We wish to thank the correspondents for their valuable comments. The comments underline the fact that abdominal pain in children is a common problem which is not always easy to treat, and often presents an interdisciplinary problem. We aimed to provide evidence based and practical instructions.
Dr Namislo points out the difficulties of distinguishing between functional and organic disorders and states that many organic causes for functional abdominal pain are not yet known. We attempted to summarize the current knowledge in our article. The mere fact that for certain subgroups of patients, further causes and more specific treatments may be found should not tempt clinicians to test unnecessary medication outside study settings.
Dr Ratzmann mentions magnesium deficiency as a possible cause of abdominal pain. Magnesium affects intestinal motility, and a deficiency can therefore cause intestinal symptoms. However, magnesium deficiency is not an oft-described cause of abdominal pain in children and adolescents. Therefore, a general recommendation to investigate magnesium deficiency without alarm signals (for example, muscle cramps) is not indicated.
In our article we pointed out the necessity to investigate nausea and vomiting to exclude central tumors/cerebral pressure. However, we did not find any evidence in the cited literature of a generally accepted causative connection between visual disorders and abdominal pain, such as described by Dr Gorzny. Controlled studies of the therapeutic efficacy of vision-correcting measures and migraine/headache show unequivocal results but as far as we are aware none exist for abdominal pain. Dr Dorlöchter describes the importance of calprotectin in the detection of organic inflammatory causes. We agree that this test has an important impact on the diagnostic evaluation of pediatric chronic abdominal pain (1), since it is non-invasive. We therefore included calprotectin in our article in the list of the (few) useful laboratory tests (2).
As described by Dr Bojack, we have also encountered patients in whom we suspected an association between abdominal pain and sexual abuse or even deemed this likely. We thank Dr Bojack for this valuable addendum. An association between gastrointestinal symptoms and sexual abuse has been described for adults, but also for children (3, 4). Even though we did not mention this explicitly, we did point out the role of psychological stressors and the need for taking a psychosocial history. As in the example described by Dr Bojack, the process of a patient’s opening up about experiences of sexual abuse can take months or even years. In such patients, specific treatment by a child and adolescent psychiatrist is reasonable, after organic causes have been ruled out.
PD Dr. med. Philip Bufler
Abt. für Pädiatrische Gastroenterologie u. Hepatologie
Dr. von Haunersches Kinderspital
Dipl.-Psych. Martina Groß
PD Dr. med. Holm H. Uhlig
Conflict of interest statement
Dr Bufler has received travel expenses and honoraria for speaking from Abbott, Roche Pharma, The Binding Site, Essex Pharma, and Given Imaging. He holds a patent (7820156) for a method that can probably be used in treating Crohn’s disease.
Dr Uhlig has received travel expenses from the Glaxo-Smith-Kline Foundation and Essex Pharma, and project funding from the Hexal Initiative. He holds a patent (DE 10065932 B4) for a method that can probably be used in diagnosing celiac disease.
Dipl-Psych Groß declares that no conflict of interest exists.
|1.||van Rheenen PF, Van de Vijver E, Fidler V: Faecal calprotectin for screening of patients with suspected inflammatory bowel disease: diagnostic meta-analysis. BMJ 2010; 341: c3369. doi: 10.1136/bmj.c3369. CrossRef MEDLINE|
|2.||Bufler P, Gross M, Uhlig HH: Recurrent abdominal pain in childhood. Dtsch Arztebl Int 2011; 108(17): 295–304. VOLLTEXT|
|3.||Berger MY, Gieteling MJ, Benninga MA: Chronic abdominal pain in children. BMJ 2007; 334(7601): 997–1002. CrossRef MEDLINE|
|4.||van Tilburg MA, Runyan DK, Zolotor AJ, et al.: Unexplained gastrointestinal symptoms after abuse in a prospective study of children at risk for abuse and neglect. Ann Fam Med 2010; 8(2): 134–40. CrossRef MEDLINE|