Abdominal pain - chronic

  • PIC logo
    PIC Endorsed
  • See also

    Abdominal pain - acute
    Adolescent gynaecology – lower abdominal pain
    Engaging with and assessing the adolescent patient

    Key Points

    1. In most children, no organic cause is found
    2. Non-specific or functional abdominal pain is a distinct diagnosis and does not require exclusion of all organic causes
    3. Many children do not need investigations. Investigations are guided by red flags or likely diagnosis. Imaging is rarely required
    4. Significant functional impairment should prompt consideration of referral to a specialist


    • Chronic abdominal pain is intermittent or constant abdominal pain that has been present for at least two months
    • Non-specific abdominal pain that self-resolves over time without specific treatment is very common in primary school aged children
    • The aetiology may be organic or functional. These are not mutually exclusive; they can exist alongside each other and interact
      • Organic: an underlying medical cause is found, either a primary gastrointestinal disorder or non-gastrointestinal disease
      • Functional: the child has physical symptoms without any readily identifiable organic cause
    • Comorbid mental health issues (including anxiety and depression) are very common in children with chronic abdominal pain. These may both result from, and contribute to, the experience of chronic pain



    • Pain characteristics (location, time course, triggers, association with meals, pain waking the child from sleep)
    • Associated symptoms:
      • unintentional weight loss/stunting of height
      • unexplained fever
      • changes in bowel habit, chronic diarrhoea, blood in stools
      • nocturnal stooling
      • appetite changes
      • dysphagia (the sensation of food sticking, or moving slowly down the oesophagus, after swallowing), odynophagia (pain on swallowing)
      • persistent vomiting (especially if bilious. See acute abdominal pain)
      • urinary symptoms
      • extraintestinal manifestations of inflammatory bowel disease (IBD) (eyes, skin, joints, perianal)
    • History of reflux symptoms (heartburn, waterbrash, regurgitation)
    • Dietary history (including foods excluded from diet)
    • Menstrual history, sexual history and contraception (if relevant)
    • Family history of IBD or coeliac disease
    • HEADSSS screen
    • Functional impact of pain on usual activities (eg school attendance, social activities, physical activity)


    • Signs of dehydration
    • Weight and height, preferably over time
    • Pubertal status
    • Abdominal examination for palpable faeces, palpable mass
    • Extraintestinal manifestations of IBD

    Differential Diagnosis

    • More likely if there are red flags


    Key features:


    • Infrequent stools (<=2 stools/week)
    • History of painful or hard bowel movements

    Gastroesophageal Reflux Disease (GORD)

    • Regurgitation, dysphagia, waterbrash
    • Pain relieved by eating


    • Diarrhoea, may contain blood or mucus
    • Fever

    Coeliac disease

    • Altered bowel habit
    • Poor weight gain or slow growth
    • Anaemia/iron deficiency (treatment resistant)
    • Bloating
    • Family history of coeliac disease

    Parasitic infection (giardia)

    • Loose, pale, greasy stools – foul-smelling
    • Bloating
    • Nausea, loss of appetite

    DKA/first presentation of Type 1 Diabetes

    • Excessive thirst, frequent urination
    • Loss of weight


    • Pain associated with menstrual cycle


    • May be exacerbated by psychosocial stressors
    • May be exacerbated by physical stressors (specific foods, missing meals, tiredness)


    Key features:

    Irritable bowel syndrome

    • Abdominal pain at least 4 days per month, associated with change in bowel habit
      • Pain associated with change in frequency or form of stool
      • Pain related to defecation

    Abdominal migraine

    • Stereotypical, paroxysmal episodes of periumbilical or diffuse abdominal pain with few or no GI complaints between attacks
    • Migraine in child (or family)

    Functional dyspepsia

    • Bothersome postprandial fullness
    • Early satiety
    • Epigastric pain and burning not associated with bowel habit

    Non-specific abdominal pain/functional abdominal pain (not otherwise specified)

    • No obvious organic aetiology
    • Pain may be episodic or continuous
    • Not associated with change in stool frequency/consistency
    • Chronic abdominal pain may develop as a response to psychosocial stressors or emotional distress

    Somatic symptom disorder

    • Child has a significant focus on physical symptoms, resulting in major distress or difficulty functioning
    • May describe symptoms that are incongruent with findings on examination or investigation



    • Many children do not need investigations
    • Investigations should be targeted to likely diagnoses

    Investigations, depending on likely diagnoses, may include:

    • urinalysis (+/- culture +/- pregnancy test +/- STI screen if indicated)
    • stool sample: M/C/S, ova, cysts and parasites
    • faecal calprotectin for children over 4 years (if features of IBD). Do not test under the age of 4 years without discussion with a paediatrician or paediatric gastroenterologist
    • blood: UEC, LFTs, CMP, lipase, TSH, blood sugar, coeliac serology and total IgA level, inflammatory markers (ESR, CRP), FBE & ferritin
    • imaging:
      • imaging is not routinely required
      • abdominal ultrasound has very low yield in childhood chronic abdominal pain
        • it may be useful in excluding an intra-abdominal mass for children with abnormal examination or significant constitutional symptoms
      • do not perform abdominal X-rays for investigation of non-specific abdominal pain. Abdominal X-rays are rarely helpful in diagnosing constipation
      • CT, MRI and other investigations (such as endoscopy) are rarely required. Seek specialist advice

    Only test for H. pylori (by stool antigen or urease breath test) if there are red flags for peptic ulcer disease (eg haematemesis, family history of H. pylori complication). Do not test H. pylori serology


    Treatment is targeted to the underlying cause

      • Constipation
      • For older children and adolescents with reflux symptoms, a 4-week trial of proton pump inhibitor (PPI) pre-referral may be helpful. Refer to a specialist if not responding appropriately or unable to wean PPI
      • If IBD is suspected, seek specialist advice, and refer to paediatric gastroenterology

    Non-specific or functional abdominal pain is a distinct diagnosis and does not require exclusion of all organic causes. Red flags should be considered, but children may not need investigations to make this diagnosis. Often multi-disciplinary input is required

    For non-specific, suspected functional abdominal pain:

    • Education and reassurance for the child and parents. There is no physical damage to treat, and most cases will resolve with time and support
    • Further investigations and medications are usually not required
    • Consider and address psychosocial stressors
    • Consider comorbid anxiety or depression. If present, discuss with the child/young person and family and consider referral to mental health team or psychologist
    • Encourage a focus on return to function: continuing or graded return to usual activities (school, social, extra-curricular, physical activity)
    • Provide follow-up

    For specific functional abdominal pain disorders (IBS, abdominal migraine, functional dyspepsia), referral to a specialist for consideration of evidence-based treatments, which include:

    • Psychology/Cognitive Behavioural Therapy/counselling
    • Specialist dietician input to discuss evidence-based dietary strategies
      • Changes to diet should not be undertaken without professional advice
    • Gut-directed hypnotherapy
    • Use of medications such as antidepressants (SSRI/low dose TCA) and antispasmodics

    If there is significant functional impairment (eg poor school attendance, concurrent depression or anxiety, sleep disturbance), consider referral to a paediatrician, adolescent medicine or a paediatric chronic pain management service

    Consider consultation with local paediatric team when

    • Child requiring admission
    • Red flags or abnormal investigations
    • Abdominal pain causing significant interruption to usual activities (schooling, social interactions, eating) – consider referral to general paediatrics, adolescent medicine or paediatric chronic pain management service

    Consider transfer when

    Child requires care beyond the comfort level of the local hospital

    For emergency advice and paediatric or neonatal ICU transfers, see Retrieval Services

    Consider discharge when

    • There are no concerning clinical features and red flags have been considered AND
    • A clear follow-up plan has been arranged, often with either general paediatrics, adolescent medicine or paediatric chronic pain management service

    Parent information

    Kids Health Info: Abdominal Pain
    Functional abdominal (tummy) pain disorders

    Last updated March 2023

  • Reference List

    1. Brusaferro, A et al. The Management of Paediatric Functional Abdominal Pain Disorders: Latest Evidence. Paediatric Drugs. 2018. 20(3), p235-247.
    2. Evelina London. Functional abdominal (tummy) pain disorders. Retrieved from https://www.evelinalondon.nhs.uk/resources/patient-information/functional-abdominal-pain-disorders.pdf (viewed 21 December 2022).
    3. Hyams, JS et al. Childhood Functional Gastrointestinal Disorders: Child/Adolescent. Gastroenterology. 2016. 150, p1456-1468.
    4. Hyman, PE. Chronic and Recurrent Abdominal Pain. Pediatrics in Review. 2016. 37(9), p377-390.
    5. Lacey, BE et al. Bowel disorders. Gastroenterology. 2016. 150(6), p1393–1407.
    6. Lewandowski, AS et al. Systematic review of family functioning in families of children and adolescents with chronic pain. Journal of Pain. 2010. 11(11), p 1027–1038.
    7. RACP Paediatrics & Child Health Division. Choosing wisely – recommendation 5: Do not routinely order abdominal X-rays for the diagnosis of non-specific abdominal pain in children. Retrieved from https://www.choosingwisely.org.au/recommendations/racp5 (viewed 21 December 2022).
    8. Ringel-Kulka, T et al. Assessment of Chronic Abdominal Pain. BMJ Best Practice. Retrieved from https://bestpractice.bmj.com/topics/en-gb/767 (viewed 21 December 2022)
    9. Wewer, AV et al. Abdominal ultrasonography in the diagnostic workup in children with recurrent abdominal pain. European Journal of Pediatrics. 1997. 156 p.787-788.