1. Recurrent Abdominal Pain In Childhood and Adolescence
Cheryl A. Little, MD
St. Vincent Pediatric Gastroenterology
8402 Harcourt Rd. Suite #402
Indianapolis, IN
(317)

2. IMPORTANT POINTS
Recurrent Abdominal Pain (RAP) represents a description of symptoms, not a diagnosis
The most common cause of RAP is a functional gastrointestinal disorder (FGID)
There are 4 major pediatric disorders associated with recurrent abdominal pain
Functional abdominal pain syndrome
Functional dyspepsia
Irritable Bowel Syndrome (IBS)
Abdominal Migraine
A FGID is a positive diagnosis
Therapy of a FGID is directed at environmental modification

3. Introduction RAP is not a diagnosis
Clinical manifestation of an organic disorder (23.6%)
(Indian Pediatrics; 46: , 2009)
Due to a FGID
Diagnosis of a FGID meets specific criteria (Rome III criteria)
Red flag symptoms concerning for an organic disorder
Pain that awakens the child
Significant vomiting, constipation, diarrhea, bloating, or gas
Blood in the stool
Unintentional weight loss or slowed growth
Changes in bowel or bladder function
Pain or bleeding with urination
Abdominal tenderness

4. Epidemiology FGID occurs in 10-12% of school-aged children
21% severe enough to affect activity
(J Pediatr 129: , 1996)
Female-to-male ratio equal up to 9 yrs of age
Female-to-male ratio 1.5:1 btw 9-12 yrs of age
Onset of pain <4 yrs
More in-depth organic evaluation

5. Pathophysiology of FGIDs
Different presentations
Heterogeneous group of disorders
Variable expressions of the same disorder
Prevailing viewpoint
Pain is visceral in origin
Involves disordered GI motility
Involves visceral hypersensitivity/hyperalgesia
Genetic vulnerability
Abnormalities in the enteric nervous system
Dysfunction of the autonomic nervous system
Altered awareness of discomfort (emotions, cognitive processes, CNS influences)

6. General Approach to RAP
History
Complete history is the MOST important component of the evaluation (Attempt to obtain directly from patient)
Focus on
Timing, frequency, location, quality of pain
Associated GI symptoms (nausea, vomiting, diarrhea, constipation, blood in stool or emesis)
Precipitating/relieving factors
Systemic symptoms ( fever, wt loss, joint pain, skin rash)
Family History of IBD or PUD
Travel History
Medication and nutritional interventions
Interference with school, play, peer relations, and family dynamics

7. General Approach to RAP
Physical Examination
Complete and not only directed toward the abdomen
Growth data
?Fall off in height or weight velocity
Delay in pubertal development
Abdominal examination
General appearance, auscultation, palpation of liver and spleen, for masses and tenderness
Rectal examination
Perianal and digital
Clubbing, rashes, arthritis
Pelvic examination (if indicated by history)

8. Rome Criteria III Functional Abdominal Pain Syndrome
At least 8 weeks of episodic or continuous abdominal pain in a school-aged child or adolescent occurring at least once/wk with one or more of the following:
some loss of daily functioning
additional somatic symptoms such as headache, limb pain, or difficulty sleeping
The patient has insufficient criteria for other functional GI disorders that can explain the pain
No evidence of an inflammatory, anatomic, metabolic or neoplastic process that is likely to explain the symptoms
Gastroenterology 2006;130:

9. Functional Abdominal Pain Syndrome
Periumbilical location
Variable in severity
Pain episodes tend to cluster alternating with pain-free periods of variable length
Associated GI symptoms are denied by the patient

10. Functional Abdominal Pain Syndrome
Pain episodes begin gradually
Last less than 1 hr in 50%
Last less than 3 hrs in 40%
Continuous pain in < 10%
Child is unable to describe the pain
Radiation of pain is rare
Temporal relationship to meals, activity, bowel habits is unusual

11. Functional Abdominal Pain Syndrome
Pain rarely awakens the child from sleep
Parents describe the patient as “miserable” and “listless” during pain episodes
During severe attacks the child may exhibit a variety of motor behaviors (“doubling over in pain”)
Common associated “autonomic” symptoms
Headache, pallor, nausea, dizziness, fatigue
At least one is observed in 50-70% of cases

12. Functional Abdominal Pain Syndrome
Differential Diagnosis
Infectious
UTI, Giardia
Carbohydrate intolerance- Lactose, fructose, sorbitol, sucrase-isomaltase
Inflammatory
Crohn disease, ulcerative colitis, eosinophilic gastroenteritis, celiac disease, pancreatitis
IBS
Constipation with or without fecal impaction
Psychogenic

13. Functional Abdominal Pain Syndrome
Diagnosis
There is no dependable biological marker for functional abdominal pain syndrome
Most reliable diagnostic features are the symptoms
Should NOT require a series of diagnostic tests to rule out organic causes of pain
Reasonable to obtain CBC, ESR or CRP, UA and culture, KUB, CMP, O+P, fecal leukocytes, lactose tolerance testing/lactose elimination
US and CT are low yield
Excessive testing may increase parental anxiety and put the child through unnecessary stress
Parental anxiety/uncertainty increases the stressful environment that provokes and reinforces the pain behavior

14. Functional Abdominal Pain Syndrome
Treatment
Begins at initial office visit
Important to introduce the concept of functional pain during the initial evaluation
Review the differential diagnosis to reassure parents and child that specific organic disorders have been considered and “red flags” are absent

15. Functional Abdominal Pain Syndrome
Treatment
Focus of treatment is not “cure” but management of symptoms and adaptation to illness to provide a satisfactory quality of life through support and education
Accomodative or secondary engagement coping (distraction, acceptance, positive thinking, cognitive restructuring) is related to less pain
Passive or disengagement coping (denial, cognitive avoidance, behavioral avoidance, wishful thinking) is associated with increased levels of pain

16. Functional Abdominal Pain Syndrome
Treatment
Directed toward environmental modification
Identify, clarify, and reverse stresses that may provoke or increase the perception of pain
Reverse environmental reinforcement of the pain behavior
Lifestyle MUST be normalized regardless of the continued presence of pain
Parents should direct less social attention toward the symptoms

17. Functional Abdominal Pain Syndrome
Supportive counseling
Target at illness behavior
Can be delivered by primary care physician
Listening, empathy, encouragement
Do not allow ongoing pain-induced disability
Patient-centered participatory arrangement
Instruct parents how to respond to symptoms
Encourage school officials to participate in treatment

18. Functional Abdominal Pain Syndrome
Treatment
Pharmacologic therapy directed at reasonable physical triggers of pain
Constipation
Altered motility
Low-dose tricyclic antidepressants
Act as “central analgesics”
Raise the perception threshold for abdominal pain
Down regulate pain receptors in the intestine
Generally reserved for patients with anxiety/depression or maladaptive illness behavior

19. Functional Abdominal Pain Syndrome
Treatment
Hospitalization
Reinforces pain behavior
Consultation
Reserved for patients with depression/anxiety, PTSD, abuse, severe disability, maladaptive illness behavior, chronic refractory pain
Child Psychiatrist
Child Psychologist
Behavioral modification therapy

20. Rome Criteria III Functional Dyspepsia
At least 8 weeks (which need not be consecutive) in the preceding 12 months of persistent or recurrent pain occurring at least once/week centered in the upper abdomen AND
No evidence of an inflammatory, anatomic, metabolic or neoplastic process that is likely to explain the symptoms AND
No evidence that dyspepsia is exclusively relieved by defecation or associated with a change in stool frequency or form
Gastroenterology 2006;130:

21. Clinical Presentation
Functional Dyspepsia
Pain localized to the epigastrium, RUQ, or LUQ
Episodic vomiting
Temporal relationship with meal ingestion
Presence of anorexia, nausea, oral regurgitation, early satiety, post-prandial bloating, indigestion, and belching

22. Functional Dyspepsia
No symptoms or signs that reliably distinguish functional dyspepsia from upper GI organic disorders
More extensive diagnostic evaluation than functional abdominal pain syndrome
Usually associated with the same signs of environmental reinforcement of pain behavior

23. Functional Dyspepsia Two groups Ulcer-like dyspepsia
Pain most common symptom
Dysmotility-like dyspepsia
Often report nausea, fullness, and early satiety

24. Functional Dyspepsia Differential Diagnosis Acid-related disease
Gastritis, duodenitis, esophagitis, peptic ulcer
Infection
Helicobacter pylori
Allergic/Inflammatory
Eosinophilic esophagitis, eosinophilic gastroenteritis, gastoduodenal Crohn disease, celiac disease
Gastroparesis
Chronic cholecystitis
Chronic fibrosing pancreatitis

25. Functional Dyspepsia Diagnosis Physical exam- findings usually normal
Lab evaluation- CBC,ESR or CRP,amylase, lipase, hepatic panel, H. pylori serology or stool antigen
UGI +/- SBFT
Abdominal US
Nuclear medicine scintigraphy (HIDA scan)
Upper Endoscopy- patients with dysphagia, persistent symptoms despite the use of acid-reducing medications, or to confirm H. pylori infection.
ERCP

26. Functional Dyspepsia Treatment
Positive diagnosis, education, establishment of realistic expectations of treatment
Environmental and dietary modification
Avoid cigarette smoking, advise smoke-free home
Avoid alcohol, non-steroidal analgesics
Avoid caffeinated beverages, high-fat foods, and large meals
Address psychological comorbidity

27. Functional Dyspepsia Treatment Drug therapy
70% improvement rate by 1 year following diagnosis (JPGHAN 30: , 2000)
Ulcer-like dyspepsia
4-6 week course with H2-receptor antagonist or PPI
Dysmotility-like dyspepsia
4-6 week course with a prokinetic agent (metoclopramide or erythromycin)
Anti-emetics or low-dose tricyclic antidepressants
Serotonic agents- Buspirone (Buspar), Paroxetine (Paxil)

28. Rome Criteria III Irritable Bowel Syndrome
At least 8 weeks in the previous 12 months of abdominal discomfort or pain occurring at least once/wk with at least 2 of the following:
relief w/defecation
onset associated w/change in frequency of stool
onset associated w/ change in form of stool
No evidence of an inflammatory, anatomic, metabolic or neoplastic process that is likely to explain the symptoms
Gastroenterology 2006;130:

29. Irritable Bowel Syndrome
More common in adolescence
Pain is typically localized to the lower abdomen
Association of pain with altered bowel pattern
Diarrhea (4 or more stools per day)
Constipation (2 or less stools per week)
Sense of incomplete evacuation
Straining
Urgency
Passage of mucus
Feeling of bloating or abdominal distention
Pain is often relieved by defecation

30. Irritable Bowel Syndrome
Differential Diagnosis
Infection
Giardia
Chronic Clostridium difficile colitis
UTI
Carbohydrate intolerance
Lactose, fructose, sorbitol, sucrase-isomaltase deficiency
Inflammatory
Crohn disease, ulcerative colitis, eosinophilic gastrenteritis, celiac disease
“Microscopic” colitis

31. Irritable Bowel Syndrome
Diagnosis
Careful, sympathetic history taking
Appropriate, thorough PE ( to include rectal exam)
Negative routine diagnostic studies
Empiric lactose elimination
Full assessment of psychological and social factors as well as physical symptoms

32. Irritable Bowel Syndrome
Diagnosis
Colonoscopy is indicated in pts in whom the history or PE suggest the possibility of IBD
Evidence of GI bleeding
Profuse diarrhea
Involuntary wt loss or growth deceleration
Fe deficiency anemia
Elevated ESR or CRP
Extra-intestinal symptoms (fever, recurrent mouth sores, rash, joint pain)

33. Irritable Bowel Syndrome
Management
Symptomatic and supportive care
Development of a positive relationship between doctor and patient/parents
Validate the symptoms that they are experiencing
Address the patient’s agenda by asking directly about their concerns and fears
Initial Management
Positive, confident diagnosis communicated with clarity and honesty
Educate about the pathophysiology of FGIDs and bring focus to the multifactorial nature of IBS

34. Irritable Bowel Syndrome
Dietary Management
Constipation predominant
Insoluable fiber diet ( root vegetables, skinned fruits, bran, whole-wheat products)
Diarrhea predominant
Eat slowly, avoid chewing gum, avoid excessive intake of alcohol, carbonated and caffeinated beverages, high-fat foods, legumes, and foods or beverages with fructose or sorbitol
Soluable fiber diet (dried beans and fruits, peas, oats, barley, carrots, flesh of fruits such as apples and organges)
Response rates of 70% (Lancet 2: , 1982)

35. Irritable Bowel Syndrome
Drug Therapy
Antispasmodics
Anticholinergics
Used in diarrhea predominant or variable stool IBS
Dicyclomine-Bentyl
Hyoscyamine-Levsin,Levbid
Enteric-coated Peppermint Oil
Amitiza- chloride channel activator
Indicated for constipation predominant IBS in adults
Antibiotics/Probiotics- to treat bacterial overgrowth
Tricyclic Antidepressants
Serotonic drugs- Buspar, Celexa

36. Summary
FGIDs can occur as a well defined clinical entity (e.g. IBS) or a less defined clinical syndrome (e.g. functional abdominal pain syndrome)
Essential for physicians to take a biopsychosocial approach to diagnosis and treatment
Appreciate the close interaction of the gut and brain
Allows the child, parent and physician to address the pain on many levels
Further understanding of brain-gut axis and the role of serotonin in neural sensorimotor functions is needed

37. Irritable Bowel Syndrome
Probiotics
Replace deficiencies of “normal” colonic bacteria and reduce fermentation
Randomized double-blind controlled trial
Lactobacillus plantarum
Reduction in the degree of flatulence
Improved overall GI function at 12 months
(Am J Gastroenterol 95: , 2000)

38. Irritable Bowel Syndrome
Tricyclic Antidepressants
Effect significant on primary outcome measures and on global response and pain
89% improvement in adult pts 61% remission of symptoms (Gut 2005;54: )
Effectiveness in clinical practice limited by side effects (sleepiness)
Reserved for patients with severe symptoms or symptoms resistant to common first-line approaches

39. Irritable Bowel Syndrome
Serotonic Agents
5-HT1 agonists
Buspirone (Buspar)
Reduce gastric acid and colonic responses to volume distention
Anxiolytic activity
SSRIs
Citalopram (Celexa)
Reduce colonic sensation to volume distention in healthy subjects

40. Irritable Bowel Syndrome
Psychological Treatment
Stress management
Psychotherapy
Introduce early in the discussion of pathophysiology and management of IBS
Do not leave as “last-ditch” treatment after medical therapy has proved less than optimal
Therapy often combination of parent training, altering reinforcement of various behaviors and stress management
Statistically significant improvement of pain with adjunctive cognitive-behavioral therapy
(J Consult Clin Psychol 57: , 1989, and 62: , 1994)