Abdominal Pain Abdominal Pain in Childrenin Children

Modified from a lecture by Dr. John Snyder, CNMC

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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

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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

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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

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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

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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

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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

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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

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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

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MYTHSMYTHS

NOT associated with:• Super-intellect

• Perfectionist

• Over-achiever

• Constant worrier

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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

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Feeling like this yet?Feeling like this yet?

Don’t despair!

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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?

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““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

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““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

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““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

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““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

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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

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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

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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!!!!

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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

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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?

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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

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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

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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!

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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%

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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

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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?

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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

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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

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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

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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……

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Finally started on therapy for constipation by gastroenterologist and began counseling for chronic pain

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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!