Original Definition Recurrent abdominal pain in children described originally by Apley is defined as paroxysmal abdominal pain occurring between the ages of 4 and 16 years and has experienced at least three bouts of pain severe enough to affect activities over a period of at least 3 months
New Definitions• Chronic abdominal pain is defined aslong-lasting intermittent or constantabdominal pain• Functional: without objective evidenceof an underlying organic disorder
New Definition• Recurrent abdominal pain is adescription NOT a diagnosis– RAP includes children with a variety offunctional gastrointestinal disorderscausing abdominal pain.• It may also include children withorganic disease
Prevalence• Has been reported to occur in 10-15%of children.– Likely just as many experience this butmaintain close to normal activity– Usually two peak periods• 5-7 y.o. (beginning of school andseparation issues)- boys and girls• 9-12 y.o. – girls > boys. Manyhave a family history of functionalbowel disease
Functional abdominal pain• Rome III Criteria – 2006• Diagnostic Criteria for ChildhoodFunctional Abdominal Pain– Must include all at least 1/week for 2months• Episodic or continuous abdominal pain• Insufficient criteria for other FGIDs• No evidence of an inflammatory, anatomic,metabolic or neoplastic process to explain thesymptoms.
Changes from Rome II to III• Symptom duration from 3 to 2 months– Except abdominal migraine and CVS• No need to “rule out everything”– Use of the “red flags” to guide dx• No longer a requirement for– Continuous pattern or– Impaired daily activities
Diagnosis• The MOST IMPORTANT step directinga clinician is a good history.• Distinguish between acute and chronicpain.– As a general rule the more recent the onset of the pain, the closer one must look for organic causes and proceed with a stepwise workup.
History- Key Elements• Pain– Pattern– Localized vs. generalized– Does it occur before, during or after meals ?• How soon after eating does it occur ?• Is it made better or worse with this ?• How long does it last ?• Associated with nausea or vomiting ?• Associated with certain foods ?– Does it awaken the child at night ?• If so what is done to make it better ?
History- Key Elements• What is the timing of the pain ?– What days of the week ?– Times of the day ?• Does the pain keep the childfrom school• Bowel Movements– Pattern, consistency, completeness
History• Be sure to include a thorough review of systems and expand on it if any screening questions are positive.– CNS- migraines, vision problems– CVS/Respiratory- breathlessness, chest pain– GU- Sexually active, Dysuria– Skin- rashes• Recent use of medications• Social history, Family history
History-• Genetics• Intercurrent illnesses• Food allergies• Physical and sexual abuse• Stressful life experiences• Excessive parental anxiety
Alarm signals in the History• Involuntary weight loss• Growth retardation• Persistent vomiting• Peri-rectal disease• Dysphagia• Delayed puberty• Unexplained fever• Persistent or nocturnal diarrhea• Any GI blood loss• arthritis, rash• Family history of GI disease• Persistent RUQ or LUQ pain• Pain that wakes
Physical Examination• Weight, height and growth patterns• Check for masses or hernias• Check for any organomegaly• pelvic exam• rectal exam– Test stool for blood
Alarm Signals in the P.E.• Localized tenderness, fullness or masseffect• Hepatomegaly• Splenomegaly• Perianal fissure or fistula• Visible soiling• Guaiac-positive stools
Diagnostic Testing• Indicated when alarm signals orabnormal physical findings suggest anorganic disorder• May be considered to reassure theparent, patient or physician that themost likely diagnosis is functional.
Routine Workup for R.A.P.• Urinalysis (include pregnancy if female)• CBC with differential• Sedimentation rate/CRP• Comprehensive metabolic panel– Electrolytes, BUN, creatinine, glucose,albumin, protein, calcium, alkalinephosphatase, AST, ALT, total bilirubin• Amylase/lipase• Celiac screen
Other Diagnostic Tests• UGI & S.B. series• Abd/Pelvic U/S• Stool for WBC’s• Occult blood• Other tests as indicated by history andphysical exam
Carnetts test This test helps to determine whether pain is arising from abdominal wall or has an intra abdominal origin. The site of maximum tenderness is found through palpation The patient is then asked to cross his or her arms and assume a partial sitting position or crunch, which results in tension in the abdominal wall. If there is greater tenderness on repeat palpation in this position , abdominal wall disorders should be suspected.
Subcategories of R.A.P. R.A.P. with Dyspepsia Isolated R.A.P. R.A.P. with Altered BM
R.A.P. With Dyspepsia• G.E.R.D.• Peptic ulcer• H. Pylori• NSAIDs• Gastroparesis• Biliary dyskinesia• Pseudo-obstruction• Pancreatitis• IBD• Giardia, Blastocystis hominis• HSP• Chronic hepatitis• Cholecystitis• UPJ obstruction• Abd migraine• Psychiatric
R.A.P. With Dyspepsia• Key to deciding the extent of the initialworkup is the presence or absence ofvomiting.• In addition to the previous tests test for H. Pylori• If vomiting is a significant part of the history an UGI with SBFT should be done. Consider endoscopy
• If the time criteria for R.A.P. has not been met and you are proceeding with the workup, try acid-reducing agents as an empiric therapy as long as the symptoms are consistent with dyspepsia.• Once you are close to the time criteria you should introduce R.A.P. as a potential diagnosis.
H. pylori• Incidence in children increases with age• Positive relation between disease and low socioeconomic status and high density living• Increases in families in which an adult has had an ulcer or documented H. pylori.• If the serologic testing is positive, then treatment with triple therapy is indicated.– 2 antibiotics and an acid blocker
R.A.P. with Altered Bowel Pattern• IBD- Crohn’s or U.C.• Infectious disorders – Parasitic (Giardia, Blastocystis, Dientamoeba)– Bacterial (C.diff, Yersinia, Campylobacter)• Lactose or Fructose intolerance• Complication of constipation• OB/GYN disorders• Neoplasia• IBS
R.A.P. with Altered Bowel Pattern• The key to deciding on the extent ofthe initial workup is:– The volume/timing of diarrhea vs. degreeof constipation– Evidence of gross or occult blood in thestool– The presence of encopresis
Indications for Colonoscopy• Evidence of GI bleeding• Profuse diarrhea• Involuntary weight loss orgrowth deceleration• Fe deficiency anemia• Elevated ESR or CRP• Extra-intestinal symptoms suggestive ofIBD– Rash, joint pains, aphthous ulcerations
Functional Abdominal Pain• This is NOT the same as saying the pain is non-organic– However non-organic or psychogenic term is sometimes used• Growing body of evidence that points to a disordered brain-gut communication as the cause
Diagnosis of F.A.P.• Once organic causes have been ruled out via history and/or serum, radiologic and/or endoscopic tests, then this diagnosis should be considered• It is important to emphasize to the patient and family that it’s the most common cause of chronic pain in children and that the pain is real.
Diagnosis of F.A.P.If this diagnosis is suspected then even more time should be spent on the social history to help determine the trigger.– Any deaths of family members or friends?– Serious illness in family, friends or schoolmates?– Recent parental separation, change of school or potential of either?– Has the child started a new school?
Functional dyspepsia• Must include all the following at least 1time per week for 2 months– Persistent or recurrent pain or discomfort centered in the upper abd– Not relieved with stool or Associated with change in Stool freq. or form– No evidence of an Organic process
Functional dyspepsia- 2 Forms• Ulcer-like– Most bothersome symptom is pain in upper abdomen• Dysmotility-like dyspepsia– Most bothersome symptom is…• Early satiety• Upper abdominal fullness• Bloating• Nausea
Irritable Bowel Syndrome• Must include both of the criteria, once per week for 2 months– Abd discomfort or pain associated with 2 or more of the following 25% of the time• Improvement with defecation• Onset associated with a change in freq. of stool• Onset associated with a change in form of stool– No evidence of an Organic disease
Abd Migraine• Must include all the criteria 2 or more times in the past 12 months– Paroxysmal episodes of intense, acute periumbilical pain that lasts for 1 hour or more– Intervening periods of usual health lastingweeks to months– The pain interferes with normal activities
Abd Migraine• The pain is associated with 2 or more of the following– Anorexia– Nausea– Vomiting– Photophobia– Pallor• No evidence of organic disease
Aerophagia• Pain for 12 weeks in the past 12 months– Need not be consecutive– Negative work-up• Two or more of the following– Air swallowing– Abd distension from air– Repetitive belching and/or flatus
Treatment of F.A.P.• Reassurance– Direct at the whole family– Explain how the diagnosis was reached• Address any lingering concerns• Show normal growth curves• Acknowledge the pain is genuine
Treatment of F.A.P.• The parents and child must understand that the primary goal is resumption of a normal lifestyle NOT the eradication of the abdominal pain– Regular school attendance– School performance to child’s ability– Extracurricular activities– Normal sleep pattern
Treatment of F.A.P.• Abdominal pain diary– Empowers patients and parents• Date and time of symptom• Location of pain• Character and duration of pain• Preceding onset factors• Description of daily stool pattern• Identified relieving factors• When conservative treatment fails– Next step is pharmacotherapy and/or– Behavioral therapy
Treatment of F.A.P.• Dietary modification– No specific dietary changes have been shown effective. However some do benefit from a high fiber diet.• formula for dietary fiber intakeChilds Age + 5 = grams per day•Review the patients diary andeliminate•Foods that trigger the pain•Excess consumption of sweeteners•Mannitol or sorbitol or fructose
Treatment of F.A.P.• Anticholinergic agents– Dicyclomine– Hyoscyamine• They block muscarinic effects of acetylcholine on the GI tract– Relaxes smooth muscle– Can be used on an as needed basis 4 X/day– Can develop tachyphalaxis• Consider next class of drugs
Treatment of F.A.P.• Tricyclic Antidepressants– Anticholinergic effect on GI tract– Mood elevation– Central analgesia• Since these are used as a continuous vs.PRN basis, they are reserved for frequent or continuous pain• Risk of arrhythmias with prolonged QT• 0.2mg/kg/day and titrate up to 0.5mg/kg/day as single bedtime dose
Treatment of F.A.P.• SSRI’s– May help in patients with unremitting painand impaired daily function.– No published studies of the use in kids withFAP and little in adults– May play a role with comorbid psychiatricconditions• Anxiety, panic disorders, OCD or depression
5-HT3 receptor antagonists• Ondansetron• Granisetron– Serotonin activates vagal afferents via 5- HT3 receptors inhibiting emesis– DO NOT consistently alleviate pain or alterstool pattern– Reserved only when nausea is a predominantsymptom
5-HT4 Receptor Agonists• Tegaserod– Increases GI motility– May alter visceral sensitivity– Three large phase III randomized, double blinded,placebo trials supported improvement in• Abd pain• Stool frequency and• Consistency in adults– No pediatric studies yetNot available in India
Psychological Therapies• Cognitive-Behavioral Therapy– Coping skills• Relaxation training– Biofeedback• Hypnotherapy– Body relaxation and mental focus