Download Abdominal Pain in Children

Abdominal Pain in
Children
Modified from a lecture by Dr. John Snyder, CNMC
Objectives




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 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 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
CONTINUITY CLINIC
TRUE
FALSE
FALSE
FALSE
FALSE
FALSE
TRUE
Apley: Recurrent 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 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 Abdominal Pain
5 categories based on adult criteria:
1.
2.
3.
4.
5.
Functional dyspepsia – pain above umbilicus
Irritable bowel syndrome – improved with stooling
Functional abdominal pain – doesn’t fit other
categories
Functional abdominal pain (FAP) syndrome –
some loss of daily functioning and somatic
complaints (ie. headache, limb pain)
Abdominal migraine – severe perimbilical pain and
headache, photophobia, vomiting or nausea
CONTINUITY CLINIC
Rome Criteria

Intended as a research framework
Not clear how useful in the outpatient setting
 Does allow for comparison and perspective


Offers families a more concrete “diagnosis”

May be more practical to focus on treating
symptoms
CONTINUITY CLINIC
Recurrent Abdominal Pain
Epidemiology






10-15% of school age children seek help
10-15% more have symptoms but never seek
medical attention
10% have an organic cause
Females>males
Higher in > 10 years old
Prevalence increases during school, not
vacations
CONTINUITY CLINIC
MYTHS
NOT associated with:
•
Super-intellect
•
Perfectionist
•
Over-achiever
•
Constant worrier
CONTINUITY CLINIC
Differential Diagnosis
GI
Constipation
Parasites
Lactose Intol
Peptic Disease
IBD
Gallstones
Pancreatitis
Allergy
?H. pylori
?Celiac Dis.
GU
UTI
Renal Stones
Ovarian
PID
CONTINUITY CLINIC
OTHER
Medications
HSP
Sickle Cell
Lymphoma
Fam Med Fever
Porphyria
Lead Poisoning
Rheumatologic
FUNCTIONAL
Functional
Dyspepsia
IBS
FAP
Functional Ab
Pain
Abdominal
Migraine
Feeling like this yet?
Don’t despair!
CONTINUITY CLINIC
The 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” 8 Questions
To Separate Functional from Organic
1.
When did it start? Document duration
F – Concurrent stressful event in life
O – Trauma or travel
2.
Where is it located and where does it go?
F – Peri-umbilical or epigastric
O – Well localized away from umbilicus
CONTINUITY CLINIC
“EASY” 8 Questions
To Separate Functional from Organic
3.
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 severity
O – Isolated, sudden onset
CONTINUITY CLINIC
“EASY” 8 Questions
To Separate Functional from Organic
5.
What makes the pain better?
F – No relationship to interventions
O – Sometimes medications or position change help
6.
7.
What makes the pain worse?
F – Reinforcement from parents
Is the pain intermittent or constant
F – Constant
O - Intermittent
CONTINUITY CLINIC
“EASY” 8 Questions
To Separate Functional from Organic
8.
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
st
1


Emphasize the pain is real but the cause may
be hard to find
Exclude the functional 5:
1.
2.
3.
4.

Visit
Chronic UTI (especially in females)
Giardia
Lactose Intolerance
Stooling problems – constipation or irregular stool
pattern (IBS)
Consider Celiac Disease
CONTINUITY CLINIC
Physical 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 Work-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
st
1
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
What about H. pylori?

Circumstantial evidence against a major role for
H. pylori

Eradication: does not always result in
improvement of pain

Serology is NOT an accurate screener
CONTINUITY CLINIC
H. 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 Serology in Children

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…..


Prevalence: 1/250 (sero screening)
Children at increased risk
GI clinic “symptomatic” children
 Type I diabetic
 Down Syndrome

1/57
5-8%
1-2%

Results similar to those in Europe

ONLY 5% of US cases are diagnosed!
CONTINUITY CLINIC
Which Test for Celiac?
Antibody Test
Sensitivity Specificity
PPV
NPV
Gliadin IgG
65%
60%
30%
50%
Gliadin IgA
70%
75%
40%
80%
Endomysial
IgA
tTG human
IgA
90%
98%
95%
85%
95%
99%
99%
95%
CONTINUITY CLINIC
Medications for Abdominal 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 Abdominal Pain
Drug
Action
EtOH
Death
Mylicon
Anti-flatulence
None
No
Bentyl
Anti-spasmodic
None
Yes
AS, sedation,
anti-cholinergic
Donnatol AS, sedation,
anti-cholinergic
20%
Yes
24%
Yes
Levsin
CONTINUITY CLINIC
Ready to Apply Your
Knowledge?
Case 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 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 “EASY” 8 Questions
Functional
1. Start?
Trip to Mexico
2. Location?
Peri-umbilical
X
3. Duration?
Variable
X
4. Description?
Vague
X
X
5. Improvement? No relief on Rx
X
6. Worsens?
School Absence
X
7. Intermittent?
Variable
X
8. Signs/Sx?
None
X
CONTINUITY CLINIC
Organic
Real 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 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
CONTINUITY CLINIC
Remember to complete
the questions related to
this topic!