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DR SAMEER S
APPROACH TO RECURRENT ABDOMINAL PAIN IN CHILDREN
Clinical Definitions
Source:Hyams et.al 1996.
Acute Abdominal Pain:Less than 4-6 week ,sub acute (less than
12 weeks)Single episode, self limited and treatableEpisodic localized pain, sharp, stabbing
Chronic Abdominal Pain:Pain of at least 3 months duration; Long
lasting, intermittent or constant that is functional ororganic (disease)
Recurrent abdominal pain (Apley and Naish, 1958)
Waxes and wanes 3 episodes in 3 months Severe enough to affect activities No organic cause
Functional Abdominal Pain:Abdominal Pain without evidence of disease/pathologic
process. Can manifest with symptoms typical of functional dyspepsia, irritable bowel syndrome, abdominal migraine or functional abdominal pain syndrome.
The American Academy of Pediatrics (AAP) and North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition (NASPGHAN) guidelines for the evaluation and treatment of children with chronic abdominal pain recommend that:
the term "recurrent abdominal pain" should not be used as a synonym for functional, psychological, or stress-related abdominal pain . Functional abdominal pain, which is the most common cause of chronic abdominal pain, is a specific diagnosis that must be distinguished from other causes of abdominal pain (eg, anatomic, infectious, inflammatory, metabolic) Source: AAP, 2005
Abdominal pain: evidence-based data
Incidence 5 % of patients presenting to the pediatric clinic and ED (2 – 12 years
old, <72 hours duration) 1% of patients with abdominal pain had surgical intervention 84 % of patients were diagnosed to have
URI and/or Otitis Media Pharyngitis Viral syndrome Abdominal pain or uncertain etiology Gastroenteritis Acute febrile illness Sickle cell anemia H S Purpura 7.4% return visit 1.7% hospitalized
ABDOMINAL PAIN: EVIDENCE-BASED DATA
Associated symptoms
Fever
Vomiting
Decreased appetite
Cough
Headache
Sorethroat
(NOT GOOD)
1/3 of them presenting with Abdominal Pain get no specific diagnosis!!!
Most Common Causes in the ED(ACUTE)
Non-specific abd pain 34%
Appendicitis 28%
Biliary tract dz 10%
Obstruction 4%
Gynaecological disease 4%
Pancreatitis 3%
Renal colic 3%
Perforated ulcer 3%
Cancer 2%
Diverticular dz 2%
Other 6%
Age
Type of Pain
Visceral
Parietal
Refered
Visceral Pain
Stretching of nerve fibresof walls or capsules of organs
Crampy
Dull
Achy
Often unable to lie
Bilateral innervation
Parietal Pain
Parietal peritoneum irritated
Usually anterior abdominal wall
Localised to the dermatome superficial to the site of painful stimulus
Localized
Tenderness,Guarding,Ridigity,Rebound as peritonities
Classification of Pain In Abdomen
A) Organic and Non-organic
B)Etiological
C) Age
D) Location/ quadrant
(B)Etiological Classification
Infections: Viruses or bacteria. Food-related: Food introlarance,food allergies,
eating excessive food, or gas production – any of these can cause bloating and temporary discomfort, rapid after eating.
Poisoning: This can range from simple problems (such as eating soap) to more serious issues like swallowing iron pills, magnets, coins, botulism from spoiled food, or an overdose of medications (such as acetaminophen poisoning [Tylenol]).
Surgical problems: These includeappendicitis or blockage of the bowels.
Medical
Genitourinary causesUrinary tract infectionUrinary calculiDysmenorrheaMittelschmerzPelvic inflammatory diseaseThreatened abortion
Ectopic pregnancyOvarian/testicular torsionEndometriosisHematocolpos
Liver, spleen, and biliary tract disordersHepatitisCholecystitisCholelithiasisSplenic infarctionRupture of the spleenPancreatitis
• GASTROINTESTINALGastroenteritisAppendicitisMesentric lymphadenitisConstipationAbdominal trumaIntestinal obstPeritonitis
• Metabolic disordersDiabetic ketoacidosisHypoglycemiaPorphyriaAcute adrenal insufficiencyHematologic disordersSickle cell anemiaHenoch-Schönlein purpuraHemolytic uremic syndrome
• Pulmonary causesPneumoniaDiaphragmatic
• Drugs and toxinsErythromycinSalicylatesLead poisoningVenoms
• Miscellaneous causesAbdominal epilepsyGilberts syndromeFamilial Mediterranean feverSickle cell crisisLead poisoningHSPAngioneurotic edemaAcute intermittent porphyria
(C)Classification as per age
(D) Classification as per Quadrant
HISTORY
Pain: Location, Quality, Severity, Onset, Duration Modifying factors Change over time R your child eating poorly Poor eating
GI symptoms
Nausea, vomiting, hematemesis, anorexia, diarrhea, constipation, bloody stools, melena stools
GU symptoms
Dysuria, frequency, urgency, hematuria, incontinence
Gyn symptoms
Vaginal discharge, vaginal bleeding
General
Fever, lightheadedness,cough,cold
And don’t forget the history
GI Past abdominal surgeries, h/o GB disease, ulcers;
FamHx IBD GU Past surgeries, h/o kidney stones, pyelonephritis, UTI
Gyn Last menses, sexual activity, contraception, h/o PID or
STDs, h/o ovarian cysts, CVS h/o heart disease, CHF, Other medical history DM, SCD, Allergies, Recurrent chest infection
Medications NSAIDs, H2 blockers, PPIs, immunosuppression,
Moving on to the Physical Exam
General Pallor, diaphoresis, general appearance, level of
distress or discomfort, is the patient lying still or moving around in the bed. Drawing legs up toward to belly
Ht , weight,Head Circumference (Abnormal growth and/or involuntary weight loss)
Signs of delyed Puberty
Vital Signs
Abdominal Findings
Guarding Voluntary
Contraction of abdominal musculature in anticipation of palpation
Diminish by having patient flex knees
Involuntary Reflex spasm of abdominal muscles rigidity Suggests peritoneal irritation
Rebound Present in 1 of 4 patients without peritonitis
Pain referred to the point of maximum tenderness when palpating an adjacent quadrant is suggestive of peritonitis Rovsing’s sign in appendicitis
Rectal exam Most important Gross blood or melena indicates a GI Bleeding Examination of Genitalia
Other system
R/S - Pnemonia
CVS –CHD,Murmur
Pelvic Exam-Vaginal disharge ,Plapable masses
Diagnostic Tools
Rome III Criteria Essential Investigations : according to symptoms e.g.- CBC- U A , Stool exam- LDG, Amylase ,lipase- Ultrasound- Barium study- Gastric emptying time test ,Intestinal transit time
,Colonic transit time test- Hydrogen breath test: lactose ,lactulose,glucose- Endoscopy- Skin Prick test- Urea Breath test
Imaging
Depends what you are looking for! Abdominal series
3 views: upright chest, flat view of abdomen, upright view of abdomen
Limited utility: restrict use to patients with suspected obstruction or free air
Ultrasound Good for diagnosing, Good for pelvic pathology
CT abdomen/pelvis Non-contrast for free air, renal colic,, bowel obstruction Contrast study for abscess, infection, inflammation, unknown cause
MRI Most often used when unable to obtain CT due to contrast issue
Recommendation of North American Society for Pediatric Gastroenterology,
Hepatology and Nutrition
Additional diagnostic evaluation is not required in children without alarm symptoms
Testing may be carried out to reassure children and theirparents
What are the predictive values of diagnostic tests?
There is no evidence to suggest that the use ofultrasonographic examination of the abdomen and pelvis in the absence of alarm symptoms has a significant yield of organic disease .
There is little evidence to suggest that the use of endoscopy and biopsy in the absence of alarm symptoms has a significant yield of organic disease .
There is insufficient evidence to suggest that the use ofesophageal pH monitoring in the absence of alarmsymptoms has a significant yield of organic disease .
PITFALLS:
• Incomplete exams (rectals, pelvics and genital exams)
• Incomplete histories
• Missing abnormal vitals
• Relying on labs
• Relying on imaging
• Not performing serial exams
• Infant, the pregnant, altered or psychiatric patients
• “Constipation” “GERD” “Gastroenteritis” and “UTI”
Simple advice & Health Education
Home Care
Most of the time, you can wait for your child to get better and use home care remedies. If you are worried or your child’s pain is getting worse or lasts longer than 24 hours, call your health care provider.
Offer sips of water or other clear fluids.
Suggest that your child try to pass stool.
Avoid solid foods for a few hours. Then try small amounts of mild foods such as rice, applesauce, or crackers.
Do not give your child foods or drinks that are irritating to the stomach.
Avoid:Caffeine Carbonated beverages,Citrus,Dairy productsFried, or greasy foods,High-fat foods,Tomato products
Do not give aspirin, ibuprofen, acetaminophen without first asking your child's health care provider.
To prevent many types of abdominal pain:
Avoid fatty or greasy foods.
Drink plenty of water each day.
Eat small meals more often.
Exercise regularly.
Limit foods that produce gas.
Make sure that meals are well-balanced and high in fiber. Eat plenty of fruits and vegetables.
WHEN TO CONTACT A MEDICAL PROFESSIONAL
Abdominal pain does not go away in 24 hours
Is a baby younger than 3 months and has diarrhea or vomiting
Is unable to pass stool, especially if the child is also vomiting
Is vomiting blood or has blood in the stool (especially if the blood is maroon or dark, tarry black)
Has sudden, sharp abdominal pain
Has a rigid, hard belly
Has had a recent injury to the abdomen
Is having trouble breathing
Abdominal pain that lasts 1 week or longer, even if it comes and goes.
A burning sensation during urination
Diarrhea for more than 2 days
Vomiting for more than 12 hours
Fever over 100.4 degrees F
Poor appetite for more than 2 days
Unexplained weight loss
DICTUM
All child of non-verbal age presenting with Significant
Pain should be considered to have abdominal pathological
until proven otherwise.
HOW TO APPROACH
Non Organic Cause
Rome III criteria, 2006
Functional dyspepsia
Irritable bowel syndrome
Functional abdominal pain
Functional abdominal pain syndrome
Abdominal migraine
- No evidence of an inflammatory, anatomical, metabolic or neoplastic process
- Criteria fulfilled at least once a week for at least two months before diagnosis
Dyspepsia = Epigastric discomfort
14 year old boy with two month history Bothersome post-prandial fullness Early satiation Epigastric pain Epigastric burning
Normal physical examination Normal screening labs CBC Hepatobiliary enzyme tests IgA and tTG Lipase or amylase Stool for occult blood
What should we do next?
Recommend endoscopy when
Vomiting or weight loss
Positive screening test
Low yield test
Often, does not relieve anxiety
Should we do radiologic testing?
Obstructive symptoms or signs
Should we do testing for H. pylori?
Family history
Acute symptoms
How effective is therapy for dyspepsia?
Proton pump inhibitor < 50% response
No increase in response to high doses
Anti-helicobacter 10-15% response
No improvement with repeated courses
Prokinetic agents Side effects frequent
Antispasmodics No benefit
Antidepressants No benefit
Irritable Bowel Syndrome
Abdominal discomfort or pain associated with 2 or more of the following at least 25% of the time Improvement with
defecation Onset associated with a
change in stool frequency Onset associated with a
change in stool consistency
No evidence of another disorder
Present for two months or more
What is effective therapy for IBS?
Dietary changes
Lactose restriction
Gluten restriction
Medications
Loperamide
Low dose TCA
Psychosocial support
Most effective
No side effects
Fiber supplements
Lactose restriction Vitamin D restriction
Low calcium intake
Oral antibiotics
Anticholinergics
Probiotics
What is the role of gluten restriction?
Gluten sensitive enteropathy = celiac disease. Eat a gluten free diet.
Gluten sensitivity or intolerance.
GI symptoms associated with gluten intake
Early age of onset.
Functional abdominal pain syndrome
1. Continuous or nearly continuous abdominal pain
2. Little to no relationship of pain with eating, defecation, or menses
3. Some loss of daily functioning
4. The pain is not feigned (e.g., malingering)
5. Does not fit another functional gastrointestinal disorder
6. Duration = prior last 2 months with symptom onset at least 6 months before
Paroxysmal episodes of intense, acute periumbilical pain that lasts for one or more hours
Intervening periods of usual health lasting weeks to months
The pain interferes with normal activities The pain is associated with two or more of the
following:- Anorexia- Nausea- Vomiting- Headache- Photophobia- PallorCriteria fulfilled two or more times in the preceding 12
months
ABDOMINAL MIGRAINE
Treatment
Deal with psychological factors
Educate the family (an important part of treatment)
Focus on return to normal functioning rather than on the complete disappearance of pain
Best prescribe drugs judiciously as part of amultifaceted, individualised approach, to relievesymptoms and disability
Pharmacologic treatment approach
Medicines:
Acid lowering agents
Mucoprotective drugs
Motility regulators
Laxatives
Analgesics
Probiotics
Gas adsorbants
Dietary and life style change
Psychotherapy
Treatment of Acid-related disorders H2-receptor Antagonists:Ranitidine (2-4 mg/kg/d up to 150 mg bid),Famotidine (1-1.2 mg/kg/d up to 20 mg bid) PPI:Omeprazole (0.8 mg/kg/d;effective dose range
of 0.3-3.3 mg/kg/d),Lansoprazole (0.8 mg/kg/d) Cytoprotective Agents:Sucralfate(40-80 mg/kg/d up to 1 g qid)Rabemipride ( 1 x 3 )
Abdominal Pain Clinical Pearls
Significant abdominal tenderness should never be attributed to gastroenteritis
Incidence of gastroenteritis in the Older child are very low Always perform genital examinations when lower abdominal pain is
present – in males and females, in young and old Aways perform Rectal Examination Bilious vomiting consider abdominal pathology unless until proved Severe pain should be taken as an indicator of serious disease Pain awakening the patient from sleep should always be considered
signficant Sudden, severe pain suggests serious disease Pain almost always precedes vomiting in surgical causes; converse is
true for most gastroenteritis and NSAP A lack of free air on a chest xray does NOT rule out perforation Signs and symptoms of PUD, gastritis, reflux and nonspecific
dyspepsia have significant overlap.
Thank you