Functional Gastrointestinal Disorders Robert Rothbaum, MD

Functional Gastrointestinal Disorders Functional dyspepsia Irritable bowel syndrome Functional abdominal pain syndrome

Dyspepsia = Epigastric discomfort 14 year old boy with two month history –Bothersome post-prandial fullness –Early satiation –Epigastric pain –Epigastric burning Normal physical examination Normal screening labs –CBC –Hepatobiliary enzyme tests –IgA and tTG –Lipase or amylase –Stool for occult blood

What should we do next? Should we recommend an ugi endoscopy? –Vomiting or weight loss –Positive screening test –Low yield test –Often, does not relieve anxiety Should we do radiologic testing? –Obstructive symptoms or signs Should we do testing for H. pylori? –Family history –Acute symptoms

Mechanisms of functional dyspepsia Post-infectious changes: More common after bacterial gastroenteritis Diminished gastric accomodation Increased gastric sensitivity No increase in acid production No reproducible delay in gastric emptying

How effective is therapy for dyspepsia? Proton pump inhibitor –< 50% response –No increase in response to high doses Anti-helicobacter –10-15% response –No improvement with repeated courses Prokinetic agents –Side effects frequent Antispasmodics –No benefit Antidepressants –No benefit

Irritable Bowel Syndrome Abdominal discomfort or pain associated with 2 or more of the following at least 25% of the time –Improvement with defecation –Onset associated with a change in stool frequency –Onset associated with a change in stool consistency No evidence of another disorder Present for two months or more

Evaluation Physical exam normal CBC IgA and tTG Giardia antigen Thyroid studies Detailed psychosocial history 95-99% IBS accuracy Colonoscopy for IBD

Associations with IBS Post-infectious alterations in bowel function. Visceral hypersensitivity –Lower threshold to detect distention –Distention felt more intensely –Magnified gastrocolic reflex –Hyperalgesia after repetitive stimulation –Decreased somatic sensitivity

What is effective therapy for IBS? Dietary changes –Lactose restriction –Gluten restriction Medications –Loperamide –Low dose TCA Psychosocial support –Most effective –No side effects Fiber supplements Lactose restriction –Vitamin D restriction –Low calcium intake Oral antibiotics Anticholinergics Probiotics

What is the role of gluten restriction? Gluten sensitive enteropathy = celiac disease. Eat a gluten free diet. Gluten sensitivity or intolerance. –GI symptoms associated with gluten intake –Before 2011, no controlled trial of gluten free diet in IBS or abdominal pain.

Re-introduction of gluten produced symptoms earlier. Patients on GFD w/IBS= Highly selected. Two groups followed for six wks with muffins/bread added. –20 with gluten flour –20 with placebo 9 patients dropped out –6 gluten group –3 placebo group Am J Gastroenterol.Am J Gastroenterol Mar;106(3):508-14;

Recurrent pain is a common complaint in children and adolescents. Roth-Isigkeit A et al. Pediatrics 2005;115:e152-e school children and adolescents interviewed. Headaches Abdominal pain 50% consulted MD 35% > 6 months 50% associated sx - sleep problems - eating problems - school absence

Functional abdominal pain syndrome 1.Continuous or nearly continuous abdominal pain 2.Little to no relationship of pain with eating, defecation, or menses 3.Some loss of daily functioning 4.The pain is not feigned (e.g., malingering) 5.Does not fit another functional gastrointestinal disorder 6.Duration = prior last 2 months with symptom onset at least 6 months before

Common symptom-related behaviors Expressing pain of varying intensity through verbal and nonverbal methods. Distraction possible. Exacerbations during discussion. Urgent reporting of intense symptoms disproportionate to available clinical and laboratory data Minimizing or denying a role for psychosocial contributors, anxiety or depression, or attributing them to the pain rather than to understandable life circumstances Requesting diagnostic studies or exploratory surgery to validate the condition as “organic” Focusing attention on relief of symptoms rather than adaptation to a chronic disorder Seeking health care frequently Taking limited personal responsibility for self-management while placing high expectations on the physician to achieve symptom relief Making requests for narcotic analgesics when other treatment options have been implemented

Further testing ? CBC –Microcytic anemia Urinalysis –Hematuria IgA level tTG antibody Stool for occult blood Abdominal ultrasound Avoid –ESR and CRP –IBD serologies –H. pylori serologies –HIDA scan –Other tests

Psychosocial contributors 1. What is the patient’s life history of illness? 2. Why is the patient presenting now for medical care? 3. Is there a history of traumatic life events? 4. What is the patient’s understanding of the illness? 5. What is the impact of the pain on activities and quality of life? 6. Is there an associated psychiatric diagnosis? 7. What is the role of family or culture? 8. What are the patient’s psychosocial impairments and resources?

Determinants of Physician Contact: Co-Morbidities with Abdominal Pain Case-control study in pediatric practice: –FAP: 79% with anxiety 43% with depression –Functional impairment more common –Anxiety may precede RAP Pediatrics 2004; 113: Family Stress: 43% Patients with UGI symptoms appear with more symptoms in other systems.

Long term follow-up of children with functional abdominal pain Shelby etal. Pediatrics. September, 2013

Hospitalization for chronic pain 16/1000 admits F:M = 2:1 Mean age = 13.5 yrs. LOS = 7 days Procedures = 3 per patient Repeat hospital. = 12% Medication side effect= 10% Anxiety/depression= 50% Coffelt etal. Pediatrics. July, 2013.

Parental worries about chronic abdominal pain. Fear of disease = pain worries –Identify specific disorders of concern –Prior experience and family history Pain is real = pain threshold –Child suffering and is not a complainer. –Ambivalent about distraction –Review visceral hypersensitivity and effects of prior illness Van Tilburg etal JPGN. 2009

Parental worries and concerns Thoughts about providers –Desire for relief/care = one step to cure –Frustration with misunderstanding= “nothing serious is wrong” –Treating symptoms obscures true cause –Define the disorder = make the diagnosis of functional disorder using defined criteria –“I know what this is…I am familiar with this diagnosis…it is disruptive but not progressive”

Parental worries and concerns Thoughts about coping –Parents not able to cope with complaints –“I know nothing bad is wrong but I do not know what to do to help.” –Provide specifics: distraction, relaxation, simple meds Difficulty ignoring pain –“I might miss something.” –Provide specific symptoms of concern

Parental worries and concerns Diet, eating habits, stress, and heredity may contribute –Begin to identify common ground with parents –Identify family patterns of similar complaints Eventual diagnosis Outcome Do not make organic diagnoses. Discuss the potential impact of further diagnostic tests: How will results help you?

Determinants of consultation “My doctor did not tell me what is wrong with my child.” “I would like the doctor to suggest a treatment.” “I worry about my child missing things due to the pain.” “It is difficult to dismiss my child’s stomach aches.”

Chronic pain factors Pain worries: severity & consequences Disease Fear High pain threshold No malingering Exacerbating factors Heredity Diet Stress Coping concerns Unclear what to do Ignoring difficult MD thoughts Desire for relief Frustration Symptom treatment only

Management plans Dyspepsia –PPI may or may not help –Probably not H. pylori Irritable bowel syndrome –Low fat diet may help. Other diets may be useful. –Exercise and healthy lifestyle Alcohol Caffeine Nicotine –Medications Imodium or Lomotil Low dose TCA Peppermint oil Functional abdominal pain syndrome –Low dose TCA For all disorders: Refocus on function, maintain relationship, discuss worries, and encourage insight via counseling.

Resources for Management of Abdominal Pain For Pediatricians –Pain in Children: A Practical Guide for Primary Care by Gary Walco, Ph.D. and Kenneth Goldschneider, M.D. –Subcommittee on Chronic Abdominal Pain 2005 Technical Report Available online –Chronic Abdominal Pain in Children: A Clinical Report of the American Academy of Pediatrics and the North American Society for Pediatric Gastroenterology, Hepatology and Nutrition (2005) Available Online For Families – Online resource that teaches kids guided imagery, deep breathing, etc. to cope with pain –Conquering Your Child’s Chronic Pain: A Pediatrician’s Guide for Reclaiming a Normal Childhood by Lonnie Zeltzer, M.D. and Christina Schlank –IBS brochure: