“Abdominal pain is one of the most common reasons school-aged children and parents come see me,” says Rami Arrouk, MD, a pediatric gastroenterologist at Atlantic Health. “Our first job is to figure out the source of the pain. Is it a problem within the inner lining (mucosa) of the gastrointestinal (GI) tract? Or is it, more commonly, a mismatched interaction between the gut and the brain.”
Dr. Arrouk explains that these are two very different groups of diagnoses—with two very different approaches to treatment. The first, organic gastrointestinal diseases, affect the inner lining of the stomach, and the small and large intestine. The second, disorders of gut-brain interactions (DGBIs), have no structural or inflammatory abnormalities.
Two categories of abdominal pain
1. Organic gastrointestinal diseases occur when there’s an injury to the gastrointestinal (GI) tract. It is caused when the inner skin or mucosal lining somewhere in the gastrointestinal system shows signs of inflammation, ulceration, bleeding, or other types of injury. Some common conditions include:
- Stomach or small intestines ulcers (peptic ulcer disease)
- Celiac disease
- Eosinophilic esophagitis
- Inflammatory bowel diseases (Crohn’s disease, ulcerative colitis)
“These diseases often present with additional warning signs that help us distinguish them from other reasons for the pain,” says Dr. Arrouk. “Red flags can include blood in the stool, recurrent unexplained fevers, difficulty swallowing, or pain that wakes a child from sleep.”
2. Disorders of gut-brain interactions are far more common. They involve the network of nerves in the gut that communicate with each other and with the brain to regulate digestion, sensation, and movement within the GI tract. When the gut’s nervous system is overly sensitive or has a low pain threshold, digestion—which should be painless or even pleasurable—may instead trigger discomfort. Unlike the diseases in the first category, DGBIs are not associated with injury to the GI tract. Some of these disorders include:
- Functional constipation
- Irritable bowel syndrome (IBS)
- Cyclic vomiting syndrome
- Functional abdominal pain
- Functional nausea
“These conditions often flare during times of stress or emotional distress,” says Dr. Arrouk. “The pain is not psychological, yet psychological factors like anxiety can worsen or trigger symptoms because of the close relationship between the gut and brain.”
Diagnosing abdominal pain
Diagnosing the first category of abdominal pain, when children have organic gastrointestinal disease, is fairly straightforward. Through blood work, stool studies, imaging tests, and endoscopy or colonoscopy, Dr. Arrouk can determine the cause and provide treatment. However, if all these tests come back normal and organic disease is ruled out, Dr. Arrouk looks to the second category.
“If a child continues to experience abdominal pain, we will explore the gut-brain relationship,” says Dr. Arrouk. “Treatment for gut-brain disorders is not a ‘one-size-fits-all’ approach. It is based on how the symptoms interfere with a child’s quality of life. Each of these gut-brain disorders meets its own unique symptom-based criteria.”
Dr. Arrouk explains that some children cope well on their own and can manage their pain without medication or therapy. Others become severely debilitated—missing school, social events, and other daily activities. For this reason, doctors take a multidisciplinary treatment plan that may involve a team:
- Pediatric gastroenterologist for medical management
- Behavioral health professional for managing anxiety or stress
- Dietitian to identify and eliminate potential food triggers
- Physical therapist for pain relief and body retraining
- Natural therapies like peppermint oil
- Medications when necessary
“The goal is not to eliminate every symptom, but to restore functionality and improve the child’s quality of life. We help the child return to school, participate in daily life, and regain confidence in their body,” says Dr. Arrouk. “One powerful concept in recovery is self-efficacy—the belief that one can get better. This mindset significantly improves outcomes.”
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