Transcript Functional Abdominal Pain In Childhood and Adolescence

Recurrent Abdominal Pain In
Childhood and Adolescence
Cheryl A. Little, MD
[email protected]
St. Vincent Pediatric Gastroenterology
8402 Harcourt Rd. Suite #402
Indianapolis, IN 46260
(317) 338-9450
IMPORTANT POINTS
• Recurrent Abdominal Pain (RAP) represents a
description of symptoms, not a diagnosis
• The most common cause of RAP is a functional
gastrointestinal disorder (FGID)
• There are 4 major pediatric disorders associated with
recurrent abdominal pain
• Functional abdominal pain syndrome
• Functional dyspepsia
• Irritable Bowel Syndrome (IBS)
• Abdominal Migraine
• A FGID is a positive diagnosis
• Therapy of a FGID is directed at environmental
modification
Introduction
• RAP is not a diagnosis
• Clinical manifestation of an organic disorder (23.6%)
(Indian Pediatrics; 46: 389-399, 2009)
• Due to a FGID
• Diagnosis of a FGID meets specific criteria (Rome III
criteria)
• Red flag symptoms concerning for an organic disorder
Pain that awakens the child
Significant vomiting, constipation, diarrhea,
bloating, or gas
Blood in the stool
Unintentional weight loss or slowed growth
Changes in bowel or bladder function
Pain or bleeding with urination
Abdominal tenderness
Epidemiology
• FGID occurs in 10-12% of school-aged children
• 21% severe enough to affect activity
(J Pediatr 129:220-226, 1996)
• Female-to-male ratio equal up to 9 yrs of age
• Female-to-male ratio 1.5:1 btw 9-12 yrs of age
• Onset of pain <4 yrs
• More in-depth organic evaluation
Pathophysiology of FGIDs
• Different presentations
• Heterogeneous group of disorders
• Variable expressions of the same disorder
• Prevailing viewpoint
• Pain is visceral in origin
• Involves disordered GI motility
• Involves visceral hypersensitivity/hyperalgesia
• Genetic vulnerability
• Abnormalities in the enteric nervous system
• Dysfunction of the autonomic nervous system
• Altered awareness of discomfort (emotions, cognitive
processes, CNS influences)
General Approach to RAP
• History
• Complete history is the MOST important component of the
evaluation (Attempt to obtain directly from patient)
• Focus on
• Timing, frequency, location, quality of pain
• Associated GI symptoms (nausea, vomiting, diarrhea,
constipation, blood in stool or emesis)
• Precipitating/relieving factors
• Systemic symptoms ( fever, wt loss, joint pain, skin rash)
• Family History of IBD or PUD
• Travel History
• Medication and nutritional interventions
• Interference with school, play, peer relations, and family
dynamics
General Approach to RAP
• Physical Examination
• Complete and not only directed toward the abdomen
• Growth data
• ?Fall off in height or weight velocity
• Delay in pubertal development
• Abdominal examination
• General appearance, auscultation, palpation of
liver and spleen, for masses and tenderness
• Rectal examination
• Perianal and digital
• Clubbing, rashes, arthritis
• Pelvic examination (if indicated by history)
Rome Criteria III
• Functional Abdominal Pain Syndrome
• At least 8 weeks of episodic or continuous abdominal
pain in a school-aged child or adolescent occurring at
least once/wk with one or more of the following:
• some loss of daily functioning
• additional somatic symptoms such as headache,
limb pain, or difficulty sleeping
• The patient has insufficient criteria for other functional
GI disorders that can explain the pain
• No evidence of an inflammatory, anatomic, metabolic
or neoplastic process that is likely to explain the
symptoms
Gastroenterology 2006;130:1527-1537
Functional Abdominal Pain Syndrome
• Periumbilical location
• Variable in severity
• Pain episodes tend to cluster alternating with pain-free
periods of variable length
• Associated GI symptoms are denied by the patient
Functional Abdominal Pain Syndrome
• Pain episodes begin gradually
• Last less than 1 hr in 50%
• Last less than 3 hrs in 40%
• Continuous pain in < 10%
• Child is unable to describe the pain
• Radiation of pain is rare
• Temporal relationship to meals, activity, bowel habits is
unusual
Functional Abdominal Pain Syndrome
• Pain rarely awakens the child from sleep
• Parents describe the patient as “miserable” and “listless”
during pain episodes
• During severe attacks the child may exhibit a variety of
motor behaviors (“doubling over in pain”)
• Common associated “autonomic” symptoms
• Headache, pallor, nausea, dizziness, fatigue
• At least one is observed in 50-70% of cases
Functional Abdominal Pain Syndrome
• Differential Diagnosis
• Infectious
• UTI, Giardia
• Carbohydrate intolerance- Lactose, fructose, sorbitol,
sucrase-isomaltase
• Inflammatory
• Crohn disease, ulcerative colitis, eosinophilic
gastroenteritis, celiac disease, pancreatitis
• IBS
• Constipation with or without fecal impaction
• Psychogenic
Functional Abdominal Pain Syndrome
• Diagnosis
• There is no dependable biological marker for functional
abdominal pain syndrome
• Most reliable diagnostic features are the symptoms
• Should NOT require a series of diagnostic tests to rule out
organic causes of pain
• Reasonable to obtain CBC, ESR or CRP, UA and culture,
KUB, CMP, O+P, fecal leukocytes, lactose tolerance
testing/lactose elimination
• US and CT are low yield
• Excessive testing may increase parental anxiety and put the
child through unnecessary stress
• Parental anxiety/uncertainty increases the stressful environment
that provokes and reinforces the pain behavior
Functional Abdominal Pain Syndrome
• Treatment
• Begins at initial office visit
• Important to introduce the concept of functional pain
during the initial evaluation
• Review the differential diagnosis to reassure parents
and child that specific organic disorders have been
considered and “red flags” are absent
Functional Abdominal Pain Syndrome
• Treatment
• Focus of treatment is not “cure” but management of
symptoms and adaptation to illness to provide a
satisfactory quality of life through support and
education
• Accomodative or secondary engagement coping
(distraction, acceptance, positive thinking,
cognitive restructuring) is related to less pain
• Passive or disengagement coping (denial,
cognitive avoidance, behavioral avoidance, wishful
thinking) is associated with increased levels of pain
Functional Abdominal Pain Syndrome
• Treatment
• Directed toward environmental modification
• Identify, clarify, and reverse stresses that may
provoke or increase the perception of pain
• Reverse environmental reinforcement of the pain
behavior
• Lifestyle MUST be normalized regardless of the
continued presence of pain
• Parents should direct less social attention toward
the symptoms
Functional Abdominal Pain Syndrome
• Supportive counseling
• Target at illness behavior
• Can be delivered by primary care physician
• Listening, empathy, encouragement
• Do not allow ongoing pain-induced disability
• Patient-centered participatory arrangement
• Instruct parents how to respond to symptoms
• Encourage school officials to participate in treatment
Functional Abdominal Pain Syndrome
• Treatment
• Pharmacologic therapy directed at reasonable
physical triggers of pain
• Constipation
• Altered motility
• Low-dose tricyclic antidepressants
• Act as “central analgesics”
• Raise the perception threshold for abdominal pain
• Down regulate pain receptors in the intestine
• Generally reserved for patients with
anxiety/depression or maladaptive illness behavior
Functional Abdominal Pain Syndrome
• Treatment
• Hospitalization
• Reinforces pain behavior
• Consultation
• Reserved for patients with depression/anxiety,
PTSD, abuse, severe disability, maladaptive
illness behavior, chronic refractory pain
• Child Psychiatrist
• Child Psychologist
• Behavioral modification therapy
Rome Criteria III
• Functional Dyspepsia
• At least 8 weeks (which need not be consecutive) in
the preceding 12 months of persistent or recurrent
pain occurring at least once/week centered in the
upper abdomen AND
• No evidence of an inflammatory, anatomic, metabolic
or neoplastic process that is likely to explain the
symptoms AND
• No evidence that dyspepsia is exclusively relieved by
defecation or associated with a change in stool
frequency or form
Gastroenterology 2006;130:1527-1537
Clinical Presentation
• Functional Dyspepsia
•
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Pain localized to the epigastrium, RUQ, or LUQ
Episodic vomiting
Temporal relationship with meal ingestion
Presence of anorexia, nausea, oral regurgitation,
early satiety, post-prandial bloating, indigestion, and
belching
Functional Dyspepsia
• No symptoms or signs that reliably distinguish functional
dyspepsia from upper GI organic disorders
• More extensive diagnostic evaluation than functional
abdominal pain syndrome
• Usually associated with the same signs of environmental
reinforcement of pain behavior
Functional Dyspepsia
• Two groups
• Ulcer-like dyspepsia
• Pain most common symptom
• Dysmotility-like dyspepsia
• Often report nausea, fullness, and early satiety
Functional Dyspepsia
• Differential Diagnosis
• Acid-related disease
• Gastritis, duodenitis, esophagitis, peptic ulcer
• Infection
• Helicobacter pylori
• Allergic/Inflammatory
• Eosinophilic esophagitis, eosinophilic
gastroenteritis, gastoduodenal Crohn disease,
celiac disease
• Gastroparesis
• Chronic cholecystitis
• Chronic fibrosing pancreatitis
Functional Dyspepsia
• Diagnosis
• Physical exam- findings usually normal
• Lab evaluation- CBC,ESR or CRP,amylase, lipase,
hepatic panel, H. pylori serology or stool antigen
• UGI +/- SBFT
• Abdominal US
• Nuclear medicine scintigraphy (HIDA scan)
• Upper Endoscopy- patients with dysphagia, persistent
symptoms despite the use of acid-reducing
medications, or to confirm H. pylori infection.
• ERCP
Functional Dyspepsia
• Treatment
• Positive diagnosis, education, establishment of
realistic expectations of treatment
• Environmental and dietary modification
• Avoid cigarette smoking, advise smoke-free home
• Avoid alcohol, non-steroidal analgesics
• Avoid caffeinated beverages, high-fat foods, and
large meals
• Address psychological comorbidity
Functional Dyspepsia
• Treatment
• Drug therapy
• 70% improvement rate by 1 year following
diagnosis (JPGHAN 30: 413-418, 2000)
• Ulcer-like dyspepsia
• 4-6 week course with H2-receptor antagonist or
PPI
• Dysmotility-like dyspepsia
• 4-6 week course with a prokinetic agent
(metoclopramide or erythromycin)
• Anti-emetics or low-dose tricyclic antidepressants
• Serotonic agents- Buspirone (Buspar), Paroxetine
(Paxil)
Rome Criteria III
• Irritable Bowel Syndrome
• At least 8 weeks in the previous 12 months of
abdominal discomfort or pain occurring at least once/wk
with at least 2 of the following:
• relief w/defecation
• onset associated w/change in frequency of stool
• onset associated w/ change in form of stool
• No evidence of an inflammatory, anatomic, metabolic or
neoplastic process that is likely to explain the symptoms
Gastroenterology 2006;130:1527-1537
Irritable Bowel Syndrome
• More common in adolescence
• Pain is typically localized to the lower abdomen
• Association of pain with altered bowel pattern
• Diarrhea (4 or more stools per day)
• Constipation (2 or less stools per week)
• Sense of incomplete evacuation
• Straining
• Urgency
• Passage of mucus
• Feeling of bloating or abdominal distention
• Pain is often relieved by defecation
Irritable Bowel Syndrome
• Differential Diagnosis
• Infection
• Giardia
• Chronic Clostridium difficile colitis
• UTI
• Carbohydrate intolerance
• Lactose, fructose, sorbitol, sucrase-isomaltase
deficiency
• Inflammatory
• Crohn disease, ulcerative colitis, eosinophilic
gastrenteritis, celiac disease
• “Microscopic” colitis
Irritable Bowel Syndrome
• Diagnosis
• Careful, sympathetic history taking
• Appropriate, thorough PE ( to include rectal exam)
• Negative routine diagnostic studies
• Empiric lactose elimination
• Full assessment of psychological and social factors
as well as physical symptoms
Irritable Bowel Syndrome
• Diagnosis
• Colonoscopy is indicated in pts in whom the history or
PE suggest the possibility of IBD
Evidence of GI bleeding
Profuse diarrhea
Involuntary wt loss or growth deceleration
Fe deficiency anemia
Elevated ESR or CRP
Extra-intestinal symptoms (fever, recurrent mouth
sores, rash, joint pain)
Irritable Bowel Syndrome
• Management
• Symptomatic and supportive care
• Development of a positive relationship between
doctor and patient/parents
• Validate the symptoms that they are experiencing
• Address the patient’s agenda by asking directly
about their concerns and fears
• Initial Management
• Positive, confident diagnosis communicated with
clarity and honesty
• Educate about the pathophysiology of FGIDs and
bring focus to the multifactorial nature of IBS
Irritable Bowel Syndrome
• Dietary Management
• Constipation predominant
• Insoluable fiber diet ( root vegetables, skinned
fruits, bran, whole-wheat products)
• Diarrhea predominant
• Eat slowly, avoid chewing gum, avoid excessive
intake of alcohol, carbonated and caffeinated
beverages, high-fat foods, legumes, and foods or
beverages with fructose or sorbitol
• Soluable fiber diet (dried beans and fruits, peas,
oats, barley, carrots, flesh of fruits such as apples
and organges)
• Response rates of 70% (Lancet 2: 1115-1117, 1982)
Irritable Bowel Syndrome
• Drug Therapy
• Antispasmodics
• Anticholinergics
• Used in diarrhea predominant or variable stool IBS
• Dicyclomine-Bentyl
• Hyoscyamine-Levsin,Levbid
• Enteric-coated Peppermint Oil
• Amitiza- chloride channel activator
• Indicated for constipation predominant IBS in adults
• Antibiotics/Probiotics- to treat bacterial overgrowth
• Tricyclic Antidepressants
• Serotonic drugs- Buspar, Celexa
Summary
• FGIDs can occur as a well defined clinical entity (e.g.
IBS) or a less defined clinical syndrome (e.g. functional
abdominal pain syndrome)
• Essential for physicians to take a biopsychosocial
approach to diagnosis and treatment
• Appreciate the close interaction of the gut and brain
• Allows the child, parent and physician to address the
pain on many levels
• Further understanding of brain-gut axis and the role of
serotonin in neural sensorimotor functions is needed
Irritable Bowel Syndrome
• Probiotics
• Replace deficiencies of “normal” colonic bacteria and
reduce fermentation
• Randomized double-blind controlled trial
• Lactobacillus plantarum
• Reduction in the degree of flatulence
• Improved overall GI function at 12 months
(Am J Gastroenterol 95:1231-1238, 2000)
Irritable Bowel Syndrome
• Tricyclic Antidepressants
• Effect significant on primary outcome measures and
on global response and pain
• 89% improvement in adult pts 61% remission of
symptoms (Gut 2005;54:1332-1341)
• Effectiveness in clinical practice limited by side effects
(sleepiness)
• Reserved for patients with severe symptoms or
symptoms resistant to common first-line approaches
Irritable Bowel Syndrome
• Serotonic Agents
• 5-HT1 agonists
• Buspirone (Buspar)
• Reduce gastric acid and colonic responses to
volume distention
• Anxiolytic activity
• SSRIs
• Citalopram (Celexa)
• Reduce colonic sensation to volume distention in
healthy subjects
Irritable Bowel Syndrome
• Psychological Treatment
• Stress management
• Psychotherapy
• Introduce early in the discussion of
pathophysiology and management of IBS
• Do not leave as “last-ditch” treatment after medical
therapy has proved less than optimal
• Therapy often combination of parent training,
altering reinforcement of various behaviors and
stress management
• Statistically significant improvement of pain with
adjunctive cognitive-behavioral therapy
(J Consult Clin Psychol 57: 294-300, 1989, and 62: 306314, 1994)