Transcript 4 Challenges about Abdominal Pain

Functional Gastrointestinal
Disorders
Robert Rothbaum, MD
Functional Gastrointestinal Disorders
• Functional dyspepsia
• Irritable bowel syndrome
• Functional abdominal pain syndrome
Dyspepsia = Epigastric discomfort
• 14 year old boy with two month history
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Bothersome post-prandial fullness
Early satiation
Epigastric pain
Epigastric burning
• Normal physical examination
• Normal screening labs
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CBC
Hepatobiliary enzyme tests
IgA and tTG
Lipase or amylase
Stool for occult blood
What should we do next?
• Should we
recommend an ugi
endoscopy?
– Vomiting or weight
loss
– Positive screening test
– Low yield test
– Often, does not relieve
anxiety
• Should we do
radiologic testing?
– Obstructive symptoms
or signs
• Should we do testing
for H. pylori?
– Family history
– Acute symptoms
Mechanisms of functional dyspepsia
• Post-infectious changes: More common
after bacterial gastroenteritis
• Diminished gastric accomodation
• Increased gastric sensitivity
• No increase in acid production
• No reproducible delay in gastric emptying
How effective is therapy for dyspepsia?
• Proton pump inhibitor
– < 50% response
– No increase in response to high doses
• Anti-helicobacter
– 10-15% response
– No improvement with repeated courses
• Prokinetic agents
– Side effects frequent
• Antispasmodics
– No benefit
• Antidepressants
– No benefit
Irritable Bowel Syndrome
• Abdominal discomfort or
pain associated with 2 or
more of the following at
least 25% of the time
– Improvement with
defecation
– Onset associated with a
change in stool frequency
– Onset associated with a
change in stool consistency
• No evidence of another
disorder
• Present for two months or
more
Evaluation
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Physical exam normal
CBC
IgA and tTG
Giardia antigen
Thyroid studies
Detailed psychosocial
history
• 95-99% IBS accuracy
• Colonoscopy for IBD
Associations with IBS
• Post-infectious alterations in bowel
function.
• Visceral hypersensitivity
– Lower threshold to detect distention
– Distention felt more intensely
– Magnified gastrocolic reflex
– Hyperalgesia after repetitive stimulation
– Decreased somatic sensitivity
What is effective therapy for IBS?
• Dietary changes
– Lactose restriction
– Gluten restriction
• Medications
– Loperamide
– Low dose TCA
• Psychosocial support
– Most effective
– No side effects
• Fiber supplements
• Lactose restriction
– Vitamin D restriction
– Low calcium intake
• Oral antibiotics
• Anticholinergics
• Probiotics
What is the role of gluten restriction?
• Gluten sensitive enteropathy = celiac
disease. Eat a gluten free diet.
• Gluten sensitivity or intolerance.
– GI symptoms associated with gluten intake
– Before 2011, no controlled trial of gluten free
diet in IBS or abdominal pain.
Re-introduction of gluten produced
symptoms earlier.
• Patients on GFD w/IBS=
Highly selected.
• Two groups followed for
six wks with
muffins/bread added.
– 20 with gluten flour
– 20 with placebo
• 9 patients dropped out
– 6 gluten group
– 3 placebo group
Am J Gastroenterol. 2011 Mar;106(3):508-14;
Recurrent pain is a common complaint in children and adolescents.
750 school children and
adolescents interviewed.
Headaches
Abdominal pain
50% consulted MD
35% > 6 months
50% associated sx
- sleep problems
Roth-Isigkeit A et al. Pediatrics 2005;115:e152-e162
- eating problems
- school absence
Functional abdominal pain syndrome
1. Continuous or nearly continuous abdominal pain
2. Little to no relationship of pain with eating, defecation,
or menses
3. Some loss of daily functioning
4. The pain is not feigned (e.g., malingering)
5. Does not fit another functional gastrointestinal disorder
6. Duration = prior last 2 months with symptom onset at
least 6 months before
Common symptom-related behaviors
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Expressing pain of varying intensity through verbal and nonverbal methods.
Distraction possible. Exacerbations during discussion.
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Urgent reporting of intense symptoms disproportionate to available clinical and
laboratory data
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Minimizing or denying a role for psychosocial contributors, anxiety or depression, or
attributing them to the pain rather than to understandable life circumstances
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Requesting diagnostic studies or exploratory surgery to validate the condition as
“organic”
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Focusing attention on relief of symptoms rather than adaptation to a chronic disorder
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Seeking health care frequently
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Taking limited personal responsibility for self-management while placing high
expectations on the physician to achieve symptom relief
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Making requests for narcotic analgesics when other treatment options have been
implemented
Further testing ?
• CBC
– Microcytic anemia
• Urinalysis
– Hematuria
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IgA level
tTG antibody
Stool for occult blood
Abdominal ultrasound
• Avoid
– ESR and CRP
– IBD serologies
– H. pylori serologies
– HIDA scan
– Other tests
Psychosocial contributors
1. What is the patient’s life history of illness?
2. Why is the patient presenting now for medical care?
3. Is there a history of traumatic life events?
4. What is the patient’s understanding of the illness?
5. What is the impact of the pain on activities and quality of life?
6. Is there an associated psychiatric diagnosis?
7. What is the role of family or culture?
8. What are the patient’s psychosocial impairments and resources?
Determinants of Physician Contact:
Co-Morbidities with Abdominal Pain
• Case-control study in pediatric
practice:
– FAP: 79% with anxiety
43% with depression
– Functional impairment more
common
– Anxiety may precede RAP
Pediatrics 2004; 113:817-824
• Family Stress:
43%
• Patients with UGI symptoms
appear with more symptoms in
other systems.
Long term follow-up of children
with functional abdominal pain
Shelby etal. Pediatrics. September, 2013
Hospitalization for chronic pain
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Coffelt etal. Pediatrics. July, 2013.
16/1000 admits
F:M = 2:1
Mean age = 13.5 yrs.
LOS = 7 days
Procedures = 3 per
patient
• Repeat hospital. =
12%
• Medication side
effect= 10%
• Anxiety/depression=
50%
Parental worries about chronic
abdominal pain.
• Fear of disease = pain worries
– Identify specific disorders of concern
– Prior experience and family history
• Pain is real = pain threshold
– Child suffering and is not a complainer.
– Ambivalent about distraction
– Review visceral hypersensitivity and effects of
Van Tilburg etal
prior illness
JPGN. 2009
Parental worries and concerns
• Thoughts about providers
– Desire for relief/care = one step to cure
– Frustration with misunderstanding= “nothing
serious is wrong”
– Treating symptoms obscures true cause
– Define the disorder = make the diagnosis of
functional disorder using defined criteria
– “I know what this is…I am familiar with this
diagnosis…it is disruptive but not progressive”
Parental worries and concerns
• Thoughts about coping
– Parents not able to cope with complaints
– “I know nothing bad is wrong but I do not
know what to do to help.”
– Provide specifics: distraction, relaxation,
simple meds
• Difficulty ignoring pain
– “I might miss something.”
– Provide specific symptoms of concern
Parental worries and concerns
• Diet, eating habits, stress, and heredity
may contribute
– Begin to identify common ground with parents
– Identify family patterns of similar complaints
• Eventual diagnosis
• Outcome
• Do not make organic diagnoses.
• Discuss the potential impact of further
diagnostic tests: How will results help
you?
Determinants of consultation
• “My doctor did not tell me what is wrong
with my child.”
• “I would like the doctor to suggest a
treatment.”
• “I worry about my child missing things due
to the pain.”
• “It is difficult to dismiss my child’s
stomach aches.”
Chronic pain factors
Pain worries: severity
& consequences
Exacerbating factors
Heredity
Diet
Stress
Coping concerns
Unclear what to do
Ignoring difficult
Disease Fear
High pain threshold
No malingering
MD thoughts
Desire for relief
Frustration
Symptom treatment only
Management plans
•
Dyspepsia
– PPI may or may not help
– Probably not H. pylori
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Irritable bowel syndrome
– Low fat diet may help. Other diets may be useful.
– Exercise and healthy lifestyle
• Alcohol
• Caffeine
• Nicotine
– Medications
• Imodium or Lomotil
• Low dose TCA
• Peppermint oil
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Functional abdominal pain syndrome
– Low dose TCA
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For all disorders: Refocus on function, maintain relationship, discuss
worries, and encourage insight via counseling.
Resources for Management of
Abdominal Pain
• For Pediatricians
– Pain in Children: A Practical Guide for Primary Care by Gary Walco,
Ph.D. and Kenneth Goldschneider, M.D.
– Subcommittee on Chronic Abdominal Pain 2005 Technical Report
Available online
– Chronic Abdominal Pain in Children: A Clinical Report of the American
Academy of Pediatrics and the North American Society for Pediatric
Gastroenterology, Hepatology and Nutrition (2005) Available Online
• For Families
– www.painretreat.net
• Online resource that teaches kids guided imagery, deep breathing,
etc. to cope with pain
– Conquering Your Child’s Chronic Pain: A Pediatrician’s Guide for
Reclaiming a Normal Childhood by Lonnie Zeltzer, M.D. and Christina
Schlank
– IBS brochure: www.gastro.org/ibs-patient