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Abdominal Pain in Children

Abdominal Pain in Children. Tina Williams FPH. Acute Infective/Inflammatory Obstructive Chronic or Recurrent Organic Functional / Non-organic. Acute - Inflammatory. Infections . Viral or bacterial GE . Gastritis may be part of systemic illness . Appendicitis

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Abdominal Pain in Children

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  1. Abdominal Pain in Children Tina Williams FPH

  2. Acute • Infective/Inflammatory • Obstructive • Chronic or Recurrent • Organic • Functional / Non-organic

  3. Acute - Inflammatory • Infections . Viral or bacterial GE . Gastritis may be part of systemic illness . Appendicitis . Mesenteric Adenitis . UTI’s . Psoas abscess . Pneumonias . Pancreatitis

  4. Constipation Malrotations Volvolus Intussuception Biliary – calculi, cholecystitis Renal calculi Obstructive

  5. Other Acute Causes • DKA, Shock • Referred Hip Pain • Testicular torsion • Henoch Schonlein Purpura

  6. Recurrent Abdominal Pain

  7. Recurrent Abdominal Pain Episodes of Abdominal Pain occurring at least monthly for 3 consecutive months with a severity that interrupts normal functioning John Apley, Bristol 1958

  8. Magnitude of the problem • Huge percentage of new GP referrals in POPD • 15% of children over age 6yrs • About 10% of them seek medical attention • Majority of teenagers, no organic cause

  9. RAP defined by Apley 1958 – Bristol • 8% organic cause found • 10 – 15 % from some early studies • Of 103 children referred to a tertiary GI Unit • 30% organic pathologies • 50% non-organic pain, half fulfilled criteria for IBS (36% of total) El-Matary et al 2004 – Bristol • Not representative

  10. Functional/Non-Organic RAP • Usually periumbilical p<0.002-Bristol • Can be epigastric or suprapubic • Cramps, IBS symptoms in 30% of these children • Anxiety related • Pain alleviated by defaecation p<0.04

  11. Organic RAP - Red Flags • < 6 years • Growth / Weight affected • Vomiting • Fever • “Diarrhoea” • Disturbed sleep p<0.01- Bristol 2004 • Abdominal tenderness p<0.005

  12. Organic Causes - GIT • Constipation • Food intolerance • Lactose Intolerance/ Sucrase-Isomaltase def. • Peptic Ulcer Disease/ • *H.pylori gastritis Finland J Clin Gastr Sep 2004 • Oesophagitis • Coeliac Disease • Meckel’s diverticulum • Recurrent intussuception • Malrotation

  13. Gall Bladder / Pancreatic • Cholelithiasis, cholecystitis • Choledochal Cyst • Pancreatitis Genitourinary • UTI • Urolithiasis • Wilm’s • Pelvic Inflammatory Disease - Chlamydia • Pregnancy related

  14. Miscellaneous • Abd migraine • Sickle cell crisis • Pb, Fe poisoning • HSP • Familial Mediterranean fever

  15. Environment Stress Illness Peripheral Nociceptive receptors - GIT Gut mucusal inflammation Increased Motility Stretch Genetics Visceral Hypersensitivity Perception of Pain Brain Pathophysiology of Abdominal Pain

  16. Peripheral Nociceptors in GIT Cell bodies of afferent fibres in Dorsal Root ganglia of spinal cord Medulla, Midbrain, Thalami Cortical Pain Perception Pathophysiology of Abdominal Pain

  17. Localisation of Pain • Visceral Pain felt in corresponding dermatome • Liver, Pancreas, Biliary tree, stomach, upper bowel - Epigastrium • Distal SB, Caecum, Appendix, Prox colon - umbilical • Distal LB, Urinary tract, pelvic organs - suprapubic

  18. Diagnosis • History + Examination • Dietary • Family • Psychosocial • Red flags of organic disease

  19. Investigations I • FBC, ESR, CRP, Amylase • Coeliac serology • *H.pylori serology/ Urea breath test • Urine mcs • Stool mcs, OCP • Abd USS

  20. Investigations II - Specific • Stool for occult blood • Stool Reducing substances • Upper GI contrast studies • ?? Empirical PPI’s, H2 blockers • Endoscopy • Meckels scan • Wireless capsule

  21. Management • Organic – Treat cause identified • Functional • Multidisciplinary • Dietician – Dietary exclusions for 6-8 wks • Psychologists • School • Play therapists • Medical : Antispasmodics, Bulk forming laxatives, TCA’s, ? Pizotifen

  22. Irritable Bowel Syndrome • El-Matary et al Bristol 2004 • 36% of referred children fulfilled criteria • 51% of functional abd pain • ROME Classification • Diagnostic criteria for functional gastrointestinal disorders

  23. ROME Classifications • 1989 Working Team Report • 1995 ROME I • 2000 ROME II In use • 2006 ROME III

  24. ROME II • At least 12 weeks of abd. Discomfort or pain in last 12 months with at least 2 of the following: • Relief with defaecation and/or • Onset assoc with change in stool freq. and/or • Onset assoc. with change in form or appearance of stools In the absence of organic disease

  25. Other features of IBS Not essential but supportive of diagnosis • Abnormal stool freq • Abnormal stool form • Abnormal stool passage • Passage of mucous • Bloating • Lower abdominal cramps • Family history/ somatisation

  26. Management • MDT approach • Rehabilitation – school + physiotherapy • Drugs as adjunct • Antispasmodics: Mebeverine • Laxatives – bulk forming - if required • Amytryptiline, Imipramine - dampen afferent neurones • Probiotics

  27. Summary • Recurrent abdominal pain over the age of 6 yrs more often than not is functional • Remember Red flags of organic disease • Basic investigations required • Multidisciplinary approach to management

  28. Questions?

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