CHRONIC ABDOMINAL PAIN: A PAEDIATRIC HEADACHE

1. CHRONIC ABDOMINAL PAIN: A PAEDIATRIC HEADACHE Dr P Mandi Paediatric Gastroenterologist

3. Longlasting, chronic, recurrent, constant, intermittent, are very common complaints accompanied with signs like distension bloating, nausea, general feeling of unhappiness • Causes distress to: Parents: stress, anxiety, misconceptions, feeling of inadequate workup Doctor: pushed to do more & more tests, Management can be time consuming & frustrating

4. Format • Definition • Pathogenesis • FGIDs Types • Diagnostics • Management principals

5. CAP Definition • At least 3 abdominal pain episodes , severe enough to affect activities in the last 3 months

6. Most Chronic Abdominal pain is functional in Nature Diagnosing pediatric functional abdominal pain in children (4-15 years old) according to the Rome III Criteria: results from a Norwegian prospective study. Helgeland H, Flagstad G, et al .  J PediatrGastroenterolNutr. 2009;49(3):309–315

8. Functional Gastrointestinal Disorders (FGIDs) types: Young Children and Adolescents Functional dyspepsia Irritable bowel syndrome Abdominal migraine Functional abdominal pain syndrome Infants and toddlers • Infant Colic • Infant Dyschezia • Rumination syndrome • Cyclic vomiting syndrome • Functional diarrhoea • Functional constipation The new Rome IV criteria for functional gastrointestinal disorders in infants and toddlers J Zeevenhooven, IJN Koppen, MA BenningaPediatrGastroenterolHepatol NUTR, 20: 1-13, 2017

9. Pathophysiology • Thought to involve abnormalities in the enteric nervous system “gut brain” • It interacts with the CNS allowing bidirectional communication “ gut-brain axis” • It’s believed the children have abnormal bowel reactivity to: • Physiological stimuli eg. meals, gut distension, hormonal activity Noxious stimuli eg. inflammatory processes • Psychological stimuli eg anxiety, Psychosocial issues parental separation, school change, etc • “Biopsychosocial model”

13. Rome Criteria • A symptom-based criteria for diagnosing FGIDs • Have been updated since Rome I (1994) to current ROME IV (2016) • Rome III criteria distinguished between FGIDs in younger children ( infants/toddlers) & older children (child/adolescents) Drossman DA. Gastroenterology. 2016;150:1262–1279.e2 HymanPE, et Al,. Gastroenterology. 2006;130:1519–1526. Rasquin A, et al. Gastroenterology. 2006;130:1527–1537

14. Rome III criteria for functional Gl disorders in Children • Functional Dyspepsia Must include all the following (criteria fulfilled at least once per week for at least 2 months before( • Persistent or recurrent pain or discomfort centered in the epigastrium (above umbilicus) • Not relieved by defecation or associated with onset or change in stool frequency or form • No evidence of an inflammatory, anatomic,metabolic, or neoplastic process that explains the subjects symptoms

15. Rome III criteria for functional Gl disorders in Children Irritable Bowel Syndrome Must include all the following (criteria fulfilled at least once per week for at least 2 months before diagnosis) • Abdominal discomfort (an uncomfortable sensation not described as pain) or pain associated with two or more of the following at least 25% of the time a) Improved with defecation. b) onset associated with a change in frequency of stool (four or more stools of & two or less stools PW) c) Onset associated with a change in form (appearance) of stool • No evidence of an inflammatory, anatomic,metabolic, or neoplastic process that explains the subjects symptoms

16. Rome III criteria for functional Gl disorders in Children Abdominal migraine Mustinclude all of the following criteria Fulfilled two or more times in the preceding 12 months • Paroxysmal episodes of intense, acute periumbilicall pain that lasts for 1 hour or more • Intervening periods of usual health lasting weeks to months • The pain interferes with normal activities • The pain is associated with two or more of the following (a)annorexia (b) nausea (c) vomiting (d) headaches (e) photophobia (f) pallor • No evidence of an inflammatory, anatomic, metabolic, or neoplastic process that explains the subjects symptoms

17. Rome III criteria for functional Gl disorders in Children Childhood Functional abdominal pain syndrome Must include childhood FAP at least 25% of the time and one or more of the following (criteria fulfilled at least once per week for at least 2 months before diagnosis) • Some loss off daily functioning • Additional somatic symptoms such as headaches,limb painor difficulty sleeping

18. Rome III criteria for functional Gl disorders in Children • Childhood FAP Must include all of the following ( criteria fulfilled at least once per week for at least 2 months before diagnosis) • Episodic or continuous abdominal pain • Insufficient criteria for other FGIDs • No evidence of an inflammatory, anatomic, metabolic or neoplastic process that explains the subjects symptoms

19. Diagnostic Evaluation • Individualized based on history & physical exam • Baseline Stool, Blood and Radiological • Indication for further testing: Presence of danger signs eg weight loss , stunting, significant vomiting or diarrhea, fevers or abnormal physical findings, . . .to test for specific infectious, anatomic, metabolic etiologies • Testing may be therapeutic, gives reassurance to patient,parent & Paediatrician of absence of organic disease • Evaiuation is best done in the context of biopsychosocial model of care

20. Management Principals • Classified into: • Non pharmacological • Pharmacological • Placebo • Aims of Treatment: • Reduce suffering • Improve overall Quality of Life

21. Management Principals • Management can be frustrating to all parties involved in care • Paediatrician must understand that: • FGIDs are a positive diagnosis based on clinical criteria (Rome III) • Goal of treatment is resumption of normal functioning and not complete disappearance of abdominal pain. • Patient and family bear significant responsibility for disease management. i.e. correct & accurate information. • Paediatrician empathy, support, guidance and hopeful attitude

22. Management Principals • Provide clear appropriate examples of conditions associated with hyperalgesia eg chronic headache without intracranial pathology, Abnormall sensation from burns scar long after its healed • Brain-gut axis eg diarrhoea or vomiting in a stressed situation eg exams etc • Reasonable therapeutic goals: • Regular school attendance • Early Resumption of normal activities including particioation in extracurricular activities • Reduce stress of chronic disease

23. Management Principals • Non-Pharma treatment strategies • Dietary interventions: • May involve reducing or excluding specific food types eglactose, fructose, fermentable oligosaccharides, Disaccharides, monosaccharides, and Polyols (FODMAPS) • Increasing amounts of others egfibres • FODMAPS poorly absorbed from gut thus are a potential intervention, Regimen involves 2-6 weeks complete elimination then gradual structured reintroduction of specific FODMAPS as per tolerance. • Despite various successful interventions data not consistent to definitely recommend specific dietary regimen

24. Dietary interventions • Francavilla R, Miniello V, Magistà AM, De Canio A, Bucci N, Gagliardi F, et al. A randomized controlled trial of Lactobacillus GG in children with functional abdominal pain. Pediatrics. 2010;126:e1445–e1452. • FrancavillaR, Miniello V, Magistà AM, De Canio A, Bucci N, Gagliardi F, et al. A randomized controlled trial of Lactobacillus GG in children with functional abdominal pain. Pediatrics. 2010;126:e1445–e1452.

25. Management PrinciplesProbiotics • Human Microbiota composed >1 x1014 Bacteria • Functions include: • Enhancing gut barrier function • Inhibiting pathogen binding • Modulating gut inflammatory response • Reducing visceral hypersensitivity associated with inflammation and psych stress • Altering colonic fermentation • Associations have been shown between modification of microbiota and IBS, FAP, Diarrhoea, Constipation

26. Various studies with single or mixed strains have shown usefuleness in IBS • L. rhamnosus, B. infantis +B. breve+ B. longum, L.reuteri • Evidence for their use as !st line treatment is still not strong • Spiller R. Review article: probiotics and prebiotics in irritable bowel syndrome. Aliment PharmacolTher. 2008;28:385–396. • Francavilla R, Miniello V, Magistà AM, De Canio A, Bucci N, Gagliardi F, et al. A randomized controlled trial of Lactobacillus GG in children with functional abdominal pain. Pediatrics. 2010;126:e1445–e1452. • Horvath A, Dziechciarz P, Szajewska H. Meta-analysis: Lactobacillus rhamnosus GG for abdominal pain-related functional gastrointestinal disorders in childhood. Aliment PharmacolTher. 2011;33:1302–1310 • Saneian H, Pourmoghaddas Z, Roohafza H, Gholamrezaei A. Synbiotic containing Bacillus coagulansandfructo-oligosaccharides for functional abdominal pain in children. GastroenterolHepatol Bed Bench. 2015;8:56–65. 

27. Management Principals • Pharmacological Treatment • Several studies done with contradictory results • Quality of studies low, due to small numbers or methodological flaws • Martin AE, Newlove-Delgado TV, Abbott RA, Bethel A, Thompson-Coon J, Whear R, Logan S. Pharmacological interventions for recurrent abdominal pain in childhood. Cochrane Database Syst Rev.

28. Management Principals • Antispasmodics • Peppermint oil: acts via menthol component that blocks Ca²± channels • Used in adult IBS • Others tested: Drotaverine , Mebeverine ,trimebutine • Otilonium, Phloroglucinol Kline RM, Kline JJ, Di Palma J, Barbero GJ. Enteric-coated, pH dependent peppermint oil capsules for the treatment of irritable bowel syndrome in children. J Pediatr. 2001;138:125–128.

29. Management Principals • Antidepressants • Amitryptilline: efficacious in adult IBS & FD • In 2 RCT child studies 123contrasting results BaharRJ, Collins BS, Steinmetz B, Ament ME. Double-blind placebo controlled trial of amitriptyline for the treatment of irritable bowel syndrome in adolescents. J Pediatr. 2008;152:685–689. Hyman P, Cocjin J, et al. Multicenter, randomized, placebo-controlled trial of amitriptyline in children with functional gastrointestinal disorders. Gastroenterology. 2009

30. Management Principals • Antihistamines; Cyproheptadinewas efficacious except for its side effects profile • Other drugs: • Anti Reflux • Ca channel blockers • Antibiotics • Serotonin antagonists • Melatonin • Krasaelap A, Madani S. Cyproheptadine: a potentially effective treatment for functional gastrointestinal disorders in children. Pediatr Ann. 2017;46:e120–e125 • KothareSV. Efficay of flunarizine in the prophylaxis of cyclical vomiting syndrome and abdominal migraine. Eur J Paediatr Neurol. 2005;9:23–26. • Collins BS, Lin HC. Double-blind, placebo-controlled antibiotics treatment study of small intestinal bacterial overgrowth in children with chronic abdominal pain. J PediatrGastroenterolNutr. 2011;52:382–386.

31. Prognosis • Most pts do well after diagnosis made & reassurance of no organic disease • 30-50% improve after 2-6weeks • 30% will continue with pain • Adverse prognostic factors: male sex, onset less than 6yrs, strong h/o “painful family”, symptoms duration>6months (Apley & Hale) Apley J, Hale B, BMJ 1973;3(5870):7-9

32. Summary • CAP is a common complaint • FGID’S account for majority • Diagnosis is symptoms-based Rome criteria • Evaluation & treatment is best in the context of biopsychosocial model of care • Education of the family essential • Treatment goals should be reasonable aim at return to normal function rather than complete disappearance of pain • Medications are part of multifaceted management, & should be individualized

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36. Management Principals • Pain diary : triggers, emotional responses. Coping style & degree of disability. • Identify & modify Pain triggers eg dyspepsia may be associated with GER, or IBS with constipation; psychosocial stressors egparental separation death, boarding school. • Diet: avoid food triggers eg spicy food, fatty, gas-forming ( vegetables, legumes), fibre in IBS, reduce sorbitol chewing gum, carbonated drinks, • Pharmacotherapy: famotidine in FD, Pizotifen for abd. Migraine , peppermint in IBS have been proven to be useful • Others: PPIs, Antispasmodics, Prokinetics, Antidepressants eg amytriptylline, PEG