8/7/2019 Chronic Abdominal Pain and Headache in an Adolescent Female
1/18
Chronic Abdominal Pain and Headache in
an Adolescent Female
Ben Wright, MD, PGY-2
University of Utah
8/7/2019 Chronic Abdominal Pain and Headache in an Adolescent Female
2/18
Recurrent abdominal pain
History of at least three episodes of pain
Pain sufficiently severe to affect activities
Episodes occur over a period of three months
No known organic cause
8/7/2019 Chronic Abdominal Pain and Headache in an Adolescent Female
3/18
Prevalence 9 -15% - all comers
10-15% - PCMC GI inpatient service
70-80% - proportion of time spent by the
pediatric GI resident in these patients
rooms
8/7/2019 Chronic Abdominal Pain and Headache in an Adolescent Female
4/18
Abdominal Pain Two types of nerve
fibers
A fibers - sharplocalized pain in skinand muscle,
C fibers - transmit
poorly localized, dullpain from viscera,peritoneum, andmuscle
8/7/2019 Chronic Abdominal Pain and Headache in an Adolescent Female
5/18
Visceral Pain
Epigastrium - liver,pancreas, biliary tree,stomach, or upper
bowel Umbilicus - distal small
bowel, cecum,appendix, or proximalcolon
Suprapubic distal largebowel, urinary tract, orpelvic organs
8/7/2019 Chronic Abdominal Pain and Headache in an Adolescent Female
6/18
Words to Live ByAssume that all pediatric abdominal pain
is constipation until proven otherwise.
-Molly OGorman, attributed to Dan Jackson
8/7/2019 Chronic Abdominal Pain and Headache in an Adolescent Female
7/18
So What Do We Do? Biopsychosocial model of care
Primary goal is return to normal function, rather than
complete elimination of pain. Education of the family is an important aspect.
Cognitive-behavioral therapy
Evidence regarding the benefit of treatment with H2
receptor agonists, supplemental fiber, or a lactose-free diet is inconclusive.
8/7/2019 Chronic Abdominal Pain and Headache in an Adolescent Female
8/18
Celiac Disease 3 to 13/1,000 children or 1/300 to 1/80 children
The gliadin fraction sensitizes lamina propria
lymphocytes Concordance in monozygotic twins approaching
100%
associated with MHC class II alleles DQA1*0501 and
DQB1*0201 More common in kids with DMI and T21 (x 50)
8/7/2019 Chronic Abdominal Pain and Headache in an Adolescent Female
9/18
Celiac Disease
8/7/2019 Chronic Abdominal Pain and Headache in an Adolescent Female
10/18
The Damage Villus atrophy, crypt hyperplasia, and
damage to the surface epithelium in the
small bowel
Decreased absorptive and digestive
capacity
Relative increase in immature epithelialcells
8/7/2019 Chronic Abdominal Pain and Headache in an Adolescent Female
11/18
Histology
8/7/2019 Chronic Abdominal Pain and Headache in an Adolescent Female
12/18
Symptoms and Signs Failure to thrive 36
Diarrhea 30
Irritability 30 Vomiting 24
Anorexia 24
Foul stools 21
Abdominal pain 8
Excessive appetite 6
Rectal prolapse 3
Height
8/7/2019 Chronic Abdominal Pain and Headache in an Adolescent Female
13/18
Non-Intestinal Manifestations and
Association of Celiac Disease Dental enamel hypoplasia of
permanent teeth
Osteopenia/osteoporosis
Short stature Delayed puberty
Iron-deficiency anemia notresponding to oral iron therapy
Hepatitis (elevated liverenzymes)
Arthritis Epilepsy with occipital
calcification
Headache
Depression
Ataxia
Myelopathy
Autoimmunity
Diabetes mellitus type 1 Thyroiditis
Primary biliary cirrhosis
Addison disease
Dermatitis herpetiformis
Syndromes
Turner
Down
William
Malignancy
8/7/2019 Chronic Abdominal Pain and Headache in an Adolescent Female
14/18
Idiopathic Intracranial Hypertension
raised intracranial pressure in absence of
space-occupying lesion.
often presents as headache syndrome
can lead to permanent visual loss
opening pressure > 25 cm H20
8/7/2019 Chronic Abdominal Pain and Headache in an Adolescent Female
15/18
Irritable Bowel Syndrome Definition:
abdominal
discomfort or painassociated with
disturbed defecation
8/7/2019 Chronic Abdominal Pain and Headache in an Adolescent Female
16/18
Rome III Criteria
Recurrent abdominal pain or discomfortat least three days/month in the last
three months associated with two ormore of the following:
Improvement with defecation
Onset associated with a change in
frequency of stool
Onset associated with a change in form(appearance) of stool
8/7/2019 Chronic Abdominal Pain and Headache in an Adolescent Female
17/18
AR
ole for Integrative Therapies peppermint oil appears effective for treatment
of IBS symptoms.1
evidence is inconclusive for effectiveness ofacupuncture for IBS.2
some probiotics or probiotic mixtures may
reduce IBS symptoms.
1. Ford, et al. BMJ. 2008 Nov 13;337:a2313
2. Lim, et al. Cochrane Database Syst Rev. 2006 Oct 18;(4)
8/7/2019 Chronic Abdominal Pain and Headache in an Adolescent Female
18/18
Special thanks to Jessica Howsley and her excellent history taking
skills
Clint Nelson being able appreciate papilledema priorto a dilated optho exam
Sir Tapsalot, aka Brian Sullivan and his accurate
opening pressure
Lynn Gershan and her acupuncture needles
Pysch, GI, Social Work, Ophtalmology, and everyone
else who had a hand in caring for this patient.