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

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

• Midwest Pediatric Hospital Medicine Conference,
  2013
• Susan Maisel, MD Allyson Boodram, MD

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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

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case Scenario
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Definitions

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

SourceHyams et.al 1996.
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• 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.

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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.

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• 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

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other causes

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

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Is there evidence that children with chronic
abdominal pain have symptom patterns that can be
categorized as functional versus organic?

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

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History

• When did it start? Document duration
• F Concurrent stressful event in life
• O Trauma or travel
• Where is it located and where does it go?
• F Peri-umbilical or epigastric
• O Well localized away from umbilicus

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• How long does it last?
• F Prolonged duration with no clear signs
• O Variable signs raise the ante
• What does the pain feel like?
• F Vague, gradual onset, variable severity
• O Isolated, sudden onset

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• What makes the pain better?
• F No relationship to interventions
• O Sometimes medications or position change help
• What makes the pain worse?
• F Reinforcement from parents
• Is the pain intermittent or constant
• F Constant
• O - Intermittent

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• 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

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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

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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

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location, location,location
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(No Transcript)
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Differential of chronic abdominal Pain
GI ConstipationParasitesLactose IntolPeptic
DiseaseIBDGallstonesPancreatitisAllergy?H.
pylori?Celiac Dis.
GU UTIRenal StonesOvarianPID
OTHER MedicationsHSPSickle CellLymphomaFam Med
FeverPorphyriaLead PoisoningRheumatologic
FUNCTIONAL Functional DyspepsiaIBSFAPFunctional
Ab PainAbdominal Migraine
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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 - Whats 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

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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

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diagnostic studies

• CBC
• ESR, CRP
• CMP, Amylase, Lipase, H. Pylori, Celiac
• TSH, T4
• UA
• Imaging Ultrasound, Abdominal/Pelvic CT/MR
• Procedures Endoscopy

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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

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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

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All Studies normalNow what?
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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

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Goals of Treatment/Management

• Primary goal - Return to normal function
• Secondary goal - Relief of symptoms

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Primary goal - Return to normal function

• 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

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Secondary goal - Relief of symptoms

• Pharmacologic
• Cognitive Therapy
• Relaxation
• Massage/PT/OT/Exercise

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Useful Analogies

• HA
• Dont use it - Lose it
• Christmas tree lights
• Worst Nightmare

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Drug Action Indication Risk
Peppermint Oil ? Smooth Muscle Relaxation IBS None
Fiber Stool Bulking Constipation Predominant Bowel obstruction
Lactose Free Diet / Lactaid Eliminates Lactose Lactase Deficiency None
Probiotics Replacement of Toxic Bacteria S/P Antibiotics / Enteritis Systemic Translocation
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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
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Drug Action Indication Risk
Mylicon Anti - Flatulance Excessive/Discomfort/ Gas Pains
Bentyl Anti - Spasmodic (AS) Spasms / Cramping
Levsin AS, Sedation Spasms / Cramping
Donnatol AS, Sedation Spasms / Cramping
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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

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• 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

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Treatment/Management options

• Resuming normal daily life
• PT/OT for reconditioning
• Relaxation/Massage/Exercise
• Cognitive Therapy

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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

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• 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

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Functional abdominal Pain (FAP)

• Uncommon under 5
• females gt 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

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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

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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

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• 10-15 more have symptoms but never seek medical
  attention
• 10 have an organic cause
• Femalesgtmales
• Higher in gt 10 years old
• Prevalence increases during school, not vacations

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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

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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.

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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 1153 812-815

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• 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. 1996129220226
• Pediatric Functional Gastrointestinal disorders
  Nutr Clin Pract 2008 233 268-274