Recurrent Abdominal Pain In Childhood and Adolescence

1. Recurrent Abdominal Pain In Childhood and Adolescence Cheryl A. Little, MD clitt002@stvincent.org St. Vincent Pediatric Gastroenterology 8402 Harcourt Rd. Suite #402 Indianapolis, IN 46260 (317) 338-9450

2. IMPORTANT POINTS • Recurrent Abdominal Pain (RAP) represents a description of symptoms, not a diagnosis • The most common cause of RAP is a functional gastrointestinal disorder (FGID) • There are 4 major pediatric disorders associated with recurrent abdominal pain • Functional abdominal pain syndrome • Functional dyspepsia • Irritable Bowel Syndrome (IBS) • Abdominal Migraine • A FGID is a positive diagnosis • Therapy of a FGID is directed at environmental modification

3. Introduction • RAP is not a diagnosis • Clinical manifestation of an organic disorder (23.6%) (Indian Pediatrics; 46: 389-399, 2009) • Due to a FGID • Diagnosis of a FGID meets specific criteria (Rome III criteria) • Red flag symptoms concerning for an organic disorder • Pain that awakens the child • Significant vomiting, constipation, diarrhea, bloating, or gas • Blood in the stool • Unintentional weight loss or slowed growth • Changes in bowel or bladder function • Pain or bleeding with urination • Abdominal tenderness

4. Epidemiology • FGID occurs in 10-12% of school-aged children • 21% severe enough to affect activity (J Pediatr 129:220-226, 1996) • Female-to-male ratio equal up to 9 yrs of age • Female-to-male ratio 1.5:1 btw 9-12 yrs of age • Onset of pain <4 yrs • More in-depth organic evaluation

5. Pathophysiology of FGIDs • Different presentations • Heterogeneous group of disorders • Variable expressions of the same disorder • Prevailing viewpoint • Pain is visceral in origin • Involves disordered GI motility • Involves visceral hypersensitivity/hyperalgesia • Genetic vulnerability • Abnormalities in the enteric nervous system • Dysfunction of the autonomic nervous system • Altered awareness of discomfort (emotions, cognitive processes, CNS influences)

6. General Approach to RAP • History • Complete history is the MOST important component of the evaluation (Attempt to obtain directly from patient) • Focus on • Timing, frequency, location, quality of pain • Associated GI symptoms (nausea, vomiting, diarrhea, constipation, blood in stool or emesis) • Precipitating/relieving factors • Systemic symptoms ( fever, wt loss, joint pain, skin rash) • Family History of IBD or PUD • Travel History • Medication and nutritional interventions • Interference with school, play, peer relations, and family dynamics

7. General Approach to RAP • Physical Examination • Complete and not only directed toward the abdomen • Growth data • ?Fall off in height or weight velocity • Delay in pubertal development • Abdominal examination • General appearance, auscultation, palpation of liver and spleen, for masses and tenderness • Rectal examination • Perianal and digital • Clubbing, rashes, arthritis • Pelvic examination (if indicated by history)

8. Rome Criteria III • Functional Abdominal Pain Syndrome • At least 8 weeks of episodic or continuous abdominal pain in a school-aged child or adolescent occurring at least once/wk with one or more of the following: • some loss of daily functioning • additional somatic symptoms such as headache, limb pain, or difficulty sleeping • The patient has insufficient criteria for other functional GI disorders that can explain the pain • No evidence of an inflammatory, anatomic, metabolic or neoplasticprocess that is likely to explain the symptoms Gastroenterology 2006;130:1527-1537

9. Functional Abdominal Pain Syndrome • Periumbilical location • Variable in severity • Pain episodes tend to cluster alternating with pain-free periods of variable length • Associated GI symptoms are denied by the patient

10. Functional Abdominal Pain Syndrome • Pain episodes begin gradually • Last less than 1 hr in 50% • Last less than 3 hrs in 40% • Continuous pain in < 10% • Child is unable to describe the pain • Radiation of pain is rare • Temporal relationship to meals, activity, bowel habits is unusual

11. Functional Abdominal Pain Syndrome • Pain rarely awakens the child from sleep • Parents describe the patient as “miserable” and “listless” during pain episodes • During severe attacks the child may exhibit a variety of motor behaviors (“doubling over in pain”) • Common associated “autonomic” symptoms • Headache, pallor, nausea, dizziness, fatigue • At least one is observed in 50-70% of cases

12. Functional Abdominal Pain Syndrome • Differential Diagnosis • Infectious • UTI, Giardia • Carbohydrate intolerance- Lactose, fructose, sorbitol, sucrase-isomaltase • Inflammatory • Crohn disease, ulcerative colitis, eosinophilic gastroenteritis, celiac disease, pancreatitis • IBS • Constipation with or without fecal impaction • Psychogenic

13. Functional Abdominal Pain Syndrome • Diagnosis • There is no dependable biological marker for functional abdominal pain syndrome • Most reliable diagnostic features are the symptoms • Should NOTrequire a series of diagnostic tests to rule out organic causes of pain • Reasonable to obtain CBC, ESR or CRP, UA and culture, KUB, CMP, O+P, fecal leukocytes, lactose tolerance testing/lactose elimination • US and CT are low yield • Excessive testing may increase parental anxiety and put the child through unnecessary stress • Parental anxiety/uncertainty increases the stressful environment that provokes and reinforces the pain behavior

14. Functional Abdominal Pain Syndrome • Treatment • Begins at initial office visit • Important to introduce the concept of functional pain during the initial evaluation • Review the differential diagnosis to reassure parents and child that specific organic disorders have been considered and “red flags” are absent

15. Functional Abdominal Pain Syndrome • Treatment • Focus of treatment is not “cure” but management of symptoms and adaptation to illness to provide a satisfactory quality of life through support and education • Accomodative or secondary engagement coping (distraction, acceptance, positive thinking, cognitive restructuring) is related to less pain • Passive or disengagement coping (denial, cognitive avoidance, behavioral avoidance, wishful thinking) is associated with increased levels of pain

16. Functional Abdominal Pain Syndrome • Treatment • Directed toward environmental modification • Identify, clarify, and reverse stresses that may provoke or increase the perception of pain • Reverse environmental reinforcement of the pain behavior • Lifestyle MUST be normalized regardless of the continued presence of pain • Parents should direct less social attention toward the symptoms

17. Functional Abdominal Pain Syndrome • Supportive counseling • Target at illness behavior • Can be delivered by primary care physician • Listening, empathy, encouragement • Do not allow ongoing pain-induced disability • Patient-centered participatory arrangement • Instruct parents how to respond to symptoms • Encourage school officials to participate in treatment

18. Functional Abdominal Pain Syndrome • Treatment • Pharmacologic therapy directed at reasonable physical triggers of pain • Constipation • Altered motility • Low-dosetricyclic antidepressants • Act as “central analgesics” • Raise the perception threshold for abdominal pain • Down regulate pain receptors in the intestine • Generally reserved for patients with anxiety/depression or maladaptive illness behavior

19. Functional Abdominal Pain Syndrome • Treatment • Hospitalization • Reinforces pain behavior • Consultation • Reserved for patients with depression/anxiety, PTSD, abuse, severe disability, maladaptive illness behavior, chronic refractory pain • Child Psychiatrist • Child Psychologist • Behavioral modification therapy

20. Rome Criteria III • Functional Dyspepsia • At least 8 weeks (which need not be consecutive) in the preceding 12 months of persistent or recurrent pain occurring at least once/week centered in the upper abdomen AND • No evidence of an inflammatory, anatomic, metabolic or neoplastic process that is likely to explain the symptoms AND • No evidence that dyspepsia is exclusively relieved by defecation or associated with a change in stool frequency or form Gastroenterology 2006;130:1527-1537

21. Clinical Presentation • Functional Dyspepsia • Pain localized to the epigastrium, RUQ, or LUQ • Episodic vomiting • Temporal relationship with meal ingestion • Presence of anorexia, nausea, oral regurgitation, early satiety, post-prandial bloating, indigestion, and belching

22. Functional Dyspepsia • No symptoms or signs that reliably distinguish functional dyspepsia from upper GI organic disorders • More extensive diagnostic evaluation than functional abdominal pain syndrome • Usually associated with the same signs of environmental reinforcement of pain behavior

23. Functional Dyspepsia • Two groups • Ulcer-like dyspepsia • Pain most common symptom • Dysmotility-like dyspepsia • Often report nausea, fullness, and early satiety

24. Functional Dyspepsia • Differential Diagnosis • Acid-related disease • Gastritis, duodenitis, esophagitis, peptic ulcer • Infection • Helicobacter pylori • Allergic/Inflammatory • Eosinophilic esophagitis, eosinophilic gastroenteritis, gastoduodenal Crohn disease, celiac disease • Gastroparesis • Chronic cholecystitis • Chronic fibrosing pancreatitis

25. Functional Dyspepsia • Diagnosis • Physical exam- findings usually normal • Lab evaluation- CBC,ESR or CRP,amylase, lipase, hepatic panel, H. pylori serology or stool antigen • UGI +/- SBFT • Abdominal US • Nuclear medicine scintigraphy (HIDA scan) • Upper Endoscopy- patients with dysphagia, persistent symptoms despite the use of acid-reducing medications, or to confirm H. pylori infection. • ERCP

26. Functional Dyspepsia • Treatment • Positive diagnosis, education, establishment of realistic expectations of treatment • Environmental and dietary modification • Avoid cigarette smoking, advise smoke-free home • Avoid alcohol, non-steroidal analgesics • Avoid caffeinated beverages, high-fat foods, and large meals • Address psychological comorbidity

27. Functional Dyspepsia • Treatment • Drug therapy • 70% improvement rate by 1 year following diagnosis (JPGHAN 30: 413-418, 2000) • Ulcer-like dyspepsia • 4-6 week course with H2-receptor antagonist or PPI • Dysmotility-like dyspepsia • 4-6 week course with a prokinetic agent (metoclopramide or erythromycin) • Anti-emetics or low-dose tricyclic antidepressants • Serotonic agents- Buspirone (Buspar), Paroxetine (Paxil)

28. Rome Criteria III • Irritable Bowel Syndrome • At least 8 weeks in the previous 12 months of abdominal discomfort or pain occurring at least once/wk with at least 2 of the following: • relief w/defecation • onset associated w/change in frequency of stool • onset associated w/ change in form of stool • No evidence of an inflammatory, anatomic, metabolic or neoplastic process that is likely to explain the symptoms Gastroenterology 2006;130:1527-1537

29. Irritable Bowel Syndrome • More common in adolescence • Pain is typically localized to the lower abdomen • Association of pain with altered bowel pattern • Diarrhea (4 or more stools per day) • Constipation (2 or less stools per week) • Sense of incomplete evacuation • Straining • Urgency • Passage of mucus • Feeling of bloating or abdominal distention • Pain is often relieved by defecation

30. Irritable Bowel Syndrome • Differential Diagnosis • Infection • Giardia • Chronic Clostridium difficile colitis • UTI • Carbohydrate intolerance • Lactose, fructose, sorbitol, sucrase-isomaltase deficiency • Inflammatory • Crohn disease, ulcerative colitis, eosinophilic gastrenteritis, celiac disease • “Microscopic” colitis

31. Irritable Bowel Syndrome • Diagnosis • Careful, sympathetic history taking • Appropriate, thorough PE ( to include rectal exam) • Negative routine diagnostic studies • Empiric lactose elimination • Full assessment of psychological and social factors as well as physical symptoms

32. Irritable Bowel Syndrome • Diagnosis • Colonoscopy is indicated in pts in whom the history or PE suggest the possibility of IBD • Evidence of GI bleeding • Profuse diarrhea • Involuntary wt loss or growth deceleration • Fe deficiency anemia • Elevated ESR or CRP • Extra-intestinal symptoms (fever, recurrent mouth sores, rash, joint pain)

33. Irritable Bowel Syndrome • Management • Symptomatic and supportive care • Development of a positive relationship between doctor and patient/parents • Validate the symptoms that they are experiencing • Address the patient’s agenda by asking directly about their concerns and fears • Initial Management • Positive, confident diagnosis communicated with clarity and honesty • Educate about the pathophysiology of FGIDs and bring focus to the multifactorial nature of IBS

34. Irritable Bowel Syndrome • Dietary Management • Constipation predominant • Insoluable fiber diet ( root vegetables, skinned fruits, bran, whole-wheat products) • Diarrhea predominant • Eat slowly, avoid chewing gum, avoid excessive intake of alcohol, carbonated and caffeinated beverages, high-fat foods, legumes, and foods or beverages with fructose or sorbitol • Soluable fiber diet (dried beans and fruits, peas, oats, barley, carrots, flesh of fruits such as apples and organges) • Response rates of 70%(Lancet 2: 1115-1117, 1982)

35. Irritable Bowel Syndrome • Drug Therapy • Antispasmodics • Anticholinergics • Used in diarrhea predominant or variable stool IBS • Dicyclomine-Bentyl • Hyoscyamine-Levsin,Levbid • Enteric-coated Peppermint Oil • Amitiza- chloride channel activator • Indicated for constipation predominant IBS in adults • Antibiotics/Probiotics- to treat bacterial overgrowth • Tricyclic Antidepressants • Serotonic drugs- Buspar, Celexa

36. Summary • FGIDs can occur as a well defined clinical entity (e.g. IBS) or a less defined clinical syndrome (e.g. functional abdominal pain syndrome) • Essential for physicians to take a biopsychosocial approach to diagnosis and treatment • Appreciate the close interaction of the gut and brain • Allows the child, parent and physician to address the pain on many levels • Further understanding of brain-gut axis and the role of serotonin in neural sensorimotor functions is needed

37. Irritable Bowel Syndrome • Probiotics • Replace deficiencies of “normal” colonic bacteria and reduce fermentation • Randomized double-blind controlled trial • Lactobacillus plantarum • Reduction in the degree of flatulence • Improved overall GI function at 12 months (Am J Gastroenterol 95:1231-1238, 2000)

38. Irritable Bowel Syndrome • Tricyclic Antidepressants • Effect significant on primary outcome measures and on global response and pain • 89% improvement in adult pts 61% remission of symptoms(Gut 2005;54:1332-1341) • Effectiveness in clinical practice limited by side effects (sleepiness) • Reserved for patients with severe symptoms or symptoms resistant to common first-line approaches

39. Irritable Bowel Syndrome • Serotonic Agents • 5-HT1 agonists • Buspirone (Buspar) • Reduce gastric acid and colonic responses to volume distention • Anxiolytic activity • SSRIs • Citalopram (Celexa) • Reduce colonic sensation to volume distention in healthy subjects

40. Irritable Bowel Syndrome • Psychological Treatment • Stress management • Psychotherapy • Introduce early in the discussion of pathophysiology and management of IBS • Do not leave as “last-ditch” treatment after medical therapy has proved less than optimal • Therapy often combination of parent training, altering reinforcement of various behaviors and stress management • Statistically significant improvement of pain with adjunctive cognitive-behavioral therapy (J Consult ClinPsychol 57: 294-300, 1989, and 62: 306-314, 1994)