What!!! another patient with abdominal pain????

Midwest Pediatric Hospital Medicine Conference, 2013

Susan Maisel, MD & Allyson Boodram, MD

Objectives

Review the characteristics of chronic abdominal pain

Differentiate functional from organic causes of abdominal pain

Review current modalities for evalutaion, management/treatment of chronic abdominal pain

Review predictive value of these modalities

case Scenario

Definitions

Chronic Abdominal Pain:

Pain of at least 3 months duration; clinical variation that includes time frame of 1-2 months

Source:Hyams et.al 1996.

Recurrent Abdominal Pain:

One of the most common recurrent pain syndromes in children. Classic definition based 4 criteria:

Hx of at least 3 episodes of pain

Pain that is severe enough to affect activities

Episodes that occur over 3 months

No known organic cause.

Clinical Definitions

Chronic Abdominal Pain:

Long lasting, intermittent or constant that is functional or organic (disease)

Functional Abdominal Pain:

Abdominal Pain without evidence of disease/pathologic process. Can manifest with symptoms typical of functional dyspepsia, irritable bowel syndrome, abdominal migraine or functional abdominal pain syndrome.

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 . 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: AAP, 2005

other causes

Peptic ulcer H pylori Biliary dyskinesis Celiac IBD Abdominal migraine, IBS GER

Limited but credible evidence of the existence of functional dyspepsia, IBS, and abdominal migraines in children

Is there evidence that children with chronic abdominal pain have symptom

patterns that can be categorized as functional versus organic?

History

1. When did it start? Document durationF – Concurrent stressful event in lifeO – Trauma or travel

2. Where is it located and where does it go?F – Peri-umbilical or epigastricO – Well localized away from umbilicus

3. How long does it last?

F – Prolonged duration with no clear signs

O – Variable; signs raise the ante

4. What does the pain feel like?

F – Vague, gradual onset, variable severity

O – Isolated, sudden onset

5. What makes the pain better?

F – No relationship to interventions

O – Sometimes medications or position change help

6. What makes the pain worse?

F – Reinforcement from parents

7. Is the pain intermittent or constant

F – Constant

O - Intermittent

8. Association with other signs or symptoms?

F – Signs of anxiety (mottled skin, nail biting), family history of irritable bowel, migraines

O – Association with hematachezia, fever, rash, weight loss, growth faltering, family history of ulcers or IBD

What is the predictive value of the history?

There are no studies that support the history is able to differentiate functional from organic disease

Presence of headaches, joint pain, anorexia, vomiting, nausea, excessive gas and altered bowel symptoms may be more frequently associated with functional abdominal pain

Presence of Red Flags may suggest a higher probability of organic disease and warrants further diagnostic evaluation

What is the diagnostic value of the psychosocial history?

The literature reviewed 3 domains: Life-Event Stress, Emotional/Behavioral Symptoms and Family functioning.

There is no evidence on whether any of these domains influence symptom severity, course or response to treatment

location, location,location

Differential of chronic abdominal Pain

GIConstipationParasitesLactose IntolPeptic DiseaseIBDGallstonesPancreatitisAllergy?H. pylori?Celiac Dis.

GUUTIRenal StonesOvarianPID

OTHERMedicationsHSPSickle CellLymphomaFam Med FeverPorphyriaLead PoisoningRheumatologic

FUNCTIONALFunctional

DyspepsiaIBSFAPFunctional Ab

PainAbdominal Migraine

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 - What’s reuired?

Clear communication with nursing and ancillary staff (child life) regarding observation of patient behaviors and family dynamics. Importance of proper documentation for concerning observation.

Parental/patient voice regarding evaluation

Red Flags and red herrings

Systemic signs: hematachezia, rash, weight loss, growth faltering, vomiting, diarrhea, persistent RLQ/RUQ pain, unexplained fever, evidence of GI blood loss,

Historical clues: family history of ulcers or IBD

Prolonged school absence

Use of narcotic pain medication

Positive or unusual exam findings

diagnostic studies

CBC

ESR, CRP

CMP, Amylase, Lipase, H. Pylori, Celiac

TSH, T4

UA

Imaging: Ultrasound, Abdominal/Pelvic CT/MR

Procedures: Endoscopy

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?

No evidence to suggest that abdominal and pelvic ultrasounds in the ABSENCE of Red Flags has a significant yield of organic disease

There is little evidence to suggest that the use of endoscopy and biopsy in the ABSENCE of Red Flags has a significant yield of organic disease

Insufficient evidence to suggest that esophageal pH monitoring in the ABSENCE of Red Flags has a significant yield of organic disease

All Studies normalNow what?

Treatment/management

Delivery of diagnosis to families - clear, education of FAP; reassurance; emphasize that there is no seriouslife threatening process/condition; there may be resistance to a diagnosis of non organic disease; use simple language stressing that the pain is real despite lack of organic cause; families/patients resistant to a functional cause may be more likely to continue to have missed school days and somatic complaints

Goals of Treatment/Management

Primary goal - Return to normal function

Secondary goal - Relief of symptoms

Avoidance of reinforcement of pain behaviours

Distraction, providing attention, rest, identifying triggers for pain

Reassurance

Education to the family

Emphasize that there is no serious life threatening process/condition

Primary goal - Return to normal function

Secondary goal - Relief of symptoms

Pharmacologic

Cognitive Therapy

Relaxation

Massage/PT/OT/Exercise

Useful Analogies

HA

Don’t use it - Lose it

Christmas tree lights

Worst Nightmare

Drug Action Indication Risk

PeppermintOil

? Smooth Muscle

RelaxationIBS None

Fiber StoolBulking

ConstipationPredominant

Bowel obstruction

Lactose FreeDiet / Lactaid

EliminatesLactose

Lactase Deficiency None

ProbioticsReplacement

of “Toxic Bacteria”

S/P Antibiotics /

EnteritisSystemic

Translocation

Drug Action Indication Risk

PEG Stool Softner Constipation

Dehydration / Bowel Obstruction

H2 Blocker Histamine Antagonist Dyspepsia Tachyphalaxis after

2 weeks

PPI Inhibits Acid Production

Dyspepsia / PUD

?Osteopenia/Bacterial

Overgrowth/ Gastronoma

Serotonin 2A Antagonist

Serotonin Blockade

Abdominal Migraine / Anxiety

Drowsiness, Dizziness

Anti - Tricyclics

Anti - Depressant Depression Dependancy /

Suicide / Arrythmias

Drug Action Indication Risk

Mylicon Anti - Flatulance

Excessive/Discomfort/ Gas Pains

BentylAnti -

Spasmodic (AS)

Spasms / Cramping

Levsin AS, Sedation Spasms / Cramping

Donnatol AS, Sedation Spasms / Cramping

what is the effectiveness of pharmacologic treatment?

Through review of literature revealed a paucity of studies on pharmacological and dietary intervention, thus definitive statements regarding efficacy are limited.

Evidence that treatment with peppermint oil for 2 weeks may provide benefit in children with IBS

Inconclusive evidence of the benefit of H2 antagonists to treat dyspepsia

Inconclusive evidence that fiber intake decreases the frequency of pain attacks for patients with chronic abdominal pain

Inconclusive evidence that a lactose free diet decreases symptoms in children with chronic abdominal pain

Limited data regarding efficacy of serotonin 2A antagonists in treatment of abdominal migraine

Treatment/Management options

Resuming normal daily lifePT/OT for reconditioningRelaxation/Massage/ExerciseCognitive Therapy

what is the effectiveness of Cognitive - behavioral therapy?Literature reviewed 3 domains of psychosocial history: life - event stress, child emotional / behavioral symptoms and family functioning.

Life - Event Stress

There is no evidence on whether this influences symptom severity, course, or response to treatment

Emotional/Behavioral Symptoms

There is evidence that patients with chronic abdominal pain have more symptoms of anxiety/depression than do healthy controls

There is evidence that suggests the presence of anxiety, depression, or other behavior problems is NOT useful in distinguishing between functional abdominal pain and organic abdominal pain

Family Functioning -

There is evidence that parents of patients with recurrent abdominal pain have more symptoms of anxiety, depression, and somatization than do parents of community controld or parents of other pediatric patients

There is also evidence that families of patients with recurrent abdominal pain do not differ from families of control or families of patients with acute illness in broad areas of functioning such as family cohesion, conflict and marital satisfaction

Functional abdominal Pain (FAP)

Uncommon under 5

females > males

Real pain; not faking or malingering

Pathogenesis

abnormal bowel reactivity to physiologic stimuli (meal, gut distention, hormonal), noxious stressful stimuli (inflammatory procees), psychological stressful stimuli (parental seperation, anxiety) Leading to the development of visceral hyperalgesia

FAP is a POSITIVE diagnosis and not a failure to the true cause of the pain

Functional gastrointestinal disorders

FGIDS

Variable combination of chronic and/or recurrent symptoms that are not explained by biochemiacal or anatomical abnormalities.

ROME Committee, 2009: Updates information on FGIDS for clinical and research

Symptoms of chronic or recurrent abdominal pain in children where there is no identifiable structural, inflammatory, infectious, neoplastic or metabolic cause.

Symptoms that occur once a week for a druation of at least 2 months

Epidemiology of Chronic Abdominal Pain in children

One of the most common complaints in children and adolescents

13% of Middle School aged; 17% of High School aged children experience weekly abdominal pain (Hyams JS et al J Pediatr. 1996)

Functional Abdominal Pain was found in 15% of school aged children (Youssef NN. Clinical Pediatrics 2007)

10-15% of school age children seek help

10-15% more have symptoms but never seek medical attention

10% have an organic cause

Females>males

Higher in > 10 years old

Prevalence increases during school, not vacations

Myths

Functional Abdominal Pain (FAP) is NOT strictly associated with:

Overachiever

Intellect

Perfecionist

Constant worrier

Important to not be biased and have a broader differential when considering FAP

Case 1

CC: SS is a 14 y.o F that presents for evaluation of chronic abdominal pain that has been present for 4months. Her pain is localized to the periumbilical region, although occasionally she describes radiation to the lower left and right quadrants. She rates her pain as 7/10. She states that it seems to be worse in the morning but can present at any time throughout the day. There are no specific triggers such as diet or activity; and she denies any alleviating or aggrevating factors. she reports no change in appetite or bowel habits, but she has had episodes of non bilious/non bloody emesis intermittently since onset of pain. She has also had a 10lb weight loss since onset of her pain.

PMHx: unremarkable; PSurgHx: none

Social: Lives with mom, father is not consistently involved but she does see him. Has a good relationship with her mother. She is the only child. Described as a straight A student and popular amongst her peers; involved in extra curricular activities through school, including: dance, soccer, track and debate. Since onset of pain she has missed 1-2 days of school a week and has not been able to participate in her usual activities. Mother is very concerned about her and wants an answer to what is causing her abdominal pain.

References

The American Academy of Pediatrics (AAP) and North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition (NASPGHAN) guidelines, AAP 2005

Eccleston C, Yorke L, Morley S, Williams AC, Mastroyannopoulou K. Psychological therapies for the management of chronic and recurrent pain in children and adolescents. Cochrane Database Syst Rev. 2003

Recurrent abdominal pain: symptom subtypes based on the Rome II Criteria for pediatric functional gastrointestinal disorders; Walker LS, Lipani TA, Greene JW, Caines K, Stutts J, Polk DB, Caplan A, Rasquin-Weber, J Pediatr Gastroenterol Nutr. 2004 Feb; 38(2):187-91.

Chronic abdominal Pain in Children; Pediatrics 2005; 115:3 812-815

Weydert JA, Ball TM, Davis MF. Systematic review of treatments for recurrent abdominal pain. Pediatrics. 2003;

Hyams JS, Burke G, Davis PM, Rzepski B, Andrulonis P. Abdominal pain and irritable bowel syndrome in adolescents: a community-based study. J Pediatr. 1996;129:220–226

Pediatric Functional Gastrointestinal disorders; Nutr Clin Pract 2008; 23:3 268-274