1. Chronic Abdominal Pain AMANPREET DHALIWAL JULY 23, 2015

2. Learning Objectives 1.To learn what aspects are important in medical history (present illness, past family and personal history) 2.To establish a differential diagnosis for chronic abdominal pain 3.To recognize red flags in children with chronic abdominal pain 4.To review the management and basic investigations pertinent to children with chronic abdominal pain

3. Bidirectional Gut-Brain Axis

4. Definition Chronic abdominal pain is defined as A.Continuous or intermittent abdominal discomfort lasting for atleast 6 months B.3 episodes of severe pain in a child >3 years old for atleast 3 months C.Pain of more than 2 weeks duration D.Severe pain in a child >3 years old for more than 3 months

5. Definition Chronic abdominal pain is defined as A.Continuous or intermittent abdominal discomfort lasting for atleast 6 months B.3 episodes of severe pain in a child >3 years old for atleast 3 months C.Pain of more than 2 weeks duration D.Severe pain in a child >3 years old for more than 3 months

6. Remember the Rule of 3s 3 episodes of severe pain Child >3 yr old Over 3 month period

7. Key History Questions Present Illness Past Family History Personal History

8. Key History Questions Present Illness ◦Description of pain- location, quality, frequency, duration and timing of episodes ◦Associated symptoms Past Family History ◦Recurrent abdominal pain ◦Peptic ulcer ◦IBS/IBD ◦Food allergies ◦Lactose intolerance ◦Gall bladder disease ◦Kidney stones ◦Migraine headaches ◦Mediterranean descent Personal History ◦Travel history ◦Congenital or acquired immunodeficiencies ◦Intra-abdominal surgeries ◦Dietary history ◦Medications ◦Sexual activity ◦Menses

9. Patterns of recurring pain which may allow further diagnostic differentiation 1.Dyspepsia 2.Altered bowel movements 3.Paroxysmal abdominal pain lasting hours with asymptomatic periods in between

10. Case A 9-year-old girl is brought to your office with a 6-month history of peri-umbilical pain. Characteristics of pain are described as follows: it occurs mainly after eating, lasts from 10 minutes to one hour, frequency varies since there might be times when she complains of pain twice a day but there are other times when she is symptom free for a month. She described the pain as if someone was “punching” her belly. Her symptoms worsen at school but acknowledge she eats a lot of junk food. There is no history of nocturnal pain but halitosis has been noticed. Her weight, appetite and energy level have been stable. Further history revealed BMs every 3 days and stools are hard and some intermittent soiling. Mild headaches have been associated. Her family history revealed migraines and irritable bowel syndrome on the mother. There were no abnormalities on exam; anthropometrics plotted her on the 25 th percentile.

11. Back to case A 9-year-old girl is brought to your office with a 6-month history of peri- umbilical pain. Characteristics of pain are described as follows: it occurs mainly after eating, lasts from 10 minutes to one hour, frequency varies since there might be times when she complains of pain twice a day but there are other times when she is symptom free for a month. She described the pain as if someone was “punching” her belly. Her symptoms worsen at school but acknowledge she eats a lot of junk food. There is no history of nocturnal pain but halitosis has been noticed. Her weight, appetite and energy level have been stable. Further history revealed BMs every 3 days and stools are hard and some intermittent soiling. Mild headaches have been associated. Her family history revealed migraines and irritable bowel syndrome on the mother.

12. Physical Exam OSCE Station Vitals are vital Growth parameters: weight, height, growth velocity Inspection ◦General Appearance and level of comfort or discomfort Abdominal Exam ◦Auscultate ◦Percuss Palpation (to assess enlarged organs or masses) ◦Carnett sign (differentiate visceral from abdominal wall pain DRE ◦Impacted stool, perinanal fistuals or deep fissures ±Pelvic Exam if history suggests

14. Red Flags Adapted from Uptodate

15. Red Flags

16. Differential Diagnosis Ask yourself is this ORGANIC or FUNCTIONAL? ◦Think about information gathered from history and physical

17. Differential Diagnosis Organic ◦Many but to name a few ◦Gastritis ◦Duodenal ulcer ◦Pancreatitis ◦Hepatitis ◦Celiac ◦IBD ◦SLE

18. Differential Diagnosis Functional ◦Rome-III Diagnostic Categories ◦H1. Vomiting and Aerophagia ◦H1a. Adolescent Rumination Syndrome ◦H1b. Cyclic Vomiting Syndrome ◦H1c. Aerophagia ◦H2. Abdominal Pain-related Functional GI Disorders ◦H2a. Functional Dyspepsia ◦H2b. Irritable Bowel Syndrome ◦H2c. Abdominal Migraine ◦H2d. Childhood Functional Abdominal Pain ◦H2d1. Childhood Functional Abdominal Pain Syndrome ◦H3. Constipation and Incontinence ◦H3a. Functional Constipation ◦H3b. Non-retentive Fecal Incontinence

19. Differential Diagnosis Functional ◦Rome-III Diagnostic Categories ◦H1. Vomiting and Aerophagia ◦H1a. Adolescent Rumination Syndrome ◦H1b. Cyclic Vomiting Syndrome ◦H1c. Aerophagia ◦H2. Abdominal Pain-related Functional GI Disorders ◦H2a. Functional Dyspepsia ◦H2b. Irritable Bowel Syndrome ◦H2c. Abdominal Migraine ◦H2d. Childhood Functional Abdominal Pain ◦H2d1. Childhood Functional Abdominal Pain Syndrome ◦H3. Constipation and Incontinence ◦H3a. Functional Constipation ◦H3b. Non-retentive Fecal Incontinence

20. Irritable Bowel Syndrome Rome III Criteria Must include all of the following: ◦Within the preceding two months, at least weekly occurrence of: ◦Abdominal discomfort or pain associated with ≥2 of the following: ◦Relieved with defecation, and/or ◦Onset associated with a change in frequency of stool, and/or ◦Onset associated with a change in form (appearance) of stool ◦No evidence of inflammatory, anatomic, metabolic, or neoplastic process to explain the symptoms

21. Abdominal Migraine ◦Must include ALL of the following criteria, fulfilled two or more times in the preceding 12 months: ◦Paroxysmal episodes of intense, acute periumbilical pain that lasts for 1 hour or more. ◦Intervening periods of usual health lasting weeks to months. ◦The pain interferes with normal activities. ◦The pain is associated with ≥2 of the following: ◦a. Anorexia. ◦b. Nausea. ◦c. Vomiting. ◦d. Headache. ◦e. Photophobia. ◦f. Pallor. ◦No evidence of an inflammatory, anatomic, metabolic, or neoplastic process considered that explains the subject’s symptoms.

22. Functional Constipation ◦Must include ≥ 2 of the following: ◦Straining during at least 25% of defecations ◦Lumpy or hard stools in at least 25% of defecations ◦Sensation of incomplete evacuation for at least 25% of defecations ◦Sensation of anorectal obstruction/blockage for at least 25% of defecations ◦Manual maneuvers to facilitate at least 25% of defecations (e.g., digital evacuation, support of the pelvic floor) ◦Fewer than three defecations per week ◦Loose stools are rarely present without the use of laxatives ◦Insufficient criteria for irritable bowel syndrome ◦* Criteria fulfilled for the last 3 months with symptom onset at least 6 months prior to diagnosis

23. Bristol Stool Chart *Encopresis

24. Case A 9-year-old girl is brought to your office with a 6-month history of peri-umbilical pain. Characteristics of pain are described as follows: it occurs mainly after eating, lasts from 10 minutes to one hour, frequency varies since there might be times when she complains of pain twice a day but there are other times when she is symptom free for a month. She described the pain as if someone was “punching” her belly. Her symptoms worsen at school but acknowledge she eats a lot of junk food. There is no history of nocturnal pain but halitosis has been noticed. Her weight, appetite and energy level have been stable. Further history revealed BMs every 3 days and stools are hard and some intermittent soiling. Mild headaches have been associated. Her family history revealed migraines and irritable bowel syndrome on the mother. There were no abnormalities on exam; anthropometrics plotted her on the 25 th percentile.

25. Investigations Pick 5 of the following investigations you would order as initial workup 1.CBC 2.Lytes 3.ESR 4.Amylase, lipase 5.Urinalysis 6.Abdominal US 7.Stools for O&P, C&S, occult blood 8.AXR 9.CXR 10.CT abdo 11.Barium upper GI series 12.Endoscopy 13.Colonoscopy

26. Investigations Pick 5 of the following investigations you would order as initial workup 1.CBC 2.Lytes 3.ESR 4.Amylase, lipase 5.Urinalysis 6.Abdominal US 7.Stools for O&P, C&S, occult blood 8.AXR 9.CXR 10.CT abdo 11.Barium upper GI series 12.Endoscopy 13.Colonoscopy

27. Follow up Evaluation Can use the following one or more investigations if warning signs, abnormal lab results, or specific or persistent symptoms CT abdo with oral, rectal, IV contrast Celiac disease serology Barium upper GI series Endoscopy Colonscopy

28. Management Approach Combination of ◦Therapeutic relationship

29. Management Approach Combination of ◦Therapeutic relationship ◦Patient Education

30. Management Approach Combination of ◦Therapeutic relationship ◦Patient Education ◦Return to school

31. Management Approach Combination of ◦Therapeutic relationship ◦Patient Education ◦Return to school ◦Behavior modification

32. Management Approach Combination of ◦Therapeutic relationship ◦Patient Education ◦Return to school ◦Behavior modification ◦Improved coping

33. Management Approach Combination of ◦Therapeutic relationship ◦Patient Education ◦Return to school ◦Behavior modification ◦Improved coping ◦Managing Triggers ◦Lactose, fructose free diet

34. Management Approach Combination of ◦Therapeutic relationship ◦Patient Education ◦Return to school ◦Behavior modification ◦Improved coping ◦Managing Triggers ◦Managing Symptoms

35. Managing Symptoms Abdominal pain ◦Probiotics ◦Fiber ◦Peppermint oil (↓ smooth muscle spasms) Dyspepsia ◦Small frequent meals ◦Avoidance of food that aggravate symptoms ◦Trial of H2 blocker or PPI for 4-6 weeks Constipation

36. Disimpaction GoLYTELY PEG Enema Sodium phosphate Saline Mineral oil Digital disimpaction Maintenance Polyethylene glycol Magnesium hydroxide (milk of magnesia) Lactulose Mineral oil Behaviour Modification Toilet sitting Reward system Monitoring Diary, log the bowel movements Dietary changes Fiber Trial of 2 weeks of eliminating all cow’s milk protein from diet

37. Prognosis Pain resolves in 30-50% of kids within 2-6 weeks of diagnosis 30-50% of kids with recurrent abdominal pain will have functional pain as adults.

38. Follow up Bring them back in 2-3 months initially

39. Management Which of the following has shown to be most effective in treating abdominal pain in children A.CBT B.Famotidine C.Dietary changes (↑ fiber, food avoidance) D.Peppermint oil

40. Management Which of the following has shown to be most effective in treating abdominal pain in children A.CBT B.Famotidine C.Dietary changes (↑ fiber, food avoidance) D.Peppermint oil

41. Case A 9-year-old girl is brought to your office with a 6-month history of peri-umbilical pain. Characteristics of pain are described as follows: it occurs mainly after eating, lasts from 10 minutes to one hour, frequency varies since there might be times when she complains of pain twice a day but there are other times when she is symptom free for a month. She described the pain as if someone was “punching” her belly. Her symptoms worsen at school but acknowledge she eats a lot of junk food. There is no history of nocturnal pain but halitosis has been noticed. Her weight, appetite and energy level have been stable. Further history revealed BMs every 3 days and stools are hard and some intermittent soiling. Mild headaches have been associated. Her family history revealed migraines and irritable bowel syndrome on the mother. There were no abnormalities on exam; anthropometrics plotted her on the 25 th percentile.