Interactive Guide to Chronic Abdominal Pain (CAD)

Sequential management for pediatricians in primary care. pediapp.online© 2026.

Step 1: Initial Evaluation and Warning Signs

History and Physical Examination

Perform a complete medical history and a detailed physical examination, actively looking for red flags.

  • Pain that wakes the child at night.
  • Weight loss or growth curve arrest.
  • Significant vomiting (bilious, projective).
  • Blood in stool or vomit.
  • Severe chronic or nocturnal diarrhea.
  • Persistent and unexplained fever.
  • Dysphagia, odynophagia.
  • Localized pain away from the navel (especially in the right upper/lower quadrants).
  • Family history of IBD, celiac disease or peptic ulcer.
  • Abnormal findings on examination (masses, organomegaly, localized tenderness).

Initial Studies

If there are no warning signs, a wait-and-see attitude can be adopted. If there are doubts or to reassure the family, consider:

  • Complete blood count, ESR and CRP: Rule out anemia, inflammation.
  • Basic biochemistry: Kidney and liver function.
  • Celiac antibodies: Ac. anti-tissue transglutaminase IgA (with total IgA).
  • Urine analysis: Rule out urinary infection.
  • Occult blood in feces and/or fecal calprotectin: If intestinal inflammation is suspected.

Step 3: Second Line of Management (If there is no improvement)

If symptoms persist or function does not improve after 4-6 weeks, consider the following options:

Additional Therapeutic Options

  • Amitriptyline (Under supervision): For visceral hypersensitivity.
    Dose: Start with 0.1-0.2 mg/kg/day at night, gradually increase to 0.5-1 mg/kg/day.
    Presentation: 10mg, 25mg tablets.
  • Probiotics: Certain strains such as *Lactobacillus rhamnosus GG* have shown benefit.
    Dose: Follow product specifications. Evaluate for 4 weeks.

Psychotherapy and Other Approaches

  • Cognitive-Behavioral Therapy (CBT): Refer to psychology. Very effective for developing pain coping strategies.
  • Hypnotherapy: It has been shown to be effective in studies for functional pain.
  • Abdominal ultrasound: Consider whether it has not been performed to rule out anatomical pathology.

Step 4: Approach by Pediatric Gastroenterology

Specialized Studies

Upper Digestive Endoscopy (EDA) and Colonoscopy

Indicated for warning signs, elevated calprotectin or suspicion of mucosal pathology. Always with serial biopsies (esophagus, stomach, duodenum, ileum, colon).

Integer-Magnetic Resonance (Integer-MRI)

Study of choice to evaluate the small intestine non-invasively, especially in suspected Crohn's Disease.

Other Tests

pHmetry/Impedanciometry (reflux), breath test (bacterial overgrowth, malabsorption), manometry.

Specific Therapeutic Management

Inflammatory Bowel Disease (IBD)

Induction of remission with corticosteroids, exclusive enteral nutrition or biologicals. Maintenance with immunomodulators or biologicals.

Celiac Disease

Establishment of a strict gluten-free diet for life, with follow-up by a nutritionist.

Esophagitis/Eosinophilic Gastritis

Treatment with Proton Pump Inhibitors (PPI) and/or empiric or swallowed elimination diets.

Multidisciplinary Approach

Even with organic pathology, the support of Psychology (coping with chronic illness), Nutrition and, in complex cases, Pain Units.

Subtypes of Functional Abdominal Pain (Rome IV Criteria)

Irritable Bowel Syndrome (IBS)

Diagnostic Criteria

Abdominal pain at least 4 days/month associated with 1 or more of the following:

  • Related to defecation.
  • A change in the frequency of bowel movements.
  • A change in the shape (appearance) of bowel movements.
  • In children with constipation, the pain does not resolve when treating the constipation.

Specific Management

  • IBS-Constipation: Soluble fiber (psyllium), Polyethylene glycol (PEG 3350).
  • IBS-Diarrhea: Loperamide (punctual use), low FODMAP diet (with nutritionist).
  • Pain Management: Peppermint oil, antispasmodics (trimebutin).

Functional Dyspepsia

Diagnostic Criteria

At least 4 days/month with 1 or more of the following epigastric symptoms:

  • Annoying postprandial fullness.
  • Early satiety.
  • Epigastric pain or burning not related to defecation.

Specific Management

  • Rule out and treat H. pylori if present.
  • Therapeutic trial with PPI (e.g. Omeprazole) for 4-8 weeks.
  • Small and frequent meals, low in fat.
  • Prokinetics (e.g. domperidone) if early satiety predominates.

Abdominal Migraine

Diagnostic Criteria

At least 2 episodes in 6 months with all of the following:

  • Paroxysmal, intense, midline abdominal pain lasting ≥1 hour.
  • Intercritical periods of normal health (weeks-months).
  • The pain interferes with normal activity.
  • Associated with ≥2 of: anorexia, nausea, vomiting, headache, photophobia, paleness.

Specific Management

  • Sharp handling: Rest, NSAIDs, antiemetics (ondansetron). Triptans (nasal sumatriptan) in selected cases.
  • Prophylaxis: Cyproheptadine, propranolol, amitriptyline.
  • Identify and avoid triggers (stress, fasting, food).

Recommendations for Parents

What YES to do

  • Stay calm and offer emotional support without being overprotective.
  • Encourage school attendance and participation in social and sports activities.
  • Validate the child's pain ("I understand that it hurts") but redirect the focus toward pleasurable activities.
  • Keep a symptom diary (without obsessing) to identify possible triggers.
  • Ensure a balanced diet, rich in fiber, and adequate hydration.
  • Promote restful sleep and relaxation techniques (deep breathing, mindfulness).
  • Congratulate the child on his achievements in coping with pain and maintaining his routines.

What NOT to do

  • Allow pain to be the center of family life.
  • Make frequent visits to the emergency room if serious pathology has already been ruled out.
  • Limit the child's activities or allow him or her to miss school because of pain.
  • Ask constant questions about pain ("does it hurt now?", "how much does it hurt?").
  • Administer medications (pain relievers, antispasmodics) without prescription and continuously.
  • Perform restrictive elimination diets without medical supervision.
  • Show excessive anxiety or distress, as the child may perceive it and worsen their symptoms.

Knowledge Assessment

Bibliography and Resources

  • Hyams JS, Di Lorenzo C, Saps M, Shulman RJ, Staiano A, van Tilburg M. Functional Disorders: Children and Adolescents. Gastroenterology. 2016 Feb 15. pii: S0016-5085(16)00181-5.
  • Koppen IJN, Nurko S, Saps M, Di Lorenzo C, Taminiau JAJM, Benninga MA. The pediatric Rome IV criteria: what's new? Expert Rev Gastroenterol Hepatol. 2017 Mar;11(3):193-201.
  • UpToDate: "Chronic abdominal pain in children and adolescents: Approach to the evaluation." Authors: B U. K. Li, MD, Miguel Saps, MD.
  • Clinical Practice Guideline on Chronic Abdominal Pain in Pediatrics. Spanish Association of Pediatrics (AEP).
  • American Academy of Pediatrics (AAP) Clinical Report: "Pain Assessment and Management in Children With Significant Impairment of the Central Nervous System."