Functional and organic diseases of digestive tract. Etiology, pathogenesis, clinical features, diagnostics, treatment and prevention. Lecturer: Sakharova I.Ye., MD, PhD

Chronic abdominal pain

Frog position in severe crampy abdominal pain

Is it a problem? Prevalence 0.5%-19% in community 13-17% middle/high school students weekly pain 2-4% of paediatric office visits Considerable morbidity, missed school days Difficult, time-consuming and expensive to manage because of diagnostic uncertainty, chronicity and increasing parental anxiety

What I’ll talk about Definitions of functional abdominal pain Cause of functional abdominal pain Differentiating organic vs functional pain Management of functional abdominal pain

Rome III criteria, 2006 Functional dyspepsia Irritable bowel syndrome Functional abdominal pain Functional abdominal pain syndrome Abdominal migraine - No evidence of an inflammatory, anatomical, metabolic or neoplastic process - Criteria fulfilled at least once a week for at least two months before diagnosis

Functional dyspepsia Persistent or recurrent pain or discomfort centred in the upper abdomen (above the umbilicus) Not relieved by defecation or associated with the onset of a change in stool frequency or stool form

Recurrent abdominal pain (Apley and Naish, 1958) Waxes and wanes 3 episodes in 3 months Severe enough to affect activities

Irritable bowel syndrome Abdominal discomfort (uncomfortable sensation not described as pain) or pain associated with two or more of the following at least 25% of the time: Improved with defecation Onset associated with a change in frequency of stool Onset associated with a change in form (appearance) of stool

Functional abdominal pain Episodic or continuous abdominal pain Insufficient criteria for other functional gastrointestinal disorders

Functional abdominal pain syndrome Must include functional abdominal pain at least 25% of the time and one or more of the following: Some loss of daily functioning Additional somatic symptoms such as headache, limb pain, or difficulty in sleeping

Abdominal migraine Paroxysmal episodes of intense, acute periumbilical pain that lasts for one or more hours Intervening periods of usual health lasting weeks to months The pain interferes with normal activities The pain is associated with two or more of the following: - Anorexia - Nausea - Vomiting - Headache - Photophobia - Pallor Criteria fulfilled two or more times in the preceding 12 months

What causes it? Biopsychosocial model Visceral sensation, disturbances in GI motility, hormonal changes, inflammation Psychological factors Family dynamics Brain-gut axis Sexual abuse – longer duration of symptoms Parental anxiety in first year of life associated with chronic abdo pain before age 6 GI problems in parents

Chronic abdo pain in OPD Organic vs functional pain Organic pain 5% in general population, 40% in paediatric gastroenterology OPD.

Organic vs functional pain No diagnostic tools to differentiate Presence of alarm symptoms or signs increases the probability of an organic disorder and justifies further tests

History and examination Analysis of the pain GI symptoms including bowel habit Genitourinary symptoms Effect on daily living Family history – GI problems, migraine

Alarm symptoms Involuntary weight loss Deceleration of linear growth Gastrointestinal blood loss Significant vomiting Chronic severe diarrhoea Unexplained fever Persistent right upper or right lower quadrant pain Family history of inflammatory bowel disease

Organic pain - differential GI tract Chronic constipation Lactose intolerance Parasite infection (Giardia) Excess fructose/sorbitol ingestion Crohns Peptic ulcer Reflux esophagitis Meckels diverticulum Recurrent intussusception Hernia – internal, inguinal, abdominal wall Chronic appendicitis

Organic pain - differential Gallbladder and pancreas Cholelithiasis Choledochal cyst Recurrent pancreatitis Genitourinary tract UTI Hydronephrosis Urolithiasis

Miscellaneous causes Abdominal epilepsy Gilberts syndrome Familial Mediterranean fever Sickle cell crisis Lead poisoning HSP Angioneurotic edema Acute intermittent porphyria

Diagnostic Tools Rome III Criteria Essential Investigations : according to symptoms e.g. - CBC - U A, Stool exam - LDG, Amylase,lipase - Ultrasound - Barium study - Gastric emptying time test,Intestinal transit time,Colonic transit time test - Hydrogen breath test: lactose,lactulose,glucose - Endoscopy - Skin Prick test - Urea Breath test

Recommendation of North American Society for Pediatric Gastroenterology, Hepatology and Nutrition Additional diagnostic evaluation is not required in children without alarm symptoms Testing may be carried out to reassure children and their parents

What are the predictive values of diagnostic tests? There is no evidence to suggest that the use of ultrasonographic examination of the abdomen and pelvis in the absence of alarm symptoms has a significant yield of organic disease (evidence quality C). There is little evidence to suggest that the use of endoscopy and biopsy in the absence of alarm symptoms has a significant yield of organic disease (evidence quality C). There is insufficient evidence to suggest that the use of esophageal pH monitoring in the absence of alarm symptoms has a significant yield of organic disease (evidence quality C).

Treatment Deal with psychological factors Educate the family (an important part of treatment) Focus on return to normal functioning rather than on the complete disappearance of pain Best prescribe drugs judiciously as part of a multifaceted, individualised approach, to relieve symptoms and disability

Treatment Medicines: Acid lowering agents Mucoprotective drugs Motility regulators Laxatives Analgesics Probiotics Gas adsorbants Dietary and life style change Psychotherapy

Pharmacologic treatment approach A. Antacids B. H2- receptor antagonist C. Proton pump inhibitors D. Sucralfate E. Prokinetics

Treatment of Acid-related disorders H2-receptor Antagonists: Ranitidine (2-4 mg/kg/d up to 150 mg bid), Famotidine (1-1.2 mg/kg/d up to 20 mg bid) PPI: Omeprazole (0.8 mg/kg/d;effective dose range of mg/kg/d), Lansoprazole (0.8 mg/kg/d) Cytoprotective Agents: Sucralfate(40-80 mg/kg/d up to 1 g qid) Rabemipride ( 1 x 3 )

Prognosis Majority of children mild symptoms and managed in primary care Studies of prognosis are mainly in referred patients Systematic review 29.1% of children had on-going abdo pain (follow-up ranged 1-29 yrs) May develop irritable bowel synd as adults Risk of later emotional symptoms and psychiatric disorders, particularly anxiety disorders

Success is not final, failure is not fatal. It is the courage to continue that counts. Winston Churchill