Sunday, 17 May 2015

Non-specific or non-diagnosis? Non-specific abdominal pain (Easter Egg: Constipation in Children)

Non-specific abdominal pain - why I haven't made that diagnosis for quite some time



I think that I have now heard more than a dozen definitions of constipation and diarrhoea, starting from a lecture that I recall well from when I was at medical school.  The lecturer gave scientific definitions based on volumes and frequency of stool passed in a 24 hr period that led me to believe that I would be able to conclusively diagnose or rule out constipation if only I took a thorough history and a large set of scales with me.


I also recall first hearing about non-specific abdominal pain in children.  It seemed mysterious and yet strangely credible.  It was, I was told, a diagnosis of exclusion.  Presumably the diagnosis of constipation in these children was being excluded by the use of CCTV installed in the child’s toilet and a rigorous measuring of the amount and consistency of everything brown before it was flushed.


I now know the reality, which is that the diagnosis of constipation in children is usually a guess, albeit it a good guess and hopefully an educated one.  Every week I see at least one child of the many who present to our Emergency Department with what turns out to be constipation.  In most cases the most significant symptoms have been present for many days and if one enquires, the clues have been there for months or years.  These children have usually had various people consider what the cause is - parents, GPs and Emergency Physicians.  Often the parents have been given no diagnosis; on other occasions non-specific abdominal pain might have been given as the cause. In reality, the well child with unexplained abdominal pain (once an acute abdomen and a urinary tract infection have been ruled out) almost always turns out to have constipation.


So my question is, how was constipation excluded in the diagnosis of exclusion that is non-specific abdominal pain?  I suspect that there are two things getting in the way.  The first is that it is almost impossible to get a good history about the bowel habit of a child.   They think that whatever they do is normal and their parents are unlikely to know what they are passing and how often.  The second factor is time.  I know that there is limited time to assess a child in Primary Care and let’s be honest, there are other more pressing diagnoses to exclude if a child presents with abdominal pain.  Ruling out a surgical abdomen and a urinary tract infection is always going to be the priority and I can’t do that in less than 10 minutes either.


I feel that there are opportunities being missed though and childhood constipation is one of the best diagnoses to make in primary care for several reasons.
  1. It is a difficult diagnosis to make.  All clinicians want to be the first on the scene at a difficult diagnosis and this is your chance.
  2. It requires good explanation and consultation skills in order to engage the family with understanding what is happening and what to do about it.  No further comment needed.
  3. This is a condition that can be managed entirely in primary care without interference from anyone else.
  4. It is a really satisfying condition to treat.  So much childhood illness either gets better on its own, responds poorly to treatment or is untreatable that we should be genuinely excited when we find a condition that probably won’t get better until we diagnose it and do something about it.
  5. The effect on quality of life for the child and family is enormous.

I would suggest that non-specific abdominal pain is so often code for undiagnosed constipation that we only use it when constipation has been thoroughly ruled out.  I have been working to this for many years now and I find that once challenged, the evidence for constipation almost always comes out just in the history of children with abdominal pains.  If not in the history then often the examination might reveal hard stools or just a fullness in the left lower quadrant.  A normal examination does not exclude constipation.  Finally, if the pains have been consistent for a while and a macrogol laxative (1) has not yet been tried then this is the controversial bit:  I would not make a diagnosis of non-specific abdominal pain without first attempting to treat as constipation and reviewing early to assess the result.


Does non-specific abdominal pain exist?  I’m told it does but I haven’t yet seen a case myself.


Edward Snelson
Consultant in Paediatric Emergency Medicine
@sailordoctor


1)    Constipation in children and young people: Diagnosis and management of idiopathic childhood constipation in primary and secondary care https://www.nice.org.uk/guidance/cg99

Note: This material is created by the author for the sole use of qualified clinicians.  It is meant as a viewpoint and not intended to replace any applicable guidelines.  Any change in practice is solely the responsibility of the clinician.

Conflict of Interest: Loads

Easter egg: Constipation in Children - key recommendations

  • Suspect constipation whenever a child presents with abdominal pain
  • UTI is a common co-existing problem and should be ruled out concurrently. The finding of a urine infection increases the index of suspicion for constipation rather than ruling it out.
  • Do not treat with lifestyle measures only (1)
  • Treat all presentations of constipation with a macrogol laxative (either clear out or maintenance as indicated) (1)
  • Continue this treatment for at least several week. It is likely that several months will be needed to prevent recurrence. (1)

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