Gregory L. Krauss, MD

Disclosures

June 03, 2003

Question

I am following a 12-year-old girl with a 4- to 5-year history of episodic severe periumbilical abdominal pain that is mostly spontaneously relieved after about 5-10 minutes. She experiences no associated gastrointestinal symptoms except a mild giddy feeling before the attack and occasional nausea, but never vomiting. When she was 5 years old, she had an episode of tonic-clonic seizure with fever, but this never recurred. She has never received any antiepileptic therapy. Growth, development, and neuro exam are otherwise all within normal limits. She is in grade 7 in school, with average grades. No family history of seizures.

I know that abdominal epilepsy is a well-recognized clinical entity, but to confirm such a diagnosis is rather difficult. Can someone elaborate on this entity and aid me in both assessment and treatment of this condition?

N. K. Safaya, MD

Response from Gregory L. Krauss, MD

One half of patients with temporal lobe seizures have gastric auras with rising sensations.[1] Isolated ictal abdominal pain, however, is extremely rare, and common causes of intermittent abdominal pain should be screened for and ruled out. Only 2.8% of patients with partial seizures had ictal pain in a series reported by Young and Blume,[2] and this usually consisted of headache or hemisided face and body pain. Only 0.3% of their patients with epilepsy had ictal abdominal pain. In addition to being uncommon, ictal abdominal pain is usually associated with confusion and typical signs of complex partial and secondary generalized seizures.

Abdominal pain has been most frequently reported with seizures originating in the temporal area; however, seizures associated with parietal and frontal lobe lesions also have been associated with abdominal pain.[3,4,5,6,7] Eschle[3] reported a patient with amygdalar seizures and sharp, periumbilical pain similar to this girl's symptoms. Stimulation of the parietal operculum, post-rolandic gyrus, and insula can elicit pain in some patients, and seizures originating in these areas rarely may trigger abdominal pain.[8] At Johns Hopkins, we saw a patient with intermittent abdominal pain in whom ictal changes on electroencephalography (EEG) were seen only when a depth electrode was placed in the insula.

This girl has intermittent abdominal pain and only one definite seizure, so it would be particularly important to document epileptogenic activity on EEG and to exclude more likely gastrointestinal (GI) sources for abdominal pain. A gastroenterologist should screen for pancreatitis, irritable bowel syndrome, ulcers, and other GI disturbances associated with intermittent pain. She will probably require endoscopy. Acute intermittent porphyria can cause generalized seizures and recurring abdominal pain. Migraines, particularly in children, may cause abdominal pain independent of headaches, and occasionally may be associated with seizures.

If the patient has a normal GI evaluation and other, more common causes for intermittent abdominal pain are excluded, she may benefit from screening for simple partial seizures and other etiologies with video-EEG. Ictal changes may be undetected with scalp recordings in up to one half of patients with simple partial seizures. Video analysis and examinations during her episodes, however, may help identify the source for her abdominal pain.

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