Recurrent abdominal pain is common in children. Many cases are functional (real pain without dangerous disease). The goal is to identify red flags that suggest an organic cause, while avoiding unnecessary testing when the pattern is reassuring.

1) First: red flags that need prompt evaluation

Seek urgent or expedited assessment if pain is recurrent and any of the following are present:

  • Weight loss, poor growth, delayed puberty
  • Persistent vomiting, bilious vomiting, blood in vomit
  • Blood in stool, black/tarry stool
  • Chronic diarrhea, nocturnal stooling, fecal urgency
  • Unexplained fever, night sweats
  • Persistent right upper quadrant or right lower quadrant pain
  • Waking from sleep frequently due to pain
  • Significant family history: IBD, celiac disease, peptic ulcer disease
  • Abnormal exam: focal tenderness, mass, organomegaly, perianal disease

2) Common functional patterns (very common)

Functional pain does not mean “imaginary.” It means the gut is sensitive and reacts strongly to normal stretching, stool burden, stress, diet, and infections.

Common presentations:

  • Functional abdominal pain (generalized, often periumbilical)
  • Irritable bowel syndrome (IBS) (pain + stool change: constipation/diarrhea)
  • Functional dyspepsia (upper abdominal discomfort, early satiety, nausea)
  • Abdominal migraine (episodic pain with pallor/nausea; migraine history)

3) The most common driver: constipation (even when stooling daily)

Clues:

  • Hard stools, painful stooling, withholding
  • Soiling/overflow
  • Large stools clogging toilet
  • Pain improves after stooling

A structured constipation plan often improves recurrent pain dramatically.

4) When to consider testing (a practical approach)

A) Celiac disease testing is reasonable when:

  • Poor growth, weight loss, persistent GI symptoms
  • Iron-deficiency anemia
  • Family history of celiac
  • Type 1 diabetes or autoimmune thyroid disease (Testing should be done while still eating gluten.)

B) IBD evaluation is more likely when:

  • Blood in stool, chronic diarrhea, nocturnal stooling
  • Weight loss, fatigue, anemia
  • Elevated inflammatory markers (if tested)
  • Perianal disease

C) H. pylori / ulcer disease considerations:

  • Persistent epigastric pain with red flags (bleeding, weight loss)
  • Avoid “test and treat” in low-risk children without red flags unless guideline-indicated locally.

5) What helps most (home + clinic)

  • Normalize routines (school attendance, sleep, regular meals)
  • Treat constipation if present
  • Track triggers (stress, missed meals, certain foods)
  • Reassurance: pain is real, and improvement is the goal
  • Consider psychology support for brain–gut approaches when symptoms persist

Quick summary

  • Most recurrent abdominal pain is functional.
  • Red flags guide targeted testing.
  • Constipation is a frequent, treatable contributor.