Transcript What!!! another patient with abdominal pain????

What!!! another patient with
abdominal pain????
Midwest Pediatric Hospital Medicine Conference,
2013
Susan Maisel, MD & Allyson Boodram, MD
Objectives
Review the characteristics of chronic abdominal pain
Differentiate functional from organic causes of abdominal pain
Review current modalities for evalutaion, management/treatment of chronic
abdominal pain
Review predictive value of these modalities
case Scenario
Definitions
Chronic Abdominal Pain:
Pain of at least 3 months duration; clinical variation that includes time
frame of 1-2 months
Source:Hyams et.al
1996.
Recurrent Abdominal Pain:
One of the most common recurrent pain syndromes in children. Classic
definition based 4 criteria:
Hx of at least 3 episodes of pain
Pain that is severe enough to affect activities
Episodes that occur over 3 months
No known organic cause.
Clinical Definitions
Chronic Abdominal Pain:
Long lasting, intermittent or constant that is functional or organic (disease)
Functional Abdominal Pain:
Abdominal Pain without evidence of disease/pathologic process. Can
manifest with symptoms typical of functional dyspepsia, irritable bowel
syndrome, abdominal migraine or functional abdominal pain syndrome.
The American Academy of Pediatrics (AAP) and North American Society for
Pediatric Gastroenterology, Hepatology, and Nutrition (NASPGHAN)
guidelines for the evaluation and treatment of children with chronic abdominal
pain recommend that:
the term "recurrent abdominal pain" should not be used as a synonym for
functional, psychological, or stress-related abdominal pain . Functional
abdominal pain, which is the most common cause of chronic abdominal
pain, is a specific diagnosis that must be distinguished from other causes
of abdominal pain (eg, anatomic, infectious, inflammatory, metabolic)
Source: AAP, 2005
other causes
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Peptic ulcer
H pylori
Biliary dyskinesis
Celiac
IBD
Abdominal migraine, IBS
GER
Is there evidence that children with chronic
abdominal pain have symptom patterns that
can be categorized as functional versus
organic?
Limited but credible evidence of the existence of functional dyspepsia, IBS,
and abdominal migraines in children
History
1.
2.
When did it start? Document duration
F – Concurrent stressful event in life
O – Trauma or travel
Where is it located and where does it go?
F – Peri-umbilical or epigastric
O – Well localized away from umbilicus
3. How long does it last?
F – Prolonged duration with no clear signs
O – Variable; signs raise the ante
4. What does the pain feel like?
F – Vague, gradual onset, variable severity
O – Isolated, sudden onset
5. What makes the pain better?
F – No relationship to interventions
O – Sometimes medications or position change help
6. What makes the pain worse?
F – Reinforcement from parents
7. Is the pain intermittent or constant
F – Constant
O - Intermittent
8. Association with other signs or symptoms?
F – Signs of anxiety (mottled skin, nail biting), family history of irritable
bowel, migraines
O – Association with hematachezia, fever, rash, weight loss, growth
faltering, family history of ulcers or IBD
What is the predictive value of the
history?
There are no studies that support the history is able to differentiate functional
from organic disease
Presence of headaches, joint pain, anorexia, vomiting, nausea, excessive gas
and altered bowel symptoms may be more frequently associated with
functional abdominal pain
Presence of Red Flags may suggest a higher probability of organic disease
and warrants further diagnostic evaluation
What is the diagnostic value of the
psychosocial history?
The literature reviewed 3 domains: Life-Event Stress, Emotional/Behavioral
Symptoms and Family functioning.
There is no evidence on whether any of these domains influence symptom
severity, course or response to treatment
location, location,location
Differential of chronic
abdominal Pain
FUNCTIONAL
Functional
GU
DyspepsiaIBSFAPFun
UTIRenal StonesOvarianPID
ctional Ab
OTHER
PainAbdominal
GI
MedicationsHSPSickle
CellLymphomaFam Med FeverPorphyriaLead PoisoningRheumatolog
Migraine
ic DiseaseIBDGallstonesPancreatitisAllergy?H. pylori?Celiac Dis.
Initial Evaluation
Validate the symptoms and concerns of the patient and family
Make sure the patient is safe:
Organic pathology screen
Obtain and review all prior testing
Consider video if available - What’s reuired?
Clear communication with nursing and ancillary staff (child life) regarding
observation of patient behaviors and family dynamics. Importance of
proper documentation for concerning observation.
Parental/patient voice regarding evaluation
Red Flags and red herrings
Systemic signs: hematachezia, rash, weight loss, growth faltering, vomiting,
diarrhea, persistent RLQ/RUQ pain, unexplained fever, evidence of GI blood
loss,
Historical clues: family history of ulcers or IBD
Prolonged school absence
Use of narcotic pain medication
Positive or unusual exam findings
diagnostic studies
CBC
ESR, CRP
CMP, Amylase, Lipase, H. Pylori, Celiac
TSH, T4
UA
Imaging: Ultrasound, Abdominal/Pelvic CT/MR
Procedures: Endoscopy
what is the predictive value of
laboratory tests?
There is no evidence to evaluate the predictive value of blood tests
There is no evidence to evaluate the predictive value of blood tests in the face
of “Red Flags”
What are the predictive values of other
diagnostic tests?
No evidence to suggest that abdominal and pelvic ultrasounds in the
ABSENCE of Red Flags has a significant yield of organic disease
There is little evidence to suggest that the use of endoscopy and biopsy in the
ABSENCE of Red Flags has a significant yield of organic disease
Insufficient evidence to suggest that esophageal pH monitoring in the
ABSENCE of Red Flags has a significant yield of organic disease
All Studies normal
Now what?
Treatment/management
Delivery of diagnosis to families - clear, education of FAP; reassurance;
emphasize that there is no seriouslife threatening process/condition; there
may be resistance to a diagnosis of non organic disease; use simple language
stressing that the pain is real despite lack of organic cause; families/patients
resistant to a functional cause may be more likely to continue to have missed
school days and somatic complaints
Goals of
Treatment/Management
Primary goal - Return to normal function
Secondary goal - Relief of symptoms
Primary goal - Return to
normal function
Avoidance of reinforcement of pain behaviours
Distraction, providing attention, rest, identifying triggers for pain
Reassurance
Education to the family
Emphasize that there is no serious life threatening process/condition
Secondary goal - Relief of
symptoms
Pharmacologic
Cognitive Therapy
Relaxation
Massage/PT/OT/Exercise
Useful Analogies
HA
Don’t use it - Lose it
Christmas tree lights
Worst Nightmare
Drug
Action
Indication
Risk
Peppermint
Oil
? Smooth
Muscle
Relaxation
IBS
None
Fiber
Stool
Bulking
Constipation
Predominant
Bowel
obstruction
Lactose Free
Diet / Lactaid
Eliminates
Lactose
Lactase
Deficiency
None
Probiotics
Replacement of S/P Antibiotics /
“Toxic Bacteria”
Enteritis
Systemic
Translocation
Drug
Action
PEG
Stool Softner
H2 Blocker
Histamine
Antagonist
PPI
Inhibits Acid
Production
Serotonin 2A
Antagonist
Serotonin
Blockade
Anti - Tricyclics
Anti Depressant
Indication
Risk
Constipation
Dehydration / Bowel
Obstruction
Dyspepsia
Tachyphalaxis after 2
weeks
?Osteopenia/Bacterial
Dyspepsia /
Overgrowth/
PUD
Gastronoma
Abdominal
Migraine /
Anxiety
Drowsiness, Dizziness
Dependancy / Suicide /
Depression
Arrythmias
Drug
Mylicon
Bentyl
Levsin
Donnatol
Action
Indication
Excessive/Disco
Anti - Flatulance
mfort/ Gas Pains
Anti Spasmodic (AS)
Spasms /
Cramping
AS, Sedation
Spasms /
Cramping
AS, Sedation
Spasms /
Cramping
Risk
what is the effectiveness of
pharmacologic treatment?
Through review of literature revealed a paucity of studies on pharmacological
and dietary intervention, thus definitive statements regarding efficacy are
limited.
Evidence that treatment with peppermint oil for 2 weeks may provide benefit in
children with IBS
Inconclusive evidence of the benefit of H2 antagonists to treat dyspepsia
Inconclusive evidence that fiber intake decreases the frequency of pain
attacks for patients with chronic abdominal pain
Inconclusive evidence that a lactose free diet decreases symptoms in children
with chronic abdominal pain
Limited data regarding efficacy of serotonin 2A antagonists in treatment of
abdominal migraine
Treatment/Management
options
Resuming normal daily life
PT/OT for reconditioning
Relaxation/Massage/Exercise
Cognitive Therapy
what is the effectiveness of Cognitive behavioral therapy?
Literature reviewed 3 domains of psychosocial history: life - event stress,
child emotional / behavioral symptoms and family functioning.
Life - Event Stress
There is no evidence on whether this influences symptom severity,
course, or response to treatment
Emotional/Behavioral Symptoms
There is evidence that patients with chronic abdominal pain have more
symptoms of anxiety/depression than do healthy controls
There is evidence that suggests the presence of anxiety, depression, or
other behavior problems is NOT useful in distinguishing between
functional abdominal pain and organic abdominal pain
Family Functioning There is evidence that parents of patients with recurrent abdominal pain
have more symptoms of anxiety, depression, and somatization than do
parents of community controld or parents of other pediatric patients
There is also evidence that families of patients with recurrent abdominal
pain do not differ from families of control or families of patients with acute
illness in broad areas of functioning such as family cohesion, conflict and
marital satisfaction
Functional abdominal Pain
(FAP)
Uncommon under 5
females > males
Real pain; not faking or malingering
Pathogenesis
abnormal bowel reactivity to physiologic stimuli (meal, gut distention,
hormonal), noxious stressful stimuli (inflammatory procees), psychological
stressful stimuli (parental seperation, anxiety) Leading to the development
of visceral hyperalgesia
FAP is a POSITIVE diagnosis and not a failure to the true cause of the pain
Functional gastrointestinal
disorders
FGIDS
Variable combination of chronic and/or recurrent symptoms that are not
explained by biochemiacal or anatomical abnormalities.
ROME Committee, 2009: Updates information on FGIDS for clinical and
research
Symptoms of chronic or recurrent abdominal pain in children where
there is no identifiable structural, inflammatory, infectious, neoplastic or
metabolic cause.
Symptoms that occur once a week for a druation of at least 2 months
Epidemiology of Chronic
Abdominal Pain in children
One of the most common complaints in children and adolescents
13% of Middle School aged; 17% of High School aged children experience weekly
abdominal pain (Hyams JS et al J Pediatr. 1996)
Functional Abdominal Pain was found in 15% of school aged children (Youssef NN.
Clinical Pediatrics 2007)
10-15% of school age children seek help
10-15% more have symptoms but never seek medical attention
10% have an organic cause
Females>males
Higher in > 10 years old
Prevalence increases during school, not vacations
Myths
Functional Abdominal Pain (FAP) is NOT strictly associated with:
Overachiever
Intellect
Perfecionist
Constant worrier
Important to not be biased and have a broader differential when considering
FAP
Case 1
CC: SS is a 14 y.o F that presents for evaluation of chronic abdominal pain that has been
present for 4months. Her pain is localized to the periumbilical region, although
occasionally she describes radiation to the lower left and right quadrants. She rates her
pain as 7/10. She states that it seems to be worse in the morning but can present at any
time throughout the day. There are no specific triggers such as diet or activity; and she
denies any alleviating or aggrevating factors. she reports no change in appetite or bowel
habits, but she has had episodes of non bilious/non bloody emesis intermittently since
onset of pain. She has also had a 10lb weight loss since onset of her pain.
PMHx: unremarkable; PSurgHx: none
Social: Lives with mom, father is not consistently involved but she does see him. Has a
good relationship with her mother. She is the only child. Described as a straight A student
and popular amongst her peers; involved in extra curricular activities through school,
including: dance, soccer, track and debate. Since onset of pain she has missed 1-2 days
of school a week and has not been able to participate in her usual activities. Mother is
very concerned about her and wants an answer to what is causing her abdominal pain.
References
The American Academy of Pediatrics (AAP) and North American Society for
Pediatric Gastroenterology, Hepatology, and Nutrition (NASPGHAN)
guidelines, AAP 2005
Eccleston C, Yorke L, Morley S, Williams AC, Mastroyannopoulou K.
Psychological therapies for the management of chronic and recurrent pain in
children and adolescents. Cochrane Database Syst Rev. 2003
Recurrent abdominal pain: symptom subtypes based on the Rome II Criteria
for pediatric functional gastrointestinal disorders; Walker LS, Lipani TA,
Greene JW, Caines K, Stutts J, Polk DB, Caplan A, Rasquin-Weber, J Pediatr
Gastroenterol Nutr. 2004 Feb; 38(2):187-91.
Chronic abdominal Pain in Children; Pediatrics 2005; 115:3 812-815
Weydert JA, Ball TM, Davis MF. Systematic review of treatments for recurrent
abdominal pain. Pediatrics. 2003;
Hyams JS, Burke G, Davis PM, Rzepski B, Andrulonis P. Abdominal pain and
irritable bowel syndrome in adolescents: a community-based study. J Pediatr.
1996;129:220–226
Pediatric Functional Gastrointestinal disorders; Nutr Clin Pract 2008; 23:3
268-274