1. Abdominal Pain in Children Modified from a lecture by Dr. John Snyder, CNMC

2. CONTINUITY CLINIC Objectives Know the differential diagnosis of recurrent abdominal pain Recognize the clinical manifestations of chronic recurrent abdominal pain Plan the evaluation of a patient with chronic recurrent abdominal pain Understand the role of Helicobacter pylori in chronic recurrent abdominal pain

3. CONTINUITY CLINIC Self Quiz Organic cause in 10-15% of cases of abdominal pain Over-achievers and worries have more recurrent abdominal pain Recurrent abdominal pain is more common in females < 10 years old Serology is a good test for H. pylori H. pylori is an important cause of abdominal pain Prevalence of celiac disease in US is 1/2500 Serology is a good test for celiac disease

4. CONTINUITY CLINIC Self Quiz – So how did you do? Organic cause in 10-15% of cases of abdominal pain Over-achievers and worries have more recurrent abdominal pain Recurrent abdominal pain is more common in females < 10 years old Serology is a good test for H. pylori H. pylori is an important cause of abdominal pain Prevalence of celiac disease in US is 1/2500 Serology is a good test for celiac disease TRUE FALSE TRUE

5. CONTINUITY CLINIC Apley: Recurrent Abdominal Pain (RAP) Apley: Recurrent Abdominal Pain (RAP) 3 or more episodes occuring in 3 months Severe enough to affect routine activity and daily function Absence of organic pain

6. CONTINUITY CLINIC Apley Criteria Pros: Well known Provides frame of reference Cons: Based on about 1000 English students 1950s data Limited evaluations performed Few validated assessment tools in children

7. CONTINUITY CLINIC Rome Criteria for Abdominal Pain 5 categories based on adult criteria: 1. 1. Functional dyspepsia – pain above umbilicus 2. 2. Irritable bowel syndrome – improved with stooling 3. 3. Functional abdominal pain – doesn’t fit other categories 4. 4. Functional abdominal pain (FAP) syndrome – some loss of daily functioning and somatic complaints (ie. headache, limb pain) 5. 5. Abdominal migraine – severe perimbilical pain and headache, photophobia, vomiting or nausea

8. CONTINUITY CLINIC Rome Criteria Intended as a research framework Intended as a research framework Not clear how useful in the outpatient setting Not clear how useful in the outpatient setting Does allow for comparison and perspective Does allow for comparison and perspective Offers families a more concrete “diagnosis” Offers families a more concrete “diagnosis” May be more practical to focus on treating symptoms May be more practical to focus on treating symptoms

9. CONTINUITY CLINIC Recurrent Abdominal Pain Epidemiology 10-15% of school age children seek help 10-15% of school age children seek help 10-15% more have symptoms but never seek medical attention 10-15% more have symptoms but never seek medical attention 10% have an organic cause 10% have an organic cause Females>males Females>males Higher in > 10 years old Higher in > 10 years old Prevalence increases during school, not vacations Prevalence increases during school, not vacations

10. CONTINUITY CLINIC MYTHS NOT associated with: Super-intellect Perfectionist Over-achiever Constant worrier

11. CONTINUITY CLINIC Differential Diagnosis GI Constipation Parasites Lactose Intol Peptic Disease IBD Gallstones Pancreatitis Allergy ?H. pylori ?Celiac Dis. GU UTI Renal Stones Ovarian PID OTHER Medications HSP Sickle Cell Lymphoma Fam Med Fever Porphyria Lead Poisoning Rheumatologic FUNCTIONAL Functional Dyspepsia IBS FAP Functional Ab Pain Abdominal Migraine

12. CONTINUITY CLINIC Feeling like this yet? Don’t despair!

13. CONTINUITY CLINIC The Dilemma This is a very common problem 10% of cases have an organic etiology So the question you have to answer is: How many causes should be excluded? What are the clues to an organic cause?

14. CONTINUITY CLINIC “ EASY” 8 Questions To Separate Functional from Organic 1. 1. When did it start? Document duration F – Concurrent stressful event in life O – Trauma or travel 2. 2. Where is it located and where does it go? F – Peri-umbilical or epigastric O – Well localized away from umbilicus

15. CONTINUITY CLINIC “ EASY” 8 Questions To Separate Functional from Organic 3. 3. How long does it last? F – Prolonged duration with no clear signs O – Variable; signs raise the ante 4. 4. What does the pain feel like? F – Vague, gradual onset, variable severity O – Isolated, sudden onset

16. CONTINUITY CLINIC “ EASY” 8 Questions To Separate Functional from Organic 5. 5. What makes the pain better? F – No relationship to interventions O – Sometimes medications or position change help 6. 6. What makes the pain worse? F – Reinforcement from parents 7. 7. Is the pain intermittent or constant F – Constant O - Intermittent

17. CONTINUITY CLINIC “ EASY” 8 Questions To Separate Functional from Organic 8. 8. Association with other signs or symptoms? F – Signs of anxiety (mottled skin, nail biting), family history of irritable bowel, migraines O – Association with hematachezia, fever, rash, weight loss, growth faltering, family history of ulcers or IBD

18. CONTINUITY CLINIC 1 st Visit Emphasize the pain is real but the cause may be hard to find Exclude the functional 5: 1. 1. Chronic UTI (especially in females) 2. 2. Giardia 3. 3. Lactose Intolerance 4. 4. Stooling problems – constipation or irregular stool pattern (IBS) Consider Celiac Disease

19. CONTINUITY CLINIC Physical Examination Growth – evidence of faltering? Abdomen guarding? degree of pain vs. softness Tubular masses in LLQ Distractability Rectal - nature of stool, guaiac Consider Gyn examination vs abdominal ultrasound when appropriate

20. CONTINUITY CLINIC Red Flags – Rapid Work-Up Systemic signs: hematachezia, fever, rash, weight loss, growth faltering Historical clues: family history of ulcers or IBD Prolonged school absence Use of narcotic pain medication Positive exam findings If present hurry up!!!!

21. CONTINUITY CLINIC 1 st Line Evaluation Urine: UA, +/- culture Stool: guaiac, EIA antigen test (Giardia) Blood: CBC, +/- ESR, other tests indicated by history or examination Therapeutic trial: high fiber and lactose free diet

22. CONTINUITY CLINIC Circumstantial evidence against a major role for H. pylori Eradication: does not always result in improvement of pain Serology is NOT an accurate screener What about H. pylori?

23. CONTINUITY CLINIC H. Pylori Over 3000 patients in 7 studies of abdominal pain: H. pylori found in 10-15% of patients Prevalence is the same in patients with pain and without pain No randomized, controlled studies

24. CONTINUITY CLINIC H. Pylori Serology in Children Low sensitivity in young children Lower antibody titers Immunodominant proteins differ from adults Antibodies persist long after eradication Maternal antibodies often found in infants

25. CONTINUITY CLINIC Now to Celiac….. Prevalence: 1/250 (sero screening) Children at increased risk GI clinic “symptomatic” children1/57 Type I diabetic5-8% Down Syndrome1-2% Results similar to those in Europe ONLY 5% of US cases are diagnosed!

26. CONTINUITY CLINIC Which Test for Celiac? Antibody Test SensitivitySpecificityPPVNPV Gliadin IgG 65%60%30%50% Gliadin IgA 70%75%40%80% Endomysial IgA 90%98%95%85% tTG human IgA 95%99%99%95%

27. CONTINUITY CLINIC Medications for Abdominal Pain Empiric trials for acid suppression often done Many also use homeopathy For pain of unknown cause: Use of narcotics is an indication for admission and evaluation

28. CONTINUITY CLINIC Medications for Abdominal Pain DrugActionEtOHDeath MyliconAnti-flatulenceNoneNo BentylAnti-spasmodicNoneYes Levsin AS, sedation, anti-cholinergic 20%Yes Donnatol 24%Yes

29. Ready to Apply Your Knowledge?

30. CONTINUITY CLINIC Case Study 12.5 year old, previously well, hispanic female arrives in your clinic with a 6 month history of severe, intermittent abdominal pain. Travels to Mexico frequently to see family. Pain: peri-umbilical or epigastric, crampy or sharp, variable frequency and duration No emesis, diarrhea, weight loss, fever, hematachezia Intermittent hard stools Normal menstrual periods Missed 3.5 weeks of school – fair student who does “not like school” Family intact, no home stressors Meds: Mylanta, Tylenol, Ibuprofen, Ginseng

31. CONTINUITY CLINIC Case Study Diet: heavy on fast foods and diet coke PE remarkable for: Ht 153 cm (25-50%), Wt 59 kg (>90%), BMI 26 (>95%) ABD – obese, soft, pain on deep palpation of mid abdomen, no guarding, rebound, masses or hepatosplenomegaly Rectal – normal anus and tone; hard, heme negative stool

32. CONTINUITY CLINIC Remember the “ EASY” 8 Questions FunctionalOrganic 1. Start?Trip to MexicoX 2. Location?Peri-umbilicalX 3. Duration?VariableX 4. Description?VagueX 5. Improvement?No relief on RxX 6. Worsens?School AbsenceX 7. Intermittent?VariableX 8. Signs/Sx?NoneX

33. CONTINUITY CLINIC Real Story Gone Bad What was done: a battery of tests including CT, US, treatment for H. pylori, ultimately a cholecystectomy was done. The patient did not get better……

34. CONTINUITY CLINIC Finally started on therapy for constipation by gastroenterologist and began counseling for chronic pain

35. CONTINUITY CLINIC Lessons to be learned from case: H. pylori is usually not the simple solution Gallstones in the absence of specific signs and symptoms, are rarely the cause of vague abdominal pain

36. Remember to complete the questions related to this topic!