Transcript - The 1st Al-Jahra Pediatric Conference

Chronic
abdominal
pain: management
update
Ahlam Mustafa
B.Med.Sc.,BM,BCh,FAAP,MD(RES)-UK
Head Pediatric Gastroenterology
Mubarak Al-Kabeer Hospital
Kuwait
Agenda
Review the characteristics of chronic
abdominal pain
Differentiate functional from organic
causes of abdominal pain
Review current modalities for evaluation,
management/treatment of chronic
abdominal pain
Functional gastrointestinal
disorders
 Combination
of chronic or recurrent
symptoms not explained by known
biochemical or structural abnormalities
 50%
of consultations in pediatric
gastroenterology practice
 2%
to 4% of all general pediatric office
visits
Pediatrics 1984;74:991–7.
Functional gastrointestinal
disorders
 Quality
of life in affected patients is
substantially poorer than


General population
Patient with asthma or migraine
 Patients
have more somatic pain,
functional impairment, and psychiatric
symptoms than controls at 5-year followup
Clin Ther 2002;24:675–89
Acta Paediatr 2005;94:234–6
Rome III
Diagnostic
Criteria for
Functional
Gastrointestinal
Disorders
Rome III
 G.
Childhood Functional GI Disorders:
Infant/Toddler
 H.
Childhood Functional GI Disorders:
Child/Adolescent
Rome III
 H.
Childhood Functional GI Disorders:
Child/Adolescent



H1. VOMITING AND AEROPHAGIA
H2. ABDOMINAL PAIN-RELATED FUNCTIONAL
GI DISORDERS
H3. CONSTIPATION AND INCONTINENCE
Rome III
 H2.
ABDOMINAL PAIN-RELATED
FUNCTIONAL GI DISORDERS




H2a. Functional Dyspepsia
H2b. Irritable Bowel Syndrome
H2c. Abdominal Migraine
H2d. Childhood Functional Abdominal Pain
 H2d1.
Childhood Functional Abdominal Pain
Syndrome
H2. ABDOMINAL PAIN-RELATED
FUNCTIONAL GI DISORDERS
 Must
include all of the below at least
once per week for at least 2 months prior
to diagnosis
 No evidence of an inflammatory,
anatomic, metabolic, or neoplastic
process that explains the subject’s
symptoms
Rome III
 H2.
ABDOMINAL PAIN-RELATED
FUNCTIONAL GI DISORDERS




H2a. Functional Dyspepsia
H2b. Irritable Bowel Syndrome
H2c. Abdominal Migraine
H2d. Childhood Functional Abdominal Pain
 H2d1.
Childhood Functional Abdominal Pain
Syndrome
Differentiate functional from
organic causes of
abdominal pain
History

When did it start?





F – Peri-umbilical or epigastric
O – Well localized away from
umbilicus

F – Prolonged duration with no
clear signs
O – Variable
What does the pain feel like?


F – Vague, gradual onset, variable
severity
O – Isolated, sudden onset
What makes the pain better?




F – Reinforcement
Is the pain intermittent or
constant



F – No relationship to interventions
O – medications or re-positioning
What makes the pain worse?

How long does it last?


F – Concurrent stressful event in life
O – Trauma or travel
Where is it located?


F – Constant
O – Intermittent
Association with other signs
or symptoms?


F – Signs of anxiety, family history
O – Association with red flags
What is the predictive value of
the history?
No studies that support the history is able to
differentiate functional from organic disease
Functional pain
Presence of headaches, joint pain, anorexia,
vomiting, nausea, excessive gas and altered bowel
symptoms may be more frequently associated with
Organic disease
Presence of Red Flags may suggest a higher
probability of and warrants further diagnostic
evaluation
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
Red Flags and red herrings
Systemic signs: hematachezia, rash, weight loss,
growth faltering, vomiting, diarrhea, persistent
localized pain, unexplained fever, evidence of
blood loss
Historical clues: family history of ulcers or
Inflammatory bowel disease
Prolonged school absence
Use of narcotic pain medication
Positive or unusual exam findings
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?
In the ABSENCE of Red Flags non of the below has
a significant yield of organic disease
Abdominal and pelvic ultrasounds
Endoscopy and biopsy
Esophageal pH monitoring
All Studies normal
Now what?
Review current modalities for
evaluation,
management/treatment of
chronic abdominal pain
Goals of treatment
Primary goal - Return to normal function
Secondary goal - Relief of symptoms
Return to normal function
Reassurance & education to the
family
Emphasize no serious life threatening
process/condition
Distraction, providing attention, rest,
identifying triggers for pain
Avoidance of reinforcement of pain
behaviours
Management of chronic
abdominal pain in children
 Pharmacotherapy
 Psychological
therapies
 Probiotics
 FODMAP
diet
 Complimentary therapy
Pharmacology
 Laxatives
 H2
blockers and Proton pump inhibitors
 Anti-spasmotics
Brain-gut axis
 Abdominal
pain related functional GI
disorders considered states of
dysregulation within the enteric and the
central nervous systems, resulting in
alterations in sensation, motility, and
possibly, immune system function
Medications to affect brain
gut axis
 Such





medications include
Sedatives and Anxiolytics
Antidepressants
Serotonin and 5HT-3 receptor antagonists
Somatostatin receptor agonists
Anti-seizure agents
Pharmacology

Sedatives


In patients with abdominal pain and comorbid
psychological symptoms, these agents are a
logical choice
Antidepressants




anticholinergic effects, gastrointestinal transit
slowing & fundic relaxation
sleep restoration, treatment depression,
analgesia receptor binding pain transmission
system
Amitriptyline in migraine 50% to 60% of children
Pharmacology

Serotonin and 5HT-3 receptor antagonists



80% serotonin stored in enterochromaffin cells of the gut
In adults, alosteron and cilansteron, shown efficacy in
patients with diarrhea-predominant IBS
FDA restricted due complications

Somatostatin receptor agonists

Anti-seizure agents


No specific trials involving anti-seizure agents for
pediatric FGIDs
Increasingly used, off-label, for neuropathic pain
conditions, such as migraine and neuralgia, in children
Management of chronic
abdominal pain in children
 Pharmacotherapy
 Psychological
therapies
 Probiotics
 FODMAP
diet
 Complimentary therapy
Psychological therapies
1.
2.
3.
4.
5.
Cognitive Behavioral Therapy
Relaxation exercises
Psychodynamic treatment
Exposure therapy
Mindfulness
Cognitive Behavioral Therapy
 Changing
maladaptive pain beliefs,
teaching effective coping with pain and
teaching relaxation exercises
 Can be delivered to child alone, but
better if delivered to both parent and
child
Cognitive Behavioral Therapy
 Superior
to standard care (n=44) more
pain free, fewer relapse, lower disability
 Superior
to standard care (n=69): less
pain, less school absences
 Superior
to standard care (n=32) in
reducing pain frequency, but not intensity
J Consult Clin Psychol 1994, 62(2):306–314
J Pediatr Psychol 2005,30(5):397–408
JPGN 2006, 43: 59-64
Cognitive Behavioral Therapy
 Superior
to attention control (education)
(N=200): Reductions in pain intensity,
gastrointestinal symptoms, disability and
parental protective response
 Effects lasted up to 12 months
Am J Gastroenterol 2010,105(4):946–956
JAMA Pediatr, 2013, 167(2):178–184
Cognitive Behavioral Therapy
 Parent-only
CBT vs education reduces
child gastrointestinal symptoms and
disability up to 6 months after treatment
Levy et al, NASPGHAN 2015
Cognitive Behavioral
Therapy: (CBT)
 CBT
plus physiotherapy vs
physiotherapy(n=48)

No significant differences at 1 year follow
up
 Superior
to waitlist (n=29): reductions in
pain intensity and duration

No differences at 3 months follow-up
Acta Paediatr 2007,96(1):76–81
Int J Behav Med 2000,20(3):434–443
Management of chronic
abdominal pain in children
 Pharmacotherapy
 Psychological
therapies
 Probiotics
 FODMAP
diet
 Complimentary therapy
Probiotics
 “Live”
microorganisms
which when
administered in
adequate amounts
confer a health
benefit on the host
Guidelines for the evaluation of probiotics in food.
Rome/Geneva: FAO/WHO; 2002
J. Gut Microbes 2010; 1:1-16
Does the gut microbiota composition differ
between children with irritable bowel
syndrome (IBS) and healthy controls?
 Abundances
of several bacterial genera
revealed in children (pre and adolescent)
with IBS-D (n=22). Several “relationships”
identified via networking analysis
 Several differences in the abundances at
the class and genus levels in children with
IBS (n=22). Also differences in composition
to distinguish IBS subtypes and pain
severity groupings
Am J Gastroenterol,2012,107:1740-51
Gastroenterology 2011,41:1782-1791
Have probiotics demonstrated
benefit in childhood FAP/IBS?
 Double-blind,
randomized controlled trial
 Received LGG (n = 52), or placebo (n =
52) for 4 weeks
 Lactobacillus GG 3x109 CFU twice a day x
4 weeks
 Increased the likelihood of having no pain
vs. placebo (25% vs. 9.6%) NTT = 7
 Decreased overall frequency of pain
APT 2007 25:177-184
CFU: colony forming units
Have probiotics demonstrated
benefit in childhood FAP/IBS?

VSL#3 contains live, freeze-dried lactic acid
bacteria, of 450 billion lactic acid bacteria
per sachet, 8 different strains:


Bifidobacterium breve, B longum, B infantis,
Lactobacillus acidophilus, L plantarum, L casei, L
bulgaris, and Streptococcus thermophilus
VSL#3 (one or two sachets daily x 6 weeks)
decreased global score, pain, abdominal
bloating in a cross-over trial vs placebo (N=59
IBS)
JPGN 2010 51:24-30
Management of chronic
abdominal pain in children
 Pharmacotherapy
 Psychological
therapies
 Probiotics
 FODMAP
diet
 Complimentary therapy
What is FODMAP
 FODMAP





stands for
F: fermentable
O: oligosaccharides
D: disaccharides
M: monosaccharides
and
P: polyols

This diet which restricts
carbohydrates that
may be difficult to
absorb including





fructose (fruit juices)
lactose (dairy)
fructans
(wheat/onions)
galactans (beans)
and
polyols (artificial
sweeteners)
Mean overall gastrointestinal symptoms from the
(A) IBS cohort and the (B) healthy cohort using a VAS
during baseline, low FODMAP and typical Australian
diets
Symptoms improved significantly on low FODMAP compared with
baseline and the typical Australian diet for the IBS cohort
No differences were observed between any of the diets in the
healthy cohort
Gastroenterology 2014; 146:67-75
Low FODMAP diet in children



In a double-blind, children with Rome III IBS
Randomized to a low FODMAP diet or typical
American childhood diet , followed by a 5-day
washout period before crossing over to the other
diet
Assessment :
 GI symptoms frequency being the primary
outcome
 Baseline gut microbial composition (16S rRNA
sequencing) and metabolic capacity
APT 2015 42: 418-27
Low FODMAP diet in children
 Reduced
abdominal pain frequency on
low FODMAP diet
 Responders (n=8) identified with 50% or
more decrease in abdominal pain
frequency had a different gut
microbiome composition prior to the start
of the diet than those who did not
respond (N=33)
APT 2015 42: 418-27
Management of chronic
abdominal pain in children
 Pharmacotherapy
 Psychological
therapies
 Probiotics
 FODMAP
diet
 Complimentary therapy
Complimentary therapy


Commonly used complementary therapies in
functional gastrointestinal disorders (FGIDs)
are
Herbal medications


Massage therapy



Chinese herbal medicine, peppermint oil, and
ginger
reduce excitation of visceral afferent fibers and
possibly affect central pain perception
Acupuncture
Hypnotherapy
Summary
 Chronic
abdominal pain in children is not
one condition
 Challenging to have and manage and
require skills
 Consider help of gastroenterologist,
psychologist, and dietician
 Pharmacological intervention are the
least useful