Fructose Intolerance, Malabsorption a Common Culprit in Abdominal Pain

Fructose Intolerance, Malabsorption a Common Culprit in Abdominal Pain

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From MedscapeCME Clinical Briefs

Fructose Intolerance, Malabsorption a Common Culprit in Pediatric Abdominal Pain CME

News Author: Nancy A. Melville
CME Author: Désirée Lie, MD, MSEd

CME Released: 10/29/2010; Valid for credit through 10/29/2011



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CME Information

Target Audience

This article is intended for primary care clinicians and other specialists who want to maintain a current understanding of recent research and evidence in the differential diagnosis of chronic abdominal pain in children.


The goal of this activity is to provide medical news to primary care clinicians and other healthcare professionals in order to enhance patient care.

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Nancy A. Melville
Nancy Melville is a freelance writer for Medscape.
Disclosure: Nancy Melville has disclosed no relevant financial relationships.

Brande Nicole Martin
CME Clinical Editor, Medscape, LLC
Disclosure: Brande Nicole Martin has disclosed no relevant financial relationships.

Désirée Lie, MD, MSEd
Clinical Professor; Director of Research and Faculty Development, Department of Family Medicine, University of California, Irvine at Orange
Disclosure: Désirée Lie, MD, MSEd, has disclosed the following relevant financial relationship:
Served as a nonproduct speaker for: “Topics in Health” for Merck Speaker Services

Laurie E. Scudder, DNP, NP
Accreditation Coordinator, Continuing Professional Education Department, Medscape, LLC; Clinical Assistant Professor, School of Nursing and Allied Health, George Washington University, Washington, DC
Disclosure: Laurie E. Scudder, DNP, NP, has disclosed no relevant financial relationships.

Learning Objectives

Upon completion of this activity, participants will be able to:

  1. Describe updated evidence on the prevalence of fructose intolerance as a cause of unexplained chronic abdominal pain in children, as reported at the American College of Gastroenterology (ACG) 2010 Annual Scientific Meeting and Postgraduate Course.
  2. Describe the research findings on the efficacy of a low-fructose diet in children with abdominal pain and fructose intolerance.

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CME Released: 10/29/2010; Valid for credit through 10/29/2011

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October 29, 2010 — Fructose intolerance or malabsorption is a common but often undetected cause of recurrent abdominal pain in children, but the problem can be effectively resolved with a low-fructose diet, according to research presented here at the American College of Gastroenterology 2010 Annual Scientific Meeting and Postgraduate Course.

In the study of 245 patients between the ages of 2 and 18 years with unexplained chronic abdominal pain, researchers from Mary Bridge Children’s Hospital and Health Center, in Tacoma, Washington, gave patients a standard dose of fructose (1 g/kg, to a maximum of 25 g), followed by a breath hydrogen test, which measured methane levels at 30-minute intervals for 90 minutes. The researchers found that the test was positive for fructose intolerance in 132 of the patients (53.9%).

The tests were considered positive if breath hydrogen exceeded 20 ppm above baseline at 90 minutes. If a test was positive, the patient was placed on a low-fructose diet, prescribed by a staff registered dietician, and the patient and family were given nutrition consulting.

Using a standard pain scale for children, the researchers found that after at least 3 months on the low-fructose diet, 88 of the 132 patients (67.7%) with fructose intolerance showed a resolution of symptoms. Among the 113 patients who tested negative for fructose intolerance, 54 (47.8%) reported a resolution of symptoms without a low-fructose diet, but investigator Rasha Saeed, MD, observed that the findings underscore the potential benefits of weaning patients from fructose.

“It can be a great frustration for the parents of children with recurrent abdominal pain, because they possibly can’t even go to school, and they are subjected to many procedures in trying to diagnose their condition,” said Dr. Saeed, a pediatric gastroenterologist at Mary Bridge Children’s Hospital and Health Center.

“When we identified children with fructose intolerance, we placed them on a low-fructose diet and found that many had their symptoms quickly resolve,” he said.

Dr. Saeed speculated that body mass index (BMI) might be an important aspect, and future research will consider that as a possible factor in the equation. “There is definitely more to this story, and we hope to next look at the BMI and how much weight improvement occurs after patients have been on the low-fructose diet for 6 months.”

According to Steven J. Czinn, MD, chair of the Department of Pediatrics at the University of Maryland Medical Center in Baltimore, simply getting too much fructose could be the cause of many of the patients’ abdominal pain.

“There is a condition of hereditary fructose intolerance, but that is rare. I think what this mainly could be is fructose malabsorption,” he said. “Fructose is a simple sugar and, aside from those with the hereditary condition, most people can absorb only a finite amount of it.”

“You can overload the intestine’s ability to absorb the fructose, in which case, the fructose makes its way down to the colon where it’s hydrolyzed, causing gas formation and abdominal pain. I think it may be an issue of overloading the system, instead of any kind of metabolic abnormality,” Dr. Czinn observed.

Because many parents make efforts to steer their children away from sodas to more “natural” juices, they might be giving them too much fructose,” he added. “It could simply be people switching from soda to fructose and not appreciating that all of these healthy fruit juices primarily contain fructose.”

The findings serve as an important wake-up call to physicians considering the causes of recurrent pediatric abdominal pain, Dr. Czinn noted.

“Fructose is certainly on the differential for abdominal pain, and even though I think most clinicians consider it, this is a reminder that there is value in actually getting an accurate dietary history of fruit and fruit juice intake.”

The study did not receive any funding. Dr. Saeed and Dr. Czinn have disclosed no relevant financial relationships.

American College of Gastroenterology (ACG) 2010 Annual Scientific Meeting and Postgraduate Course: Poster abstract 400. Presented October 17, 2010.

Clinical Implications

  • Fructose is a source of sugar in many fruit drinks believed to be natural and healthy by parents. In children with unexplained chronic recurrent abdominal pain, the prevalence of fructose intolerance may be as high as 54%; the breath hydrogen test is used as a diagnostic measure.
  • In children diagnosed with fructose intolerance, a low-fructose diet of at least 3 months is associated with resolution of symptoms in two thirds of children.



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