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The teenager with chronic abdominal pain; the teenager with chronic symptoms

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The teenager with chronic abdominal pain; the teenager with chronic symptoms Oscar Taube, MD Coordinator, Adolescent Medicine The Children s Hospital at Sinai – PowerPoint PPT presentation

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Title: The teenager with chronic abdominal pain; the teenager with chronic symptoms


1
The teenager with chronic abdominal pain the
teenager with chronic symptoms
  • Oscar Taube, MD
  • Coordinator, Adolescent Medicine
  • The Childrens Hospital at Sinai
  • September 22, 2009

2
Case17 y.o. female seen multiple times over past
year at GPA
  • Abdominal Pain Bilateral lower abd. pain
    intermittent 4/5 pain constipation alternating
    with diarrhea BMs do not relieve pain Never
    sexually active.
  • Headaches Mainly frontal several times/week
    not interfering with activity no vision changes,
    no vomiting doesnt waken her from sleep no URI
    complaints no family hx. of migraine. Rxd in
    past for sinusitis with amoxicillin- no relief of
    pain.

3
Case History, continued
  • Backache Chronic lower back pain, not increased
    with movement.
  • Joint pains Multiple complaints in past 6
    months mostly hip pains no morning stiffness.
  • Social Hx. Patients mother recently became
    pregnant pregnancy with complications mother on
    bed rest.
  • Physical Exam Abdominal Exam Mild bilateral
    lower abd. tenderness no HSM, masses, guarding,
    rigidity.Otherwise, PE wnl.
  • Labs CBC, CMP, amylase, lipase, urine culture,
    STD testing, connective tissue disease testing
    all negative.

4
Case History 2Adolescent Consultation Service
Patient
  • KJ, 19 year old white female w. several months
    sharp stabbing upper abdominal pain sometimes
    awakens her at night. Decreased appetite. No T,
    V, D, blood in stools.
  • Previous work up Endoscopy small
    gastric/duodenal ulcers some improvement with
    PPIs. CBC/CMP/Amylase-Lipase all normal.

5
Case 2, continued
  • 10 years complaint of joint pains
  • Complaint of significant fatigue, even with
    adequate sleep.
  • Several years of frequent headaches difficulty
    with concentration, short term memory.

6
Case 2, continued
  • Psychosocial Raped at age 17, never reported.
    Admits to depressed, self deprecatory, suicidal
    ideation. Beck Depression Inventory score 48
    (severe range 29-63).
  • Physical exam WNL except for tenderness on 11
    of 18 Fibromyalgia tender-point sites.

7
Why this combination of topics? (Chronic abd.
pain/chronic symptoms)
  • The two key symptoms in children and adolescents
    with potential somatization disorders are
  • Abdominal pain
  • Headaches.
  • And chronic fatigue/muscle pain, too.

8
Epidemiology-Chronic Abdominal Pain
  • Hyams et. al. J. Pediatrics, 1996. Community
    based study of abd. pain complaints of suburban
    7th, 10th graders
  • Middle School (mean age 12.6 years)
  • 13 pain at least weekly
  • 32 pain gt 5x. per year
  • 24 pain severe enough to affect activities

9
Epidemiology, continued.
  • Hyams study, continued.
  • High school (Mean age 15.6 years)
  • 17 at least weekly pain
  • 37 pain gt 5 x/year
  • 17 pain severe enough to affect activities.
  • Chronic abdominal pain accounts for 2-4 of all
    pediatric office visits.

10
All roads lead to.
11
Rome!
  • Rome III Criteria for Functional Bowel Disorders
    Associated with Abdominal Pain or Discomfort in
    Children and Adolescents
  • Functional Dyspepsia
  • Irritable Bowel Syndrome
  • Childhood Functional Abdominal Pain and Syndrome

12
Functional Dyspepsia
  • A. Persistent/recurrent pain centered in upper
    abdomen, above umbilicus
  • B. Pain not relieved by defecation, or assoc. w.
    onset of change in stool frequency or stool form
    (i.e., NOT IBS).
  • C. No evidence of inflammatory, anatomic,
    neoplastic process to explain symptoms
  • D. Above must be present at least 1x/week, for at
    least 2 months.

13
Irritable Bowel Syndrome
  • Recurrent abdominal pain or discomfort at least 3
    days per month for the past 3 months, associated
    with two or more of the following
  • Improvement with defecation
  • Onset assoc. w. change in stool frequency
  • Onset assoc. w. change in stool form (appearance).

14
Childhood Functional Abdominal Pain
  • All of the following must be present at least
    once a week for at least 2 months before
    diagnosis
  • A. Episodic or continuous abdominal pain
  • B. Insufficient criteria for other functional GI
    disorders.
  • C. No evidence of an inflammatory, anatomic,
    metabolic, or neoplastic process that explains
    the symptoms.

15
Childhood Functional Abdominal Pain Syndrome
  • Must include Dx. of Childhood Functional
    Abdominal Pain at least 25 of the time and one
    or more of the following
  • A. Some loss of daily activity
  • B.Additional Somatic symptoms such as headache,
    limb pain, or difficulty sleeping.

16
Differential Dx. Functional Bowel Disorders
  • Functional Dyspepsia GER Peptic ulcer disease
    Biliary tract obstruction/biliary colic chronic
    pancreatitis gastroparesis.
  • IBS Lactose intolerance IBD Celiac disease
    Infection (e.g. giardiasis) constipation
  • .

17
Differential Dx. Functional Bowel Disorders,
continued
  • Gynecologic Differential Diagnosis
  • Pelvic adhesions- Pelvic inflammatory disease.
  • Mittelschmerz
  • Dysmenorrhea
  • Endometriosis
  • Ovarian mass.
  • UTI

18
Differential Dx. of Abdominal Pain by location
  • RUQHepatitis/cholecystitis/pneumonia
  • RLQ Appendicitis/IBD/Salpingitis
  • Epigastric Peptic ulcer disease/pancreatitis/peri
    carditis
  • Periumbillical Early appy/gastroenteritis
  • LUQ Splenic abcess/pancreatitis
  • A very partial list!

19
Pathogenesis of Functional Bowel Disorders
  • 1.Visceral hypersensitivity or hyperalgesia, with
    a decreased threshold for pain
  • 2. Altered GI motility
  • 3. Psychological stress as a trigger/Genetic
    factors/environmental factors
  • 4. Other Medical factors Infectious
    gastroenteritis as IBS trigger abnormal
    serotonergic mechanisms small intestinal
    bacterial overgrowth.

20
(No Transcript)
21
Approach to Functional GI Disturbances
  • CAREFUL, COMPREHENSIVE HISTORY
  • (Timing, location, radiation, quality, severity,
    precipitants, relievers of pain associated
    complaints diet family hx., etc.)
  • CAREFUL, COMPREHENSIVE PHYSICAL EXAM.
  • (Oral exam Pubertal stage abd. Exam including
    location, rebound, mass, psoas sign, mass, HSM,
    kidney size, perianal findings, rectal/pelvic
    exam, stool for occult blood).
  • Plot weight, height on a serial growth chart
  • Pay attention to the Red flags- these point to
    signs of GI diseases that may need more
    aggressive testing, more aggressive
    pharmacologic, surgical Rx, and most likely will
    need GI referral.
  • Pay attention to the Red flags that point to
    somatiform diagnoses
  • Limited General lab work up CBC/CRP/Urinalysis

22
Red Flag signs, sxs suggestive of organic
diseases
  • Weight loss
  • Unexplained fevers
  • Pain radiating to the back/pain distant from
    umbillicus
  • Bilious emesis
  • Hematemesis
  • Chronic diarrhea (gt2 weeks)
  • GI Blood loss
  • Oral ulcers
  • Dysphagia

23
Red flags, continued
  • Unexplained rashes
  • Nocturnal symptoms
  • Arthritis
  • Anemia/pallor
  • Delayed puberty
  • Deceleration of linear growth velocity
  • Family hx. of IBD, celiac, peptic ulcer disease
  • Hepatosplenomegaly
  • Perianal abnormalities

24
A brief approach to treatment of Functional Bowel
disorders
  • Functional Dyspepsia
  • Reassurance
  • D/C dyspeptic meds (e.g. ibuprofen)
  • D/C dyspeptic foods
  • H2 receptor antagonists/PPIs
  • Trial of low dose tricyclic antide-
  • pressants qHS.

25
Rx of Functional Bowel Disorders, continued
  • IBS
  • Reassurance explanation
  • Dietary modifications- If diarrhea, reduce
    sorbital, fructose, gas forming vegetables. If
    constipation Increase water.
  • PharmRx-if constipation Osmotic laxatives,
    stool softener. Trial of antidepressants?
    Probiotics?Peppermint oil?

26
Biopsychosocial model A continuum of hierachical
systems that are always interacting
  • Biosphere
  • Society-Nation
  • Culture-subculture
  • Community
  • Family
  • Person
  • Nervous system
  • Organ-organ systems
  • Tissue
  • Cell
  • Organelle
  • Molecule

27
Biopsychosocial Model-How NOT to do it
  • First well rule out organic problems, then
    well explore psych issues.
  • Well do some tests to see what is wrong.
  • The clinician focuses her/his efforts-in dealing
    with the adolescent who has chronic abdominal
    pain/chronic somatic symptoms-to determine if the
    teen is trying to a. avoid something (primary
    gain) b. seek attention (secondary gain) c.
    feign symptoms for internal or external gain.
  • I believe that your pain is real. (If youre
    really sending the message I dont believe the
    pain is real. )

28
Somatization
  • The central feature of somatiform disorders is
    that they present with features of an underlying
    medical condition, yet such a condition either is
    not found or does not fully account for the level
    of functional impairment.
  • -Silber T, Pao, M. Peds.in Review 8/03.

29
Pathogenesis Genetic/Family Factors
  • Genetics? Somatoform disorders concordant in
    twins cluster in families w. ADD/alcoholism.
  • Learned Behavior In many household, childrens
    somatic complaints more acceptable than
    expression of strong feelings.
  • Family psychosocial factors 1. If a family
    member has a chronic physical illness, somatic
    sxs among children. (A model). 2.Somatisizing
    kids often live with somatisizing parents. 3.
    These sxsa reaction to stress.

30
Somatization Differential Diagnosis
  • Unrecognized physical disease (OH NO!)
  • Unrecognized psychiatric disorder (e.g.
    depression, anxiety)
  • Factitious disorder (e.g. malingering)
  • Psychological factors affecting medical condition

31
Campo, et. al. Pediatrics 2004
Psychiatric Disorder RAP patients () Control patients () P value
Any anxiety disorder 78.6 10.5 lt.001
Any depressive disorder 42.9 7.9 lt.001
32
The approach Somatization Red Flags
  • Hx. of multiple somatic complaints
  • Multiple primary care physician visits
  • Multiple specialty consultations
  • Family members with chronic and recurrent sxs.
  • Non-nuclear family
  • Dysfunction in primary areas of life family,
    peers, school, sports, leisure activities.

33
The approach, continued
  • VERY CAREFUL, VERY COMPREHENSIVE HISTORY AND
    PHYSICAL EXAM
  • Bring up, EARLY in the evaluation, that there may
    be stress related factors.
  • Ask patient/family their theories re etiology
  • Limited lab work up, impose limits on workup.
    Suggest limitations on specialty referrals.
  • Screen for depression/anxiety, etc. YSC, BDI,etc.
  • Avoid mind-body split/Functional vs.
    organic/etc. Use an example (e.g. red face)

34
Ask the patient/parent-Mothers who endorsed
psych-social causes for their kids abd. pain
  • Cause
    endorsing
  • Child worried, nervous, tense 50
  • Stress
    32
  • Puts too much pressure on self 30
  • XS sensitivity/overreaction to pain 29
  • Abd. pain gets family attention 12

35
The approach, continued
  • Urge consolidation of care
  • Teach self-monitoring techniques (e.g.,
    relaxation, PMR, pain diary )
  • Offer reassurance when appropriate
  • Aggressively Dx. and Rx. Comorbid psychiatric
    disease. Insist upon close contact with mental
    health provider
  • Schedule frequent follow-up appts.

36
  • Finally, recognize that these patients can be
    very frustrating and difficult to treat.
  • Consultation-physician to physician-for formal
    consultation, for ideas, and for emotional
    support- can be vital!

37
References-1
  • 1. Braverman P Chronic Abdominal Pain, in
    Neinstein LS et.al. Editors, Adolescent Health
    Care A Practical Guide. Fifth Edition. 2008.
    Philadelphia, Lippincott Williams and Wilkins.
    pp. 508-516.
  • 2.Campo JV, BridgeJ, Ehmann M et. al. Recurrent
    Abdominal Pain, Anxiety and Depression in Primary
    Care. Pediatrics Vol 113 No. 4 April, 2004 pp.
    817-824
  • 3. Claar RL, Walker LS Matenal attributions for
    the causes and remedies of the childrens
    abdominal pain. J. of Pediatric Psychology 1999
    Vol. 24 No. 4 pp. 345-354.
  • 4.Collins BS, Thomas D Chronic Abdominal Pain.
    Pediatrics in Review Vol.28 No.9 Sept. 2007
    pp.323-331
  • 5. Hyams JS, Burke G, Davis PM et.al. Abdominal
    Pain and Irritable Bowel Syndrome in Adolescence
    a Community- based Study. J. of Pediatrics Vol.
    129 No. 2. 220-226
  • 6. Kriepe RE The Biopsychosocial Approach to
    Adolescents with Somatoform Disorders.
    Adolescent Medicine Clinics Vol. 17 No. 1 Feb.
    2006 pp.1-24

38
References-2
  • 7. Lake AM Chronic Abdominal Pain in Childhood
    Diagnosis and Management. Am. Family Physician
    Vol. 59 No.7 April 1, 1999.
  • 8. Miranda AM Early Life Stress and Pain An
    Important Link to Functional Bowel Disorders.
    Pediatric Annals Vol. 39 No. 5 May, 2009.
  • 9. Servan Schreiber D, Randall K, Tabas G
    Somatizing Patients Part 1 Practical Diagnosis
    Part 2 Practical Management. Am. Family
    Physician Vol. 61 No. 4, 5. 2/15 and 3/1/00.
  • 10. Silber TJ, Pao M Somatization Disorders in
    Children and Adolescents. Pediatrics in Review
    Vol. 24 No. 8 Aug. 2003
  • 11. Up to Date articles (May, 2009) on
    Evaluation/Management of Child with Chronic
    Abdominal Pain Somatization Primary Care
    Management of Medically Unexplained Symptoms.
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