Download 3. Chronic Abdominal Pain

CHRONIC ABDOMINAL PAIN:
IS IT IN YOUR HEAD OR IN YOUR
GUT?
Michelle Tobin, MD
Clinical Assistant Professor, Department of Pediatrics
Division of Pediatric Gastroenterology and Nutrition
Stony Brook Children's Hospital
DISCLOSURE
•
I have no financial relationships to disclose
CLINICAL VIGNETTE
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16yr old female previously healthy with intermittent crampy, periumbilical
abdominal pain x2 months
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Associated nausea, vomiting, diarrhea and fatigue
o 1-6 episodes of nonbloody watery stool
o Treated with Prevacid
o Nausea persisted
•
ROS negative: fever, joint pain, oral sores, rashes, weight loss, nocturnal
symptoms
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She denies recent travel or visitors from outside the country or sick contacts
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Missed several school days due to her symptoms
CLINICAL VIGNETTE CONT.
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Labwork results normal
o CBC, CMP, ESR, CRP, amylase, lipase, ASCA, ANCA and TFTs
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Stool Studies Negative
o
c. difficile, culture, O+P, and H. pylori
DIAGNOSIS
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Red Flags
o
o
o
o
o
o
o
Unexplained weight loss
Growth retardation
Delayed puberty
Significant vomiting/diarrhea
Family hx of IBD
GI blood loss
Unexplained fever, rash, arthralgia
ROME III CRITERIA FOR FUNCTIONAL ABDOMINAL PAIN
(2006)
Irritable Bowel Syndrome (IBS)
:
• 1. Abdominal discomfort** or pain associated with two or more of the
following at least 25% of the time:
• a. Improvement with defecation
• b. Onset associated with a change in frequency of stool
• c. Onset associated with a change in form (appearance) of stool
• 2. No evidence of an inflammatory, anatomic, metabolic, or
neoplastic process that explains the subject’s symptoms
• Diagnostic criteria* Must include both of the following
•
•
* Criteria fulfilled at least once per week for at least 2months prior to diagnosis
** “Discomfort” means an uncomfortable sensation not described as pain.
EPIDEMIOLOGY
• Chronic abdominal pain accounts for 2-4% of all Pediatric office visits
o
50% of all Pediatric Gastroenterology visits
• 13-19% of American school-aged children experience weekly
abdominal pain
o
o
IBS is the most often reported cause
Female gender, psychological disorders, stress and traumatic life events affect
prevalence
• Costly diagnosis
o
o
Direct Cost
IBS adults (prevalence of 11-14%) U$8-30billion per year
Diagnostic testing for chronic abdominal pain in a tertiary treatment center in
United States costs ~$6000 per patient
Indirect Cost
Parental absences from work, additional child care
Collins,BS & Lin,HC.Chronic Abdominal Pain in Children is Associated with High Prevalence of Abnormal Microbial Fermentation.Dig Dis Sci(2010).55:124-130.
Koterink, JJ et al. Epidemiology of Pediatric Functional Abdominal Pain Disorders: A Meta-analysis. PLOS ONE (2015). 10(5): e0126982.
PATHOPHYSIOLOGY OF IBS
TREATMENT FOR IBS
TREATMENT FOR IBS
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Education and Goals of therapy
o
o
o
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Reassurance
Resume a normal lifestyle
Discourage parents’ overinvolvement and reinforcement of sick behavior
Identification and modification of stress factors
o
o
Examples: death, school problems, altered peer relationships, family issues,
financial problems
Identify with a pain diary examining the frequency, duration, intensity, associated
symptoms
.
TREATMENT FOR IBS
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Dietary Interventions
o
o
o
Fiber
Lactose, Fructose Avoidance
Starch malabsorption
o FODMAP
o
Food Allergies
>5% of patients with IBS
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Probiotics
o Bifidobacteria
o E.coli + E. faecalis
o VSL#3
o lactobacillus rhamnosus
Shulman, RJ. Dietary issues in recurrent abdominal pain. JPGN (2012). 55(2) S40-S41
TREATMENT FOR IBS
• Pharmacological Treatment
o
o
o
H2 Blockers
Serotonergic Agents
Tricyclic Antidepressants
• Complementary Therapy
o Peppermint
o Ginger
o Massage therapy/Acupuncture
• Psychological Interventions
o Cognitive behavioral therapy
o Gut directed hypnotherapy
SMALL INTESTINAL BACTERIAL OVERGROWTH (SIBO):
PATHOGENESIS
SIBO: PATHOGENESIS
Sieczkowska, A. Small Bowel Bacterial Overgrowth in Children. JPGN (2016). 62(2): 196-207
SIBO: DEFINITION
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>105 CFU/ml of bacterial growth in upper small intestine luminal fluid
o
o
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No consensus on the formal definition
Limited clinical value
A more appropriate definition =
o
The presence of 105 or more of colonic type microbiota grown from the small
intestine aspirate
SIBO: RISK FACTORS
.
• Low income Countries
↑ levels of lipopolysaccharide → alters migrating motor complex → luminal stasis
Donowitz, JR & Petri Jr, WA. Pediatric Small Intestinal Bacterial Overgrowth in Low-Income Countries. Trends Mol Med. 2015. 21(1): 6-15
SIBO: EPIDEMIOLOGY
• Epidemiology
o Prevalence is increasing
Due to readily available diagnostic tests and increased awareness
o Overall prevalence is unknown
o In healthy adults, 5.9% of young adults were positive for SIBO vs 15.6% in
the older population
o 64% IBS patients SIBO+ compared to controls 7% in outpatient setting
o 63% children IBS patients SIBO+, 40 girls 67.8%, 23boys (56.1%) in
inpatient setting
o 34% of children with abdominal pain and/or diarrhea were SIBO+ vs healthy
controls
o 54% of children with IBS-C were SIBO+
Scarpellini E. et al.Prevalence of Small Intestinal Bacterial Overgrowth in Children with Irritable Bowel Syndrome:A Case-Control Study.The Journal of
Pediatrics(2009).155:416-420.
Siniewicz-Luzenczyk, K. et al. Small intestinal bacterial overgrowth syndrome in children. Prz Gastroenterol (2015). 10: 28-32.
SIBO: CLINICAL PRESENTATION
Sieczkowska, A. Small Bowel Bacterial Overgrowth in Children. JPGN (2016). 62(2): 196-207.
SIBO: CLINICAL PRESENTATION
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Vitamin Deficiencies
o Vitamin B2 (riboflavin)
fatigue, slowed growth, cheilosis, glossitis, seborrhea, photophobia
o Vitamin B6 (pyridoxine)
dermatitis, cheilosis, glossitis, microcytic anemia, weight loss,
peripheral neuritis, irritability, seizure
o Vitamin B12 (cyanocobalamin)
megaloblastic, macrocytic anemia, diarrhea, shortness of breath,
demyelinating, posterior spinal column changes
o Folic acid
megaloblastic anemia, neutropenia, altered amino acid metabolism,
impaired growth, diarrhea
SIBO: DIAGNOSIS
• Diagnosis
o Gold Standard: Jejunal aspirate
Disadvantages:
Invasive requires endoscopy
Costly
Anesthesia – conscious sedation/general anesthesia
Technical issues
SIBO: DIAGNOSIS
• Diagnosis
o
o
Breath Hydrogen Test
Glucose Breath Test
sensitivity 44%
specificity 80%
Lactulose Breath Test
sensitivity 31%
specificity 86%
False negative results
Little or no H2 production
High methane production
SIBO: BREATH TEST
SIBO: DIAGNOSIS
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Diagnosis
o 13Carbon Labeled Breath Test
sensitivity 100%
specificity 67%
rarely used due to limited accessibility of analyzing equipment
o Serum D-Lactate
>1mmol/L
rarely used; only useful in patients at risk of acidosis
o Urine Indican Concentration
rarely use; requires 24hr urine collection
o Fecal Calprotectin
no increase seen in SIBO+ pts
Fundaro C. et al.Fecal Calprotectin concentration in children affected by SIBO.European Review for Medical and Phamacological
Sciences.(2011).15:1328-1335.
SIBO: TREATMENT
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Treatment
o
o
o
Correction of the Underlying Cause
Surgery, Dietary, Pharmacology
Nutritional Support
Replenish deficiencies
Probiotics
L. casei, L. plantarum, Strep. faecalis, Bifidobacterium brevis vs
metronidazole was clinically more effective for SIBO treatment
Administration of L. rhamnosus R0011, L acidophilus R0052 to patients
while on omeprazole for 4 weeks did not decrease the risk of developing
SIBO
SIBO: TREATMENT
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Treatment
o Antibiotic Therapy
Goal: modify the microbiota, not eliminate
Empiric therapy that covers gram negative bacteria and anaerobes
o Rifaximin
Nonabsorbable antibiotic
Conflicting evidence on clinical effectiveness, dose and duration
o Metronidazole
o Trimethoprim/sulfamethoxazole
Combination therapy of Bactrim and flagyl showed 95% eradication of SIBO in
asymptomatic patients living in the slums in Brazil
Tahan S. et al. Effectiveness of Trimethoprim-Sulfamethoxazole and Metronidazole in the Treatment of Small Intestinal Bactieral Overgrowth in
Children Living in a Slum. JPGN (2013). 57(3):316-318.
SIBO: TREATMENT
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Treatment
o Other antibiotics
Augmentin
Tetracycline
Ciprofloxacin
Gentamicin
Neomycin
BACK TO THE VIGNETTE …
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•
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Patient underwent lactulose breath test
Diagnosed with Small intestinal bacterial overgrowth
Treated with Bactrim and Metronidazole with some improvement
Treated with Rifaximin which resulted in resolution of her symptoms and
normalization of her breath test results
Thank You