Transcript The teenager with chronic abdominal pain

The teenager with chronic
abdominal pain; the teenager
with chronic symptoms
Oscar Taube, MD
Coordinator, Adolescent Medicine
The Children’s Hospital at Sinai
September 22, 2009
Case:17 y.o. female seen multiple
times over past year at GPA:
Abdominal Pain: Bilateral lower abd. pain;
intermittent; 4/5 pain; constipation alternating
with diarrhea; BM’s do not relieve pain; Never
sexually active.
Headaches: Mainly frontal; several times/week;
not interfering with activity; no vision changes,
no vomiting; doesn’t waken her from sleep; no
URI complaints; no family hx. of migraine. Rx’d
in past for sinusitis with amoxicillin- no relief of
pain.
Case History, continued
• Backache: Chronic lower back pain, not increased with
movement.
• Joint pains: Multiple complaints in past 6 months;
mostly hip pains; no morning stiffness.
• Social Hx. Patient’s mother recently became pregnant;
pregnancy with complications; mother on bed rest.
• Physical Exam: Abdominal Exam: Mild bilateral lower
abd. tenderness; no HSM, masses, guarding,
rigidity.Otherwise, PE wnl.
• Labs: CBC, CMP, amylase, lipase, urine culture, STD
testing, connective tissue disease testing all negative.
Case History #2
Adolescent Consultation Service
Patient
• KJ, 19 year old white female w. several
months sharp stabbing upper abdominal
pain; sometimes awakens her at night.
Decreased appetite. No T, V, D, blood in
stools.
• Previous work up: Endoscopy: small
gastric/duodenal ulcers; some
improvement with PPI’s.
CBC/CMP/Amylase-Lipase all normal.
Case #2, continued
• 10 years complaint of joint pains
• Complaint of significant fatigue, even with
adequate sleep.
• Several years of frequent headaches;
difficulty with concentration, short term
memory.
Case #2, continued
• Psychosocial: Raped at age 17, never
reported. Admits to depressed, self
deprecatory, suicidal ideation. Beck
Depression Inventory score 48 (severe
range= 29-63).
• Physical exam WNL except for +
tenderness on 11 of 18 Fibromyalgia
tender-point sites.
Why this combination of topics?
(Chronic abd. pain/chronic
symptoms)
• The two key symptoms in children and
adolescents with potential somatization
disorders are:
• Abdominal pain
• Headaches.
• And chronic fatigue/muscle pain, too.
Epidemiology-Chronic Abdominal
Pain
Hyams et. al. J. Pediatrics, 1996.
Community based study of abd. pain
complaints of suburban 7th, 10th graders:
Middle School (mean age 12.6 years)
13% pain at least weekly
32% pain > 5x. per year
24% pain severe enough to affect activities
Epidemiology, continued.
• Hyams study, continued.
• High school (Mean age 15.6 years)
• 17% at least weekly pain
•
37% pain > 5 x/year
•
17% pain severe enough to affect
activities.
• Chronic abdominal pain accounts for 2-4%
of all pediatric office visits.
All roads lead to….
Rome!
• Rome III Criteria for Functional Bowel
Disorders Associated with Abdominal Pain
or Discomfort in Children and Adolescents
– Functional Dyspepsia
– Irritable Bowel Syndrome
– Childhood Functional Abdominal Pain and
Syndrome
Functional Dyspepsia
– A. Persistent/recurrent pain centered in upper
abdomen, above umbilicus
– B. Pain not relieved by defecation, or assoc.
w. onset of change in stool frequency or stool
form (i.e., NOT IBS).
– C. No evidence of inflammatory, anatomic,
neoplastic process to explain symptoms
– D. Above must be present at least 1x/week,
for at least 2 months.
Irritable Bowel Syndrome
• Recurrent abdominal pain or discomfort at
least 3 days per month for the past 3
months, associated with two or more of
the following:
• Improvement with defecation
• Onset assoc. w. change in stool frequency
• Onset assoc. w. change in stool form
(appearance).
Childhood Functional Abdominal
Pain
• All of the following must be present at
least once a week for at least 2 months
before diagnosis
• A. Episodic or continuous abdominal pain
• B. Insufficient criteria for other functional
GI disorders.
• C. No evidence of an inflammatory,
anatomic, metabolic, or neoplastic process
that explains the symptoms.
Childhood Functional Abdominal
Pain Syndrome
• Must include Dx. of Childhood Functional
Abdominal Pain at least 25% of the time
and one or more of the following:
• A. Some loss of daily activity
• B.Additional Somatic symptoms such as
headache, limb pain, or difficulty sleeping.
Differential Dx. Functional Bowel
Disorders
• Functional Dyspepsia: GER; Peptic ulcer
disease; Biliary tract obstruction/biliary
colic; chronic pancreatitis; gastroparesis.
• IBS: Lactose intolerance; IBD; Celiac
disease; Infection (e.g. giardiasis);
constipation
.
Differential Dx. Functional Bowel
Disorders, continued
• Gynecologic Differential Diagnosis:
• Pelvic adhesions- Pelvic inflammatory
disease.
• Mittelschmerz
• Dysmenorrhea
• Endometriosis
• Ovarian mass.
• UTI
Differential Dx. of Abdominal Pain
by location
• RUQ:Hepatitis/cholecystitis/pneumonia
• RLQ: Appendicitis/IBD/Salpingitis
• Epigastric: Peptic ulcer
disease/pancreatitis/pericarditis
• Periumbillical: Early appy/gastroenteritis
• LUQ: Splenic abcess/pancreatitis
• A very partial list!
Pathogenesis of Functional Bowel
Disorders
1.Visceral hypersensitivity or hyperalgesia,
with a decreased threshold for pain
2. Altered GI motility
3. Psychological stress as a trigger/Genetic
factors/environmental factors
4. Other “Medical” factors: Infectious
gastroenteritis as IBS trigger; abnormal
serotonergic mechanisms; small intestinal
bacterial overgrowth.
Approach to Functional GI
Disturbances
• CAREFUL, COMPREHENSIVE HISTORY
• (Timing, location, radiation, quality, severity, precipitants, relievers of
pain; associated complaints; diet; family hx., etc.)
• CAREFUL, COMPREHENSIVE PHYSICAL EXAM.
• (Oral exam; Pubertal stage; abd. Exam including location, rebound,
mass, psoas sign, mass, HSM, kidney size, perianal findings,
rectal/pelvic exam, stool for occult blood).
• Plot weight, height on a serial growth chart
• Pay attention to the “Red flags”- these point to signs of GI diseases
that may need more aggressive testing, more aggressive
pharmacologic, surgical Rx, and most likely will need GI referral.
• Pay attention to the “Red flags” that point to somatiform diagnoses
• Limited “General” lab work up: CBC/CRP/Urinalysis
Red Flag signs, sx’s suggestive of
organic diseases
• Weight loss
• Unexplained fevers
• Pain radiating to the back/pain distant from
umbillicus
• Bilious emesis
• Hematemesis
• Chronic diarrhea (>2 weeks)
• GI Blood loss
• Oral ulcers
• Dysphagia
Red flags, continued
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Unexplained rashes
Nocturnal symptoms
Arthritis
Anemia/pallor
Delayed puberty
Deceleration of linear growth velocity
Family hx. of IBD, celiac, peptic ulcer disease
Hepatosplenomegaly
Perianal abnormalities
A brief approach to treatment of
Functional Bowel disorders
• Functional Dyspepsia:
•
Reassurance
•
D/C dyspeptic meds (e.g. ibuprofen)
•
D/C dyspeptic foods
•
H2 receptor antagonists/PPI’s
•
Trial of low dose tricyclic antide•
pressants qHS.
Rx of Functional Bowel Disorders,
continued
• IBS:
•
Reassurance; explanation
•
Dietary modifications- If diarrhea,
reduce sorbital, fructose, gas forming
vegetables. If constipation: Increase water.
•
PharmRx-if constipation: Osmotic
laxatives, stool softener. Trial of
antidepressants? Probiotics?Peppermint
oil?
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Biopsychosocial model: A
continuum of hierachical systems
that
are
always
interacting:
Biosphere
Society-Nation
Culture-subculture
Community
Family
Person
Nervous system
Organ-organ systems
Tissue
Cell
Organelle
Molecule
Biopsychosocial Model-How NOT
to do it
• “First we’ll rule out organic problems, then we’ll
explore psych issues.”
• “We’ll do some tests to see what is wrong.”
• The clinician focuses her/his efforts-in dealing
with the adolescent who has chronic abdominal
pain/chronic somatic symptoms-to determine if
the teen is trying to: a. avoid something (primary
gain); b. seek attention (secondary gain); c. feign
symptoms for internal or external gain.
• “I believe that your pain is real.” (If you’re really
sending the message “I don’t believe the pain is
real.” )
Somatization
• “The central feature of somatiform
disorders is that they present with features
of an underlying medical condition, yet
such a condition either is not found or
does not fully account for the level of
functional impairment.”
• -Silber T, Pao, M. Peds.in Review 8/03.
Pathogenesis: Genetic/Family
Factors
• Genetics?: Somatoform disorders concordant in
twins; cluster in families w. ADD/alcoholism.
• Learned Behavior: In many household,
children’s somatic complaints more acceptable
than expression of strong feelings.
• Family psychosocial factors: 1. If a family
member has a chronic physical illness,
+++somatic sx’s among children. (A model).
2.Somatisizing kids often live with somatisizing
parents. 3. These sx’s=a reaction to stress.
Somatization: Differential Diagnosis
• Unrecognized physical disease (OH NO!)
• Unrecognized psychiatric disorder (e.g.
depression, anxiety)
• Factitious disorder (e.g. malingering)
• Psychological factors affecting medical
condition
Campo, et. al. Pediatrics 2004
Psychiatric RAP
Disorder
patients
(%)
Control
patients
(%)
P value
Any anxiety 78.6
disorder
10.5
<.001
Any
42.9
depressive
disorder
7.9
<.001
The approach: Somatization “Red
Flags”
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Hx. of multiple somatic complaints
Multiple primary care physician visits
Multiple specialty consultations
Family members with chronic and
recurrent sx’s.
• “Non-nuclear” family
• Dysfunction in primary areas of life: family,
peers, school, sports, leisure activities.
The approach, continued
• VERY CAREFUL, VERY COMPREHENSIVE
HISTORY AND PHYSICAL EXAM
• Bring up, EARLY in the evaluation, that there
may be stress related factors.
• Ask patient/family their theories re: etiology
• Limited lab work up, impose limits on workup.
Suggest limitations on specialty referrals.
• Screen for depression/anxiety, etc. YSC,
BDI,etc.
• Avoid “mind-body split”/”Functional vs.
organic”/etc. Use an example (e.g. red face”)
Ask the patient/parent-Mothers who
endorsed psych-social causes for
their kid’s abd. pain
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Cause
% endorsing
Child worried, nervous, tense
50%
Stress
32%
Puts too much pressure on self
30%
XS sensitivity/overreaction to pain 29%
Abd. pain gets family attention
12%
The approach, continued
• Urge consolidation of care
• Teach self-monitoring techniques (e.g.,
relaxation, PMR, pain diary )
• Offer reassurance when appropriate
• Aggressively Dx. and Rx. Comorbid
psychiatric disease. Insist upon close
contact with mental health provider
• Schedule frequent follow-up appt’s.
• Finally, recognize that these patients can
be very frustrating and difficult to treat.
• Consultation-physician to physician-for
formal consultation, for ideas, and for
emotional support- can be vital!
References-1
•
1. Braverman P: “Chronic Abdominal Pain”, in Neinstein LS et.al. Editors, Adolescent
Health Care: A Practical Guide. Fifth Edition. 2008. Philadelphia, Lippincott Williams
and Wilkins. pp. 508-516.
•
2.Campo JV, BridgeJ, Ehmann M et. al.: “Recurrent Abdominal Pain, Anxiety and
Depression in Primary Care. Pediatrics Vol 113 No. 4 April, 2004 pp. 817-824
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3. Claar RL, Walker LS: “Matenal attributions for the causes and remedies of the
children’s abdominal pain.” J. of Pediatric Psychology 1999 Vol. 24 No. 4 pp. 345354.
•
4.Collins BS, Thomas D: “Chronic Abdominal Pain.” Pediatrics in Review Vol.28 No.9
Sept. 2007 pp.323-331
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5. Hyams JS, Burke G, Davis PM et.al. “Abdominal Pain and Irritable Bowel
Syndrome in Adolescence; a Community- based Study.” J. of Pediatrics Vol. 129 No.
2. 220-226
•
6. Kriepe RE “The Biopsychosocial Approach to Adolescents with Somatoform
Disorders.” Adolescent Medicine Clinics Vol. 17 No. 1 Feb. 2006 pp.1-24
References-2
• 7. Lake AM: “Chronic Abdominal Pain in Childhood: Diagnosis and
Management.” Am. Family Physician Vol. 59 No.7 April 1, 1999.
• 8. Miranda AM: “Early Life Stress and Pain: An Important Link to
Functional Bowel Disorders.” Pediatric Annals Vol. 39 No. 5 May,
2009.
• 9. Servan Schreiber D, Randall K, Tabas G: “Somatizing Patients:
Part 1 Practical Diagnosis; Part 2 Practical Management.” Am.
Family Physician Vol. 61 No. 4, 5. 2/15 and 3/1/00.
• 10. Silber TJ, Pao M: “Somatization Disorders in Children and
Adolescents.” Pediatrics in Review Vol. 24 No. 8 Aug. 2003
• 11. Up to Date articles (May, 2009) on Evaluation/Management of
Child with Chronic Abdominal Pain; Somatization; Primary Care
Management of Medically Unexplained Symptoms.