Abdominal Pain in Children Modified from a lecture by Dr. John Snyder, CNMC.
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Transcript of Abdominal Pain in Children Modified from a lecture by Dr. John Snyder, CNMC.
Abdominal Pain Abdominal Pain in Childrenin Children
Modified from a lecture by Dr. John Snyder, CNMC
CONTINUITY CLINIC
ObjectivesObjectives
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
CONTINUITY CLINIC
Self QuizSelf 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
CONTINUITY CLINIC
Self Quiz – So how did Self Quiz – So how did you do?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
FALSE
FALSE
FALSE
FALSE
TRUE
CONTINUITY CLINIC
Apley: Recurrent Apley: Recurrent Abdominal Pain (RAP)Abdominal Pain (RAP)
3 or more episodes occuring in 3 months
Severe enough to affect routine activity and daily function
Absence of organic pain
CONTINUITY CLINIC
Apley CriteriaApley 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
CONTINUITY CLINIC
Rome Criteria for Rome Criteria for Abdominal PainAbdominal Pain
5 categories based on adult criteria:1. Functional dyspepsia – pain above umbilicus2. Irritable bowel syndrome – improved with
stooling3. Functional abdominal pain – doesn’t fit other
categories4. Functional abdominal pain (FAP) syndrome –
some loss of daily functioning and somatic complaints (ie. headache, limb pain)
5. Abdominal migraine – severe perimbilical pain and headache, photophobia, vomiting or nausea
CONTINUITY CLINIC
Rome CriteriaRome Criteria
Intended as a research frameworkIntended as a research framework Not clear how useful in the outpatient settingNot clear how useful in the outpatient setting Does allow for comparison and perspectiveDoes allow for comparison and perspective
Offers families a more concrete Offers families a more concrete “diagnosis”“diagnosis”
May be more practical to focus on May be more practical to focus on treating symptomstreating symptoms
CONTINUITY CLINIC
Recurrent Abdominal PainRecurrent Abdominal PainEpidemiologyEpidemiology
10-15% of school age children seek 10-15% of school age children seek helphelp
10-15% more have symptoms but never 10-15% more have symptoms but never seek medical attentionseek medical attention
10% have an organic cause10% have an organic cause Females>malesFemales>males Higher in > 10 years oldHigher in > 10 years old Prevalence increases during school, not Prevalence increases during school, not
vacationsvacations
CONTINUITY CLINIC
MYTHSMYTHS
NOT associated with:• Super-intellect
• Perfectionist
• Over-achiever
• Constant worrier
CONTINUITY CLINIC
Differential DiagnosisDifferential DiagnosisGI
Constipation
ParasitesLactose
IntolPeptic
DiseaseIBDGallstonesPancreatitisAllergy?H. pylori?Celiac Dis.
GUUTIRenal
StonesOvarianPID
OTHERMedicationsHSPSickle CellLymphomaFam Med
FeverPorphyriaLead
PoisoningRheumatolo
gic
FUNCTIONAL
Functional Dyspepsia
IBSFAPFunctional
Ab PainAbdominal
Migraine
CONTINUITY CLINIC
Feeling like this yet?Feeling like this yet?
Don’t despair!
CONTINUITY CLINIC
The DilemmaThe 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?
CONTINUITY CLINIC
““EASY” EASY” 8 Questions8 QuestionsTo Separate Functional from To Separate Functional from
OrganicOrganic1. When did it start? Document
durationF – Concurrent stressful event in lifeO – Trauma or travel
2. Where is it located and where does it go?
F – Peri-umbilical or epigastricO – Well localized away from umbilicus
CONTINUITY CLINIC
““EASY” EASY” 8 Questions8 QuestionsTo Separate Functional from To Separate Functional from
OrganicOrganic3. How long does it last?
F – Prolonged duration with no clear signs
O – Variable; signs raise the ante
4. What does the pain feel like?F – Vague, gradual onset, variable
severityO – Isolated, sudden onset
CONTINUITY CLINIC
““EASY” EASY” 8 Questions8 QuestionsTo Separate Functional from To Separate Functional from
OrganicOrganic5. What makes the pain better?
F – No relationship to interventionsO – Sometimes medications or position
change help
6. What makes the pain worse?F – Reinforcement from parents
7. Is the pain intermittent or constantF – ConstantO - Intermittent
CONTINUITY CLINIC
““EASY” EASY” 8 Questions8 QuestionsTo Separate Functional from To Separate Functional from
OrganicOrganic8. 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
CONTINUITY CLINIC
11stst Visit Visit
Emphasize the pain is real but the cause may be hard to find
Exclude the functional 5:1. Chronic UTI (especially in females)2. Giardia3. Lactose Intolerance4. Stooling problems – constipation or
irregular stool pattern (IBS) Consider Celiac Disease
CONTINUITY CLINIC
Physical ExaminationPhysical 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
CONTINUITY CLINIC
Red Flags – Rapid Red Flags – Rapid Work-UpWork-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!!!!
CONTINUITY CLINIC
11stst Line Evaluation 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
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?
CONTINUITY CLINIC
H. PyloriH. 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
CONTINUITY CLINIC
H. Pylori H. Pylori Serology in Serology in ChildrenChildren
Low sensitivity in young children Lower antibody titers Immunodominant proteins differ from
adults
Antibodies persist long after eradication
Maternal antibodies often found in infants
CONTINUITY CLINIC
Now to Celiac…..Now to Celiac…..
Prevalence: 1/250 (sero screening) Children at increased risk
GI clinic “symptomatic” children1/57
Type I diabetic 5-8% Down Syndrome 1-2%
Results similar to those in Europe
ONLY 5% of US cases are diagnosed!
CONTINUITY CLINIC
Which Test for Celiac?Which Test for Celiac?
Antibody Antibody TestTest
SensitivSensitivityity
SpecificSpecificityity
PPVPPV NPVNPV
Gliadin IgGGliadin IgG 65%65% 60%60% 30%30% 50%50%
Gliadin IgAGliadin IgA 70%70% 75%75% 40%40% 80%80%
Endomysial Endomysial IgAIgA
90%90% 98%98% 95%95% 85%85%
tTG human tTG human IgAIgA
95%95% 99%99% 99%99% 95%95%
CONTINUITY CLINIC
Medications for Medications for Abdominal PainAbdominal 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
CONTINUITY CLINIC
Medications for Medications for Abdominal PainAbdominal Pain
DrugDrug ActionAction EtOHEtOH DeathDeath
MyliconMylicon Anti-Anti-flatulenceflatulence
NoneNone NoNo
BentylBentyl Anti-Anti-spasmodicspasmodic
NoneNone YesYes
LevsinLevsin AS, AS, sedation, sedation, anti-anti-cholinergiccholinergic
20%20% YesYes
DonnatDonnatolol
AS, AS, sedation, sedation, anti-anti-cholinergiccholinergic
24%24% YesYes
Ready to Apply Ready to Apply Your Knowledge?Your Knowledge?
CONTINUITY CLINIC
Case StudyCase 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
CONTINUITY CLINIC
Case StudyCase 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
CONTINUITY CLINIC
Remember the “Remember the “EASY” EASY” 8 8 QuestionsQuestions
Functional Organic
1. Start? Trip to Mexico X
2. Location? Peri-umbilical X
3. Duration? Variable X
4. Description?
Vague X
5. Improvement?
No relief on Rx X
6. Worsens? School Absence
X
7. Intermittent?
Variable X
8. Signs/Sx? None X
CONTINUITY CLINIC
Real Story Gone BadReal 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……
CONTINUITY CLINIC
Finally started on therapy for constipation by gastroenterologist and began counseling for chronic pain
CONTINUITY CLINIC
Lessons to be learned Lessons to be learned from case: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
Remember to Remember to complete the complete the
questions related questions related to this topic!to this topic!