AUTHOR’S RESPONSE Author’s Response:

The location, duration, intensity, and frequency of abdominal pain in the group of children reported in our article were variable. Most patients had right lower or periumbilical abdominal pain. This pain was severe and debilitating, as it interfered with the child’s normal activities, including school attendance and family/social life. 1 In most of these patients, an organic cause for the pain was found. The cecal adhesions described in our article were abnormal adhesions, mainly from the cecum and appendix to the anterior or lateral peritoneal wall. We postulated that the adhesions were most likely secondary to a previous infection or inflammatory reaction. There was no evidence of intestinal malrotation, malfixation of the cecum or ascending colon, or intermittent cecal volvulus. I believe that these adhesions are better visualized with the use of laparoscopy, because the anterior and lateral abdominal wall are distended away from the cecum, and they can be easily missed if the procedure is done in open fashion. We recommend appendectomy when laparoscopy (or laparotomy, as done in the past) is used in children or adolescents with chronic recurrent abdominal pain, unless there is a specific contraindication to remove the appendix. There has been a reluctance to accept appendiceal colic as a clinical entity, or as an etiological factor in abdominal pain. Some authors have proposed that by distending the appendix, inspissated fecal material can cause abdominal pain, even in the presence of a histologically normal appendix. It is also possible that removal of the appendix in some of these patients may have a placebo effect. 2,3 Dr. Tirol’s comments regarding cecal adhesions are compelling. Thus, in our future efforts to treat children with chronic recurrent abdominal pain, we will look more carefully at these adhesions, perhaps biopsy them, and try to clarify their etiology.