Transcript RECURRENT ABDOMINAL PAIN

DR. KANUPRIYA CHATURVEDI
1
1.TERMINOLOGY AND DEFINITION
2.EPIDEMILOGY & ETIOLOGY
PATHOPHYSIOLOGY
3.EVALUATION AND DIAGNOSIS
4.MANAGEMENT
5.PROGNOSIS
6. SUMMARY
2




Chronic and recurrent abdominal pain are
common symptoms in children and adolescents .
Chronic abdominal pain can be organic or
nonorganic, depending on whether a specific
etiology is identified.
Nonorganic abdominal pain or functional
abdominal pain refers to pain without evidence of
anatomic, inflammatory, metabolic, or neoplastic
abnormalities.
Overlap between chronic and recurrent
abdominal pain exists, and the terms are
sometimes used synonymously.
SOURCE: J.APLEY
3


Chronic abdominal pain — Chronic abdominal pain is
defined by pain of at least three months' duration,
although some clinicians consider pain of more than
one to two months' duration to be chronic .
Recurrent abdominal pain — Recurrent abdominal
pain is one of the most common recurrent pain
syndromes in childhood. The classic definition is
based upon four criteria :
◦
◦
◦
◦
History of at least three episodes of pain
Pain sufficiently severe to affect activities
Episodes occur over a period of three months
No known organic cause
Source:Hyams et.al 1996.
4

Chronic abdominal pain
◦ Long-lasting intermittent or constant abdominal pain
that is functional or organic (disease based)

Functional abdominal pain
◦ Abdominal pain without demonstrable evidence of
pathologic condition, such as anatomic metabolic,
infectious, inflammatory or neoplastic disorder.
Functional abdominal pain can manifest with symptoms
typical of functional dyspepsia, irritable bowel
syndrome, abdominal migraine or functional abdominal
pain syndrome.

Functional dyspepsia
◦ Functional abdominal pain or discomfort in the upper
abdomen
5

Irritable bowel syndrome
◦ Functional abdominal pain associated with
alteration in bowel movements

Abdominal migraine

Functional abdominal pain syndrome
◦ Functional abdominal pain with features of migraine
(paroxysmal abdominal pain associated with
anorexia, nausea, vomiting or pallor as well as
maternal history of migraine headaches)
◦ Functional abdominal pain without the
characteristics of dyspepsia, irritable bowel
syndrome, or abdominal migraine.
6
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 . As discussed below, 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: American Academy of
Paed.2005
7


Functional gastrointestinal disorders (FGIDs)
are a group of gastrointestinal (GI) disorders
that include variable combinations of chronic
or recurrent GI symptoms not explained by
structural or biochemical abnormalities.
The Rome Committee updates and modifies
the information on FGIDs for clinical and
research purposes
8



The term is used in gastroenterology if no specific
structural, infectious, inflammatory, or biochemical
cause for the abdominal pain can be determined.
Because the exact etiology and pathogenesis of the
pain are unknown and because no specific
diagnostic markers exist, a diagnosis of functional
bowel disorder often is viewed as a diagnosis of
exclusion.
The diagnosis is established by a constellation of
criteria based on a careful history, physical
examination, and minimum laboratory
investigation.
9

Diagnostic criteria must include all of
the following:
◦ Episodic or continuous abdominal pain
◦ Insufficient criteria for other FGIDs
◦ No evidence of an inflammatory,
anatomic, metabolic or neoplastic process
that explains the subject's symptoms
10

Diagnostic criteria satisfy criteria for
childhood functional abdominal pain
and have at least 25% of the time one
or more of the following
◦ Some loss of daily function
◦ Additional somatic symptoms such
as headache, limb pain, or difficulty
sleeping
11

H1

H2b

H1a

H2c
◦ Adolescent rumination
syndrome

H2d
◦ Cyclic vomiting syndrome
H1c

H2d1
H2
Abdominal pain—–related
FGIDs
H2a

H3

H3a

H3b





◦ Vomiting and aerophagia
H1b
◦ Aerophgia
◦ Functional dyspepsia
◦ Irritable bowel syndrome
◦ Abdominal migraine
◦ Childhood functional abdominal
pain
◦ Childhood functional abdominal
pain syndrome
◦ Constipation and incontinence
◦ Functional constipation
◦ Nonr-Retentive fecal
incontinence
12




The exact incidence and prevalence of chronic
abdominal pain is not known.
There are reports of chronic abdominal pain
affecting 9-15% of children.
There are also reports that 13% of middle
school and 17% of high school children have
weekly complaints of abdominal pain.
In a study of 1,000 school-age children, RAP
affected males & females equally up to 9 yrs. of
age, the incidence in females increased such
that between 9 & 12 yrs., the female-to-male
ratio was 1.5:1.
13


The traditional concept that motility disorders
alone have an important role in functional pain
has not been confirmed.
It is believed that visceral hypersensitivity
leading to abnormal bowel sensitivity to
stimuli (physiologic, psychologic, noxious)
might have a more dominant role in functional
abdominal pain .
14



The viscera are innervated by dual set of
nerves (vagal and splanchnic spinal nerves or
pelvic and splanchnic spinal nerves).
The spinal afferents carry impulses to the
spinal cord.
The dorsal horn of the spinal cord regulates
conduction of impulses from peripheral
nociceptive receptors to the spinal cord and
brain, and the pain experience is further
influenced by cognitive and emotional
centers.
15



A normal functioning enteric nervous system
(ENS) is important for coordination of intestinal
motility, secretion and blood flow.
Abnormalities of the enteric nervous system may
be an underlying factor for functional abdominal
pain .
Inflammation of the intestine and its role in the
pathogenesis of functional abdominal pain could
be due to the effects of the inflammatory
mediators and cytokines (released by the various
inflammatory cells) on the ENS.
16
17
18

Children who have RAP tend to exhibit one of
three clinical presentations:
◦ Isolated paroxysmal abdominal pain
◦ Abdominal pain associated with symptoms of
dyspepsia
◦ Abdominal pain associated with an altered bowel
pattern.
19

Symptoms of dyspepsia include:
◦ pain associated with eating; epigastric location of
pain; nausea, vomiting, heartburn, oral
regurgitation, early satiety, excessive hiccups and
belching.

Symptoms of altered bowel pattern include:
◦ diarrhea, constipation, or a sense of incomplete
evacuation.

Functional abdominal pain is by far the most
common cause of each presentation.
20
21


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 history, physical examination, and
stool testing for occult blood to identify potential
indications of an organic etiology.
The technical review found little or no evidence to
suggest that ultrasonography, endoscopy, or
esophageal pH monitoring increase the yield of
organic disease in the absence of "alarm
findings”.
22


The history provides important clues to the
etiology of abdominal pain and must assess
possible organic causes for the pain, as well as
psychosocial factors that may be contributing
to it .
The older child or adolescent should be
encouraged to provide his or her own
description of the pain.
source: Ramchandani 2005
23




Visceral pain is dull and aching in character
and often poorly localized.
It arises from distention or spasm of a hollow
organ, such as the discomfort experienced
early in intestinal obstruction or cholecystitis.
Parietal pain is sharp and very well localized.
It arises from peritoneal irritation, such as the
pain of acute appendicitis with spread of
inflammation to the parietal peritoneum.
Referred pain is aching and perceived to be
near the surface of the body.
24




The location of abdominal pain helps to
narrow the differential diagnosis .
Pain caused by esophagitis and peptic ulcer
disease usually causes discomfort in the
upper abdomen.
The location of pain related to hypercalciuria
and/or hyperuricosuria appears to vary with
age.
Pain radiation also is important: the pain of
pancreatitis classically bores to the back,
whereas renal colic radiates to the groin.
source: Polito et al 2005
25



The onset, frequency, and duration of the
pain are helpful features.
Pain that began at the start of the school year
and never occurs on weekends is unlikely to
have an organic cause.
The quality of the pain includes determining
whether the pain is burning or gnawing, as is
typical of gastroesophageal reflux and peptic
ulcer, or colicky, as in the cramping pain of
gastroenteritis or intestinal or biliary
obstruction.
26




The severity of the pain typically is related to the
severity of the disorder.
However, this distinction often is difficult for the
clinician to evaluate because it is subjective and
dependent upon the patient's personality and
previous pain experiences
A helpful approach is to ask the child or
adolescent to compare this pain with previous
painful experiences, grading on a 1 to 10 scale.
The child should be asked whether pain disrupts
sleep or usual activities or has caused any school
absence.
27




Asking the patient for factors that can aggravate or
alleviate the pain is also important.
The pain of mesenteric ischemia usually starts
within one hour of eating, whereas the pain of
peptic ulcer disease is relieved by eating and
recurs several hours after a meal, when the
stomach is empty.
Symptoms that occur in relation to abdominal pain
may give important information.
Weight loss may occur in association with
malignancy, nausea and vomiting with bowel
obstruction, and change in bowel habits with a
colonic lesion.
28



Physical examination — A complete physical
examination with emphasis on the abdominal,
rectal, pelvic, and genitourinary regions is an
essential part of the evaluation of the child and
adolescent with abdominal pain.
General — The general appearance and level of
comfort or discomfort should be noted.
The patient's weight (percentile or percent ideal
body weight), height, growth velocity, pubertal
stage, and blood pressure should be noted.
29



Abdominal — Inspection of the abdomen
should include attention to the position
assumed by the patient when in pain.
Gentle percussion is useful to identify acute
peritonitis. It is also used to identify ascites,
liver span, and splenic enlargement.
Tympany signifies a distended bowel,
whereas dullness may signify a mass.
30




Palpation must be performed gently and while
the patient is distracted, particularly if
psychogenic pain is suspected.
Muscular rigidity or "guarding" is an important
and early sign of peritoneal inflammation; it can
be unilateral in a patient with a focal
inflammatory mass, such as a diverticular
abscess, or diffuse, as in peritonitis.
Guarding typically is absent with deeper sources
of pain, such as renal colic and pancreatitis. t.
Palpation also may detect enlarged organs or
masses (eg, fecal material in the left lower
quadrant).
31



Carnett sign is helpful in distinguishing deep
visceral pain from pain that emanates from
the abdominal wall .
Carnett sign is positive (indicating abdominal
wall pain) if the focal tenderness increases or
remains during abdominal muscle
contraction.
Abdominal wall pain can originate from a
hernia, hematoma, or the abdominal wall
musculature.
source: Thompson et al 1991
32



Rectal and pelvic — Perianal and rectal
examination and stool testing for occult
blood are required in the evaluation of all
patients.
In addition, a pelvic examination should be
performed if the history is suspicious for
gynecological problems.
A pelvic ultrasound or a referral to a
pediatric gynecologist or adolescent
medicine specialist can be helpful.
33



Other findings — The patient should be
examined for signs of nerve and muscle wall
injury and hernia.
Pain in a dermatomal distribution and
hyperesthesia are both signs of nerve
involvement.
Pain that is reproduced with hyperextension
at the hip (psoas sign) suggests inflammation
of the psoas muscle.
34



Indications — 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 stool testing for occult blood to identify
potential indications of an organic etiology.
Initial studies are performed to confirm or exclude
diagnostic possibilities that are being considered
based upon the history and physical examination.
The results of initial studies can help determine the
urgency and pace of the diagnostic evaluation.
35






Pain that wakes up the child
from sleep
Persistent right upper or
right lower quadrant pain
Significant vomiting (bilious
vomiting, protracted
vomiting, cyclical vomiting
or worrisome pattern to the
physician)
Unexplained fever
Genitourinary tract
symptoms
Dysphagia






Chronic severe diarrhea
or nocturnal diarrhea
Gastrointestinal blood
loss
Involuntary weight loss
Deceleration of linear
growth
Delayed puberty
Family history of
inflammatory bowel
disease, celiac disease,
and peptic ulcer disease
36





Localized tenderness in
the right upper
quadrant
Localized tenderness in
the right lower
quadrant
Localized fullness or
mass
Hepatomegaly
Splenomegaly






Jaundice
Costovertebral angle
tenderness
Arthritis
Spinal tenderness
Perianal disease
Abnormal or
unexplained physical
findings
37


Laboratory studies may be unnecessary if
the history and physical examination lead to
a diagnosis of functional abdominal pain.
Nonetheless, medical tests can reassure the
patient and family, and at times the
physician, if there is significant functional
disability and poor quality of life.
38



A complete blood cell count, sedimentation
rate, C-reactive protein, basic chemistry
panel, celiac panel, stool culture, stool test
for ova and parasites, and urinalysis are
reasonable screening studies.
The risk of celiac disease may be 4 times
higher in these patients compared with the
general population.
Elevated stool calprotectin levels usually
suggest an inflammatory etiology.
39



If indicated, an ultrasound examination of the
abdomen can give information about kidneys,
gallbladder, and pancreas; with lower abdominal
pain, a pelvic ultrasonogram may be indicated
An upper GI x-ray series is indicated if one
suspects a disorder of the stomach or small
intestine.
Helicobacter pylori infection does not seem to be
associated with chronic abdominal pain, but in
patients with symptoms suggesting gastritis or
ulcer, an H. pylori test (fecal H. pylori antigen)
may be performed.
40




Breath hydrogen testing is done for ruling out
lactose or sucrose malabsorption.
Lactose intolerance is so common that the
finding may be coincidental, and the clinician
must be cautious in attributing chronic
abdominal pain to this condition.
Esophagogastro-duodenoscopy is indicated
with symptoms suggesting persistent upper
GI pathology.
.
41

The two broad categories in the differential
diagnosis for chronic or recurrent abdominal
pain in children and adolescents are
◦ Organic disorders — Conditions in which
physiologic, structural, or biochemical
abnormalities are present.
◦ Functional disorders — Functional conditions are
those for which no specific test exists with which
to make the diagnosis
42

Common organic causes of chronic or
recurrent abdominal pain include
constipation,
carbohydrate malabsorption,
musculoskeletal pain,
parasitic infection,
dysmenorrhea, and
peptic disorders (eg, reflux esophagitis, gastritis,
gastric and duodenal ulcers, and
◦ H. pylori infection.
◦
◦
◦
◦
◦
◦
Dern M.S 1999
43
◦ Less common causes include:
 Urinary tract infections, inflammatory bowel
disease, endometriosis, and pelvic inflammatory
disease.
 Other, rare causes must also be considered; they
include gallstones , kidney stones , late presentation
of malrotation or volvulus , heavy metal poisoning ,
psoas abscess, meconium ileus equivalent,
imperforate hymen with hematocolpos , ovarian
neoplasm ,remote pancreatic injury, familial
Mediterranean fever , hypercalciuria , tuberculosis ,
and hereditary angioedema .
44

Historical or physical examination findings usually provide
clues to the diagnosis in the cases in which an organic
etiology is identified:
◦ Pain distant from the umbilicus
◦ Pain that awakens the child or adolescent
◦ Significant vomiting (bilious, protracted, cyclical, or an otherwise
worrisome pattern)
◦ Dysphagia
◦ Respiratory symptoms





Family history of inflammatory bowel disease, celiac
disease, peptic ulcer disease, or kidney stones
Involuntary weight loss, slowed linear growth, or delayed
puberty
Joint pain or swelling
Unexplained fever
Changes in bowel or bladder function
45









Dysuria or hematuria
Chronic severe diarrhea, nocturnal diarrhea, or excessive
gas
Persistent right upper or right lower quadrant pain or
tenderness
Localized fullness or mass effect
Hepatomegaly
Splenomegaly
Tenderness over the spine or at the costovertebral angle
Perianal abnormalities
Other abnormal, unexplained physical examination
findings
◦ Anemia
◦ Gastrointestinal blood loss
◦ Elevated erythrocyte sedimentation rate
46


Functional disorders — Functional disorders are
conditions in which the patient has a variable
combination of symptoms without any readily
identifiable structural or biochemical
abnormality.
Several functional gastrointestinal disorders of
childhood are recognizable .
◦
◦
◦
◦
◦
Functional dyspepsia
Irritable bowel syndrome (IBS)
Functional abdominal pain
Abdominal migraine
Aerophagia
47



Dyspepsia is pain or discomfort that is centered in
the upper abdomen. Discomfort may be characterized
by fullness, early satiety, bloating, nausea, retching,
or vomiting .
Functional dyspepsia symptoms may be ulcer-like,
with pain centered in the upper abdomen as the
predominant symptom, or dysmotility-like, with
discomfort (eg, fullness, early satiety, bloating, or
nausea) centered in the upper abdomen as the
predominant symptom.
Organic causes of dyspepsia symptoms include acidrelated disease (esophagitis, gastritis, duodenitis), H.
pylori, eosinophilic esophagitis, eosinophilic
gastroenteritis, Crohn's disease, and celiac disease.
48



The pathophysiology of functional dyspepsia
is not clear.
Abnormalities in gastric electrical rhythm,
delayed gastric emptying, reduced gastric
volume response to feeding, and
antroduodenal dysmotility have been
demonstrated in some children and
adolescents .
Abnormal motor function, visceral sensitivity,
and psychosocial factors have been studied
as possible contributing factors in adults.
source:Cucchiara S,et al, 1992
49


No signs or symptoms reliably differentiate
functional dyspepsia from upper
gastrointestinal inflammatory, structural, or
motility disorders.
Symptoms of dyspepsia usually generate a
more extensive diagnostic evaluation .
50


IBS is characterized by chronic abdominal
pain and altered bowel habits in the absence
of any organic cause.
Organic causes that should be considered
include Giardia, urinary tract infection,
carbohydrate intolerance, inflammatory bowel
disease, eosinophilic gastroenteritis, and
celiac disease
51


IBS occurs infrequently before late
adolescence and may be preceded by a long
history of constipation or an episode of
gastroenteritis.
The diagnosis of IBS can be made on the
basis of symptoms; it need not be a diagnosis
of exclusion .
source:Thabane M,et al, 2010
52



Children who have IBS have a lowered rectal
pain threshold and disturbed rectal
contractile response to meals .
Compared to control subjects and children
with functional dyspepsia, children with IBS
have abnormal pain referral after rectal
distension.
Adolescents who have IBS-type symptoms
have higher anxiety and depression scores
than do those without such symptoms .
source:Halac U,et al 2010
53



The symptoms in some children do not meet the
diagnostic criteria for IBS or functional dyspepsia,
nor are they consistent with organic illness.
This category most closely resembles, but is not
a substitute for, the classically defined recurrent
abdominal pain of childhood .
Functional abdominal pain may be associated
with visceral hyperalgesia, reduced threshold for
pain, abnormal pain referral after rectal
distension, or impaired gastric relaxation
response to meals.
54


Abdominal migraine is characterized by
recurrent episodes of abdominal pain,
typically midline or poorly localized, dull and
moderate to severe in intensity.
Pain is associated with at least two additional
features that may include anorexia, nausea,
vomiting, and pallor.
55

Aerophagia is excessive air swallowing that
causes
◦ progressive abdominal distension
◦ may interfere with dietary intake
56



The most important component of the
treatment is reassurance and education of the
child and family.
The child and family need to be reassured
that no evidence of a serious underlying
disorder is present.
The family and the child with functional pain
might worry about the inability to identify an
organic cause and may be resistant to a
diagnosis of nonorganic disease.
57


Explanation in simple language that although
the pain is real, there is no underlying serious
disorder usually alleviates the anxiety in the
patient and family.
Children of families that do not accept a
functional cause of the symptoms are more
likely to have persistent somatic complaints
and school absences.
58


The parents should be instructed to avoid
reinforcing the symptoms with secondary
gain
If children have missed school or have been
removed from routine activities because of
the pain, it is important that they return to
regular activities
59
Treatment goals should be set for return to
function and minimizing pain.
 Cognitive-behavioral therapy is helpful in the
short term for managing pain and functional
disability
 Biofeedback, guided imagery, and relaxation
techniques have been useful in some children
with functional pain.
 Time-limited use of medications is usually
part of the multidisciplinary approach.
60




The commonly used medications include acid
suppressants for dyspepsia symptoms,
antispasmodics, and low-dose amitriptyline.
For chronic abdominal pain with IBS symptoms,
antidiarrheals and nonstimulating laxatives are
used. Peppermint oil for 2 wk improves IBS
symptoms in children.
There is no evidence that lactose-restricted diet
and fiber supplements decrease the frequency of
attacks in chronic abdominal pain in children.
Proton pump inhibitors or visceral muscle
relaxants (anticholinergics) have been used
empirically but are often unhelpful in the absence
of specific indication.
61
DEFINITION OF
THERAPY
DISORDER
Cognitive behavioral Recurrent abdominal
(family) therapy
pain
Recurrent abdominal
Famotidine
pain and dyspeptic
symptoms
Recurrent abdominal
Added dietary fiber
pain
Recurrent abdominal
Lactose-free diet
pain
Irritable bowel
Peppermint oil
syndrome
Functional GI disorders,
Amitriptyline
Irritable bowel
syndrome
Irritable bowel
Lactobacillus GG syndrome using Rome
II criteria
EFFECTIVENESS
Beneficial
Inconclusive
Unlikely to be beneficial
Unlikely to be beneficial
Likely to be beneficial
Inconsistent results
Unlikely to be beneficial
62



Patients who have ulcer-like dyspepsia are
treated for 4 to 6 weeks with H2-receptor
antagonists.
Patients who have dysmotility-like dyspepsia
are treated for 4 to 6 weeks with prokinetic
agents
In fact, there are no objective data to support
such a treatment.
63



There are no prospective studies of the outcome of
any of the various presentations of functional
abdominal pain.
Reassuringly, retrospective studies suggest that
organic disease rarely is masked in the context of a
functional disorder.
Once functional abdominal pain is diagnosed,
subsequent follow-up rarely identifies an occult
organic disorder.
64

After 5 years, approximately one third
of children with RAP will have
resolution of their pain, one third will
continue to complain of the same
symptoms, and another one third will
have a different recurrent pain
complaint.
65


Chronic abdominal pain is defined by pain of
at least three months' duration, although
some clinicians consider pain of more than
one to two months' duration to be chronic.
Recurrent abdominal pain is defined by more
than three episodes of pain that are
sufficiently severe to affect activity and that
occur over the course of at least three
months.
66



Referred pain usually is perceived to be near
the surface of the body.
It is located in the cutaneous dermatomes
sharing the same spinal cord level as the
visceral inputs.
Referred pain may be correlated with skin
hyperalgesia and increased muscle tone of
the abdominal wall.
67