Understanding Chronic Abdominal Pain in Children: Causes, Diagnosis, and Treatment

 
Chronic Abdominal pain
 
Dr. K. Tamilselvan
Consultant Paediatrician with gastroenterology interest
East and North Hertfordshire NHS Trust
 
   
Aims & Objectives
 
Introduction
Causes/ Associate factors
Functional GI disorders – Rome criteria
Presenting symptoms and signs
Differential diagnosis
Investigations
Treatment
Primary care pathway
Take home messages
 
    
Introduction
 
Chronic abdominal pain/ Recurrent abdominal pain/ Functional
abdominal pain
 
 Very common - 10-15% children in UK
5-10% have underlying organic disease
It is uncommon < 4 years
F>M
 
  
          Causative factors
 
Visceral hyperalgesia/ altered brain-gut interaction/ cortical
nociceptive abnormal wiring
 
   Research – Functional MRI in healthy subjects vs adolescents with IBS
                    - Structural and functional differences in brain
                    - reinforces the theory of psychological aspects of treatment
 
Gut microbiota
 
   
Associated & Risk factors
 
 
Associated factors – stress
                                    -  significant event
                                    -  less coping strategies
 
 
Risk factors – parental anxiety
                           Family h/o GI illness
                           genetic predisposition
 
          Functional VS organic GI disorders
 
 
Range of disorders confined to GI tract but can’t be explained by
structural or biochemical abnormalities
 
Symptom causes - significant impact on families
                                  - Patient quality of life
                                  - healthcare utilization and costs
 
  
   Functional GI disorders
 
 
Diagnosis is based on symptoms and examination
 
Robust symptom based criteria – accurate, clear and unambiguous
 
                           Rome criteria
 
 
Definition criteria – working committee of Rome foundation through
literature review and consensus process
 
Rome criteria – 1 was published in 1990 for adults
                            - 3 including children in 2006 and 4 criteria in 2016
 
      Why the clear diagnosis is important?
 
Objective diagnosis
Monitor progress of the disease
 
Clear objective criteria mean
                   - Clear to explain the parents
                   - better understanding of the condition
                   - for accepting the diagnosis
                   - for addressing psychological aspects and personnel impact
 
          of the disease
 
  Functional GI disorders – Rome 4 criteria
 
 
Functional nausea and vomiting disorders
 
Functional abdominal pain disorders
 
Functional defecation disorders
 
 
Functional GI disorders – Rome 4 criteria
 
Functional nausea and vomiting (> 2/12 except cyclical vomiting)
    a, Cyclical vomiting syndrome
    b, Functional nausea and functional vomiting
    c, Rumination syndrome
    d, Aerophagia
 
  
Rome 4 criteria continued
 
Functional defecation disorders (>1 month)
 
     a, Functional constipation
     b, Non- retentive faecal incontinence
 
 
 
Functional abdominal pain disorders
 
Functional dyspepsia
 
Irritable bowel syndrome
 
Abdominal migraine
 
Functional abdominal pain – not otherwise specified
 
  
Functional dyspepsia (4 days/month)
 
Postprandial distress syndrome
                 Post prandial fullness/ early satiety
                 Post prandial nausea
                 upper abdomen bloating
                 Excessive belching
 
Epigastric pain syndrome
                  Burning quality, not relieved by defaecation, no retrosternal
 
      compartment, pain increased or reduced by meal
 
Criteria fulfilled at least 2 months before the diagnosis
 
      Irritable bowel Syndrome (4 days/month)
 
Related to defecation
 
Change in frequency of the stool
 
Change in form (appearance) of the stool
 
Children with constipation pain does not resolve after defecation
 
Criteria fulfilled at least 2 months before the diagnosis
 
         Abdominal migraine (at least twice)
 
Paroxysmal episodes of intense, acute, peri-umbilical or diffuse pain
lasting for 1 hour or more
Episodes separated by weeks to months
Pain affects the normal activities
Pain associated with 2 or more of the following
                 anorexia/nausea/vomiting/headache/photophobia/pallor
 
Criteria fulfilled for at least 6 months before diagnosis
 
   Functional abdominal pain – NOS ( 4
       
times/month)
 
Random functional or continuous pain
 
Insufficient criteria for IBS, functional dyspepsia or abdominal
migraine
 
Criteria fulfilled for at least 2 months before diagnosis
 
  
Presenting symptoms
 
GI symptoms – Abdominal pain, vomiting, diarrhea, abdominal
bloating, distension, dysphagia, GI blood loss
Diet h/o
Appetite/energy level/ weight loss
Joint pains/ Other symptoms
 
   
Examination findings
 
Mouth ulcers
Pallor, Jaundice
Abdominal examination – Tenderness, mass, hepatosplenomegaly
Perianal examination
 
                           Investigations
 
As clinically indicated
 
Blood tests
 
Stool tests
 
US
 
Urine
 
   
Differential diagnosis
 
Coeliac disease
IBD
 
Constipation
GORD
Lactose intolerance
 
 
                           Treatment
 
Treat as clinically indicated
              Constipation
              GORD*
              Lactose intolerance
              Functional disorders
 
 
  
Treatment-Functional disorders
 
Effective Reassurance (Visceral hypersensitivity)
Parents respond by attention or distraction/no instruction
Education to parents – Lifestyle modifications (Distraction, exercise,
diet, sleep)
Going to school important – more distractive
Use common terms
Explain overall favorable prognosis
Child should be active participant
 
   
            Diet
 
 
Fiber supplement/Lactose free  - No evidence
 
Fodmap – Some evidence in IBS
                     (hydrogen product – methane production)
 
Probiotics
 
 
 
 
   
Medications
 
        Buscopan (hyoscine)- antimuscarinic – reduce intestinal motility
           Mebevarine – better for short term –direct action on smooth
 
muscle (No significance if used >8 weeks)
           Peppermint oil capsule – direct action on smooth muscle –IBS
 
 
Antidepressants – TCA
           Improvement in global well being likely from central effect
           Lack of additional pain improvement argues its use
 
   
Psychology treatment
 
Hypnotherapy
 
CBT
 
Yoga
 
Psychology counselling
 
   
Take home messages
 
Think about coeliac disease and IBD
 
Do coeliac screen
 
Think about functional abdominal disorders
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Chronic abdominal pain in children is a common issue, with underlying organic diseases being relatively uncommon. Factors such as stress, parental anxiety, and genetic predisposition can contribute to these symptoms. It is crucial to differentiate between functional and organic GI disorders through accurate diagnosis based on robust symptom criteria like the Rome criteria, leading to appropriate treatment and improved quality of life for affected children.


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  1. Chronic Abdominal pain Dr. K. Tamilselvan Consultant Paediatrician with gastroenterology interest East and North Hertfordshire NHS Trust

  2. Aims & Objectives Introduction Causes/ Associate factors Functional GI disorders Rome criteria Presenting symptoms and signs Differential diagnosis Investigations Treatment Primary care pathway Take home messages

  3. Introduction Chronic abdominal pain/ Recurrent abdominal pain/ Functional abdominal pain Very common - 10-15% children in UK 5-10% have underlying organic disease It is uncommon < 4 years F>M

  4. Causative factors Visceral hyperalgesia/ altered brain-gut interaction/ cortical nociceptive abnormal wiring Research Functional MRI in healthy subjects vs adolescents with IBS - Structural and functional differences in brain - reinforces the theory of psychological aspects of treatment Gut microbiota

  5. Associated & Risk factors Associated factors stress - significant event - less coping strategies Risk factors parental anxiety Family h/o GI illness genetic predisposition

  6. Functional VS organic GI disorders Range of disorders confined to GI tract but can t be explained by structural or biochemical abnormalities Symptom causes - significant impact on families - Patient quality of life - healthcare utilization and costs

  7. Functional GI disorders Diagnosis is based on symptoms and examination Robust symptom based criteria accurate, clear and unambiguous

  8. Rome criteria Definition criteria working committee of Rome foundation through literature review and consensus process Rome criteria 1 was published in 1990 for adults - 3 including children in 2006 and 4 criteria in 2016

  9. Why the clear diagnosis is important? Objective diagnosis Monitor progress of the disease Clear objective criteria mean - Clear to explain the parents - better understanding of the condition - for accepting the diagnosis - for addressing psychological aspects and personnel impact of the disease

  10. Functional GI disorders Rome 4 criteria Functional nausea and vomiting disorders Functional abdominal pain disorders Functional defecation disorders

  11. Functional GI disorders Rome 4 criteria Functional nausea and vomiting (> 2/12 except cyclical vomiting) a, Cyclical vomiting syndrome b, Functional nausea and functional vomiting c, Rumination syndrome d, Aerophagia

  12. Rome 4 criteria continued Functional defecation disorders (>1 month) a, Functional constipation b, Non- retentive faecal incontinence

  13. Functional abdominal pain disorders Functional dyspepsia Irritable bowel syndrome Abdominal migraine Functional abdominal pain not otherwise specified

  14. Functional dyspepsia (4 days/month) Postprandial distress syndrome Post prandial fullness/ early satiety Post prandial nausea upper abdomen bloating Excessive belching Epigastric pain syndrome Burning quality, not relieved by defaecation, no retrosternal compartment, pain increased or reduced by meal Criteria fulfilled at least 2 months before the diagnosis

  15. Irritable bowel Syndrome (4 days/month) Related to defecation Change in frequency of the stool Change in form (appearance) of the stool Children with constipation pain does not resolve after defecation Criteria fulfilled at least 2 months before the diagnosis

  16. Abdominal migraine (at least twice) Paroxysmal episodes of intense, acute, peri-umbilical or diffuse pain lasting for 1 hour or more Episodes separated by weeks to months Pain affects the normal activities Pain associated with 2 or more of the following anorexia/nausea/vomiting/headache/photophobia/pallor Criteria fulfilled for at least 6 months before diagnosis

  17. Functional abdominal pain NOS ( 4 times/month) Random functional or continuous pain Insufficient criteria for IBS, functional dyspepsia or abdominal migraine Criteria fulfilled for at least 2 months before diagnosis

  18. Presenting symptoms GI symptoms Abdominal pain, vomiting, diarrhea, abdominal bloating, distension, dysphagia, GI blood loss Diet h/o Appetite/energy level/ weight loss Joint pains/ Other symptoms

  19. Examination findings Mouth ulcers Pallor, Jaundice Abdominal examination Tenderness, mass, hepatosplenomegaly Perianal examination

  20. Investigations As clinically indicated Blood tests Stool tests US Urine

  21. Differential diagnosis Coeliac disease IBD Constipation GORD Lactose intolerance

  22. Treatment Treat as clinically indicated Constipation GORD* Lactose intolerance Functional disorders

  23. Treatment-Functional disorders Effective Reassurance (Visceral hypersensitivity) Parents respond by attention or distraction/no instruction Education to parents Lifestyle modifications (Distraction, exercise, diet, sleep) Going to school important more distractive Use common terms Explain overall favorable prognosis Child should be active participant

  24. Diet Fiber supplement/Lactose free - No evidence Fodmap Some evidence in IBS (hydrogen product methane production) Probiotics

  25. Medications Buscopan (hyoscine)- antimuscarinic reduce intestinal motility Mebevarine better for short term direct action on smooth muscle (No significance if used >8 weeks) Peppermint oil capsule direct action on smooth muscle IBS Antidepressants TCA Improvement in global well being likely from central effect Lack of additional pain improvement argues its use

  26. Psychology treatment Hypnotherapy CBT Yoga Psychology counselling

  27. East and North Hertfordshire NHS Trust Chronic abdominal pain Primary care pathway and referral criteria for children < 16 years symptoms suggested the diagnosis Abdominal pain >2 months in 4-16 years old Presence of any of the alarm symptoms and signs Localised abdominal pain Significant vomiting/ bilious vomiting Dysphagia Significant diarrhoea Night time symptoms GI blood loss Weight loss/ Deceleration of linear growth Delayed puberty Fever Perianal disease Family history of IBD/Coeliac disease Localised abdominal tenderness Mass Hepatosplenomegaly Perianal disease No alarm symptoms and signs Normal examination Normal growth Reassure as functional abdominal pain Education to parents Should be managed in primary care Treat constipation and gastritis if Yes Investigate as clinically indicated Bloods FBC, U&E, LFT, bone profile, CRP, ESR, Coeliac screen Stools Stool mc/s, calprotectin US If localised pain/mass Urine mc/s if UTI suspected Tests may be performed to reassure the parents if the pain is severe Do FBC, U&E, LFT, Coeliac screen Referral to secondary care indicated If presence of any alarm symptoms or signs Abnormal biochemistry or stool report For suspected IBD For suspected Coeliac gluten diet should be continued as Coeliac disease should be diagnosed only in secondary care. Specialist care should be provided by Consultant with gastro interest Consider referral to secondary care if the pain has significant impact on their daily activities, the school attendance or abnormal lab results

  28. Take home messages Think about coeliac disease and IBD Do coeliac screen Think about functional abdominal disorders

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