedimentation rate and perhaps a screening chemistry panel.
Blood tests show normal CBC, sed rate of 10 mm/hour and no abnormalities on chemistry panel.
Regarding his psychosocial history: It would be important to get a complete history from the mother on her perspectives on both the abdominal pain and her thoughts on how things are going with her son. It would also be important to evaluate how the two react together, so bringing the mom in and reviewing the evaluation of the abdominal pain with the two together may be helpful. Obviously there are significant issues with the teen and the family unit. It would be important to assess with the teen alone his degree of suicidal ideation. If very high, then an immediate referral would be necessary. In this case, there is no current desire to hurt himself and no current or past plan or attempts. You discuss that with the teen the probability that the pain is related to some of the difficulties he is experiencing and that some additional help with his relationship with his mother might be helpful to sort things out. While initially somewhat reluctant he is willing to see your colleague for individual and family sessions. These are scheduled as well as scheduling a follow-up with the teen for his abdominal pain. He is also asked to keep a diary of his pain.
A 15 year old comes in complaining of 3 months of occasional chest pain.
What would be the important historical questions in this teen?
- Characterization of pain
The pain is a sharp but occasionally aching pain in anterior chest. The pain does not prevent him from doing his normal activities. The pain is unrelated to exercise or meals but his occasionally worse on movement or turning his body.
- Precipitating and alleviating factors
Unrelated to food intake. It is worse with coughing or deep breathing. It does not awaken the teen at night.
- Recent trauma
There is no history of any recent trauma
- Recent infections or systemic illness
There is no history of any recent infections, the teen has no serious illnesses, no asthma and no history of cough.
- Medications or drugs
Teen is on no medications and has no used any illicit drugs. Teen does not smoke.
- Associated symptoms
There is no history of shortness of breath, dyspnea on exertion, wheezing, syncope, lightheadedness or paresthesias.
- Family history
There is no family history of cardiovascular diseases.
- Recent stress
There is no history of recent stress and teen is doing well at home and at school.
What are important things to be checking on physical examination:
- General state
Teen is in no acute distress and appears healthy
- Vital signs
BP 110/80, respirations 12, pulse: 80, height and weight: 40 th percentile
- Chest wall palpation
There is slight tenderness along the left costochondral junction at about the third and fourth ribs. There is no swelling or masses. There is no evidence of trauma.
- Cardiopulmonary examination
The pulmonary exam is normal with normal bilateral breath sounds and no rales or rubs. The heart sounds are normal with no murmurs or clicks.
- Breast exam
There is no gynecomastia and no breast tenderness
- Abdominal examination
There is no tenderness or masses or organomegaly
What is the most likely diagnosis?
Given the negative history to suggest any chronic disease, the negative history of trauma or infections, the negative history of association with exercise but some increase with movement and the exam showing tenderness at the costochondral junction, the most likely diagnosis is costochondritis.
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