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CHRONIC ABDOMINAL PAIN IN CHILDREN

CHRONIC ABDOMINAL PAIN IN CHILDREN. David Suskind M.D . Associate Professor of Pediatrics Division of Gastroenterology Hepatology and Nutrition University of Washington Seattle Children’s Hospital. Talk outline. General over view of chronic abdominal pain Disease specific entities

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CHRONIC ABDOMINAL PAIN IN CHILDREN

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  1. CHRONIC ABDOMINAL PAIN IN CHILDREN David Suskind M.D. Associate Professor of Pediatrics Division of Gastroenterology Hepatology and Nutrition University of Washington Seattle Children’s Hospital

  2. Talk outline • General over view of chronic abdominal pain • Disease specific entities • Constipation • Lactose • Fructose intolerance • Celiac • GERD • H. pylori • General work-up

  3. Primary Causes of Chronic Abdominal pain • Constipation  • Lactose intolerance • Fructose intolerance • Functional abdominal pain • Celiac • Food allergies eosinophilic esophagitis • Acid related disorders: Gastroesophageal reflux disease gastritis and ulcers • Infections: Mononucleosis, intestinal parasites, H. pylori bacterial infection • inflammatory bowel disease: ulcerative colitis and Crohn’s disease

  4. A Physicians Aspiration • ‘Our goal is to diagnose and treat our patients’ • Unfortunately we only have a handful of minutes to do so • So we triage our patients based upon our knowledge, our experience and the medical literature

  5. The History Apley’s Rule • Timeframe and time of day • Location • Intensity and character • Aggravating or alleviating factors • Associated signs and symptoms • Bowel habits • Vomiting • Gassiness • Weight loss • Dietary habits • Psychosocial stressors • Diagnosis / Family history

  6. “Red Flags” in Chronic Abdominal Pain Weight loss or growth deceleration Vomiting Pain awakens patient Radiation pain Recurrent oral ulcerations • Rectal bleeding • Constitutional symptoms • Rash • Arthralgia • Temperature • Pain well localized away from umbilicus • Positive family history of celiac, H. pylori or inflammatory bowel disease, pancreatitis

  7. Physical exam • Rectal exam

  8. Constipation: Recognition • 3% of general pediatric outpatient visits and 25% of pediatric gastroenterology Archives of disease, child 1983; 58:257 – 61.

  9. Variable Symptoms

  10. Constipation Treatment • After two-month period - 37% remained constipated • Specific fixed dose of laxative • parents did not realize that they needed to adjust the dose • failure to mention behavioral interventions and dietary interventions • Treatment success corresponded to how aggressively treated • colonic evacuation followed by daily laxative therapy Borowitz, SM, et al treatment of childhood constipation by primary care physicians: efficacy and predictors of outcome, Pediatrics 2005 April;115 (4):873-7.

  11. The treatment plan Step1 : Cleanout phase: emptying the colon Step 2: Maintenance phase: keeping the colon empty Step 3: Changing the behaviors and habits that increase the problem Step 4: Recognizing and treating relapses early The four-step treatment plan

  12. The treatment plan • Cleanout phase is to empty the old stool out of the colon. • Floppy colon can’t move firm stool • Maintenance is to keep stools soft to let colon empty itself easily. • Exercise itself back into shape • Can take a year or more to shrink

  13. The treatment plan – cleanout Step 1: The cleanout phase Get old stool emptied out of the colon. • Polyethylene Glycol • Each cleanout lasts 2 days • Usually needs to be repeated. • May cause cramping as the stool moves through the colon • Stay near a bathroom during the cleanout

  14. The treatment plan – cleanout Cleanout, cont. • Results during the first cleanout will vary from a slightly noticeable increase to 4 to 6 large volume stools a day. • Cleanout should be repeated every 2 weeks until stools are daily, very soft and pain is gone. • Symptoms will improve over time, not always immediately.

  15. The treatment plan – clean out AND • Stimulant laxatives • Increase the strength of the colon’s contractions and help move stool out. • Examples: Senna, Little Tummy’s Laxative or bisacodyl (Dulcolax)

  16. The treatment plan – maintenance Step 2: Maintenance phase • Continue giving the stool softener once every day at the maintenance dose • Adjust maintenance to assure soft stool • 1-3 soft mashed-potato-consistency stools per day. • Wait 3 days between dose changes • Continue treatment for 4 to 6 months • Even if things seem much better • Improves colonic tone

  17. Treatment plan – changing behaviors Step 3: Changing old behaviors and habits • Constipation gets worse with certain habits • Waiting too long to go • Not drinking enough liquid • Too much dairy • Not eating enough fiber • Eating too many constipating foods like bananas and cheese

  18. Treatment plan – changing behaviors New behaviors to adopt Have your child: Drink enough liquid throughout the day so their urine stays clear or pale yellow.

  19. Treatment plan – changing behaviors Get enough fiber every day • General rule: Your child’s age plus 5 = grams of fiber per day. Teens over 15 years old need 20-30 grams per day, just like adults.

  20. Treatment plan – changing behaviors Get enough fiber every day • fruits and vegetables, legumes and whole grains • Eat most grains as whole grains • Include 5 servings of fruit or vegetables every day. (Serving size: 1 serving = 1/4-1/2 cup brown rice, ½ c or 5 broccoli flowers, 1 handful raisins)

  21. Treatment plan – changing behaviors Know how to read food labels for fiber

  22. Treatment plan – changing behaviors Regular, relaxed toilet time. • After meals, sit on the toilet for about 5 minutes. • Use a foot stool so their feet don’t dangle when sitting. • Reward your child for cooperation in sitting on toilet. They don’t need to stool to be rewarded. • Star charts and point systems • Make it fun and avoid getting into arguments. • Continue this at least 2 times a day, consistently for at least the next year.

  23. Treatment plan – respond to relapses Step 4: Recognize and respond to relapses quickly • The children with the least frequent relapses are the ones who make the needed diet and behavior changes. • Restart stool softeners at the first sign of a relapse. • Cleanout whenever needed, as often as every 2 weeks.

  24. Lactose intolerance • Symptoms caused by maldigestion of lactose • Lactose is the carbohydrate (sugar) of milk • Lactase splits lactose in the intestine

  25. Disaccharidase Activities in Children: Normal Values and Comparison Based on Symptoms and Histologic Changes Gupta, Sandeep K.; Chong, Sonny K. F.; Fitzgerald, Joseph F. Journal of Pediatric Gastroenterology & Nutrition 28(3), March 1999, pp 246-251

  26. Diagnostic tests • H2 Breath Test • bacteria in the bowel digest lactose • generating hydrogen (H2) → detection of H2 in the exhaled air • Biopsy for lactase deficiency • Removal of lactose from diet

  27. Celiac disease • Immune-mediated enteropathy caused by a permanent sensitivity to gluten in genetically susceptible individuals • Healthy population: 1:133 • 1st degree relatives: 1:18 to 1:22 • 2nd degree relatives: 1:24 to 1:39 • Symptomatic and asymptomatic individuals • including subjects affected by: • Type 1 diabetes • Williams/Downs/Turner syndrome • Selective IgA deficiency

  28. The Celiac Iceberg Symptomatic Celiac Disease Manifest mucosal lesion Silent Celiac Disease Normal Mucosa Latent Celiac Disease Genetic susceptibility: - DQ2, DQ8 Positive serology

  29. Prevalence 1:133 Celiac: Epidemiological Study in USA Population screened 13145 Healthy Individuals Risk Groups 4126 9019 2nd degree relatives Symptomatic subjects 1st degree relatives 1275 3236 4508 Positive Negative Positive Negative Positive Negative Positive Negative 1242 81 3155 205 4303 33 31 4095 Prevalence Prevalence Prevalence 1:40 1:22 1:39 Projected number of celiacs in the U.S.A.: 2,115,954 Actual number of known celiacs in the U.S.A.: 40,000 For each known celiac there are 53 undiagnosed patients. A. Fasano et al., Arch Int Med 2003;163:286-292.

  30. Celiac Disease Prevalence Data *based on classical, clinical presentation Fasano & Catassi, Gastroenterology 2001; 120:636‑651.

  31. 2 1 2b 2a 8 3 8 TTG Cytokines (IL2, IL15) Tk 6b 7 4 P 6a APC T AGA, EMA, atTG B 5 Submucosa

  32. Gastrointestinal Manifestations 6-24 months • Chronic or recurrent diarrhea • Abdominal distension • Anorexia • Failure to thrive or weight loss • Vomiting • Constipation • Irritability Older Children and Adults • Dermatitis Herpetiformis • Dental enamel hypoplasia • Osteopenia/Osteoporosis • Short Stature • Delayed Puberty • Iron-deficient anemia • Resistant to oral Fe • Hepatitis • Arthritis

  33. Typical Celiac Disease

  34. Asymptomatic Celiac • Silent - No or minimal symptoms • Damaged mucosa and positive serology • Asymptomatic individuals from groups at risk such: • First degree relatives • Down syndrome patients • Type 1 diabetes patients • Latent - No symptoms, normal mucosa • May show positive serology. • Identified by following in time asymptomatic individuals previously identified at screening from groups at risk

  35. Short stature Dermatitis herpetiformis Dental enamel hypoplasia Recurrent stomatitis Fertility problems Osteoporosis Gluten ataxia and other neurological disturbances Refractory celiac disease and related disorders Intestinal lymphoma Major Complications of Celiac Disease

  36. Celiac Diagnosis Diagnostic principles • Confirm diagnosis before treating • Diagnosis of Celiac Disease mandates a strict gluten-free diet for life • following the diet is not easy • QOL implications • Failure to treat has potential long term adverse health consequences • increased morbidity and mortality

  37. SerologicTesting for Celiac Role of serological tests: • Identify symptomatic individuals who need a biopsy • Screening of asymptomatic “at risk” individuals • Supportive evidence for the diagnosis • Monitoring dietary compliance

  38. Serological Tests for Celiac • Antigliadin antibodies (AGA) • Antiendomysial antibodies (EMA) • Anti tissue transglutaminase antibodies (TTG) • first generation (guinea pig protein) • second generation (human recombinant) • HLA typing

  39. Serological Test Comparison Sensitivity % Specificity % AGA-IgG 69 – 85 73 – 90 AGA-IgA 75 – 90 82 – 95 EMA (IgA) 85 – 98 97 – 100 TTG (IgA) 90 – 98 94 – 97 Farrell RJ, and Kelly CP. Am J Gastroenterol 2001;96:3237-46.

  40. Histological Features Normal 0 Infiltrative 1 Hyperplastic 2 Partial atrophy 3a Subtotal atrophy 3b Total atrophy 3c Horvath K. Recent Advances in Pediatrics, 2002.

  41. Treatment • Only treatment for celiac disease is a gluten-free diet (GFD) • Strict, lifelong diet • Avoid: • Wheat • Spelt • Rye • Barley

  42. Gastroesophageal Reflux Disease Regurgitation - Gastric contents pass the lower and upper esophageal sphincter Vomiting - Ejection of gastric contents through the mouth.

  43. Pathophysiology • Lower Esophageal Sphincter (LES) • Cardioesophageal angle of His • Size Matters

  44. Pathophysiology cont. • Intragastric pressure • gastric compliance • meal size/volume relation • gastric emptying • body position

  45. Diagnostic tests • Upper GI x-ray • Rules out structural causes of reflux • congenital and acquired • webs, rings, slings, strictures, or malrotation • DOES NOT DIAGNOSE REFLUX

  46. Diagnostic tests • Upper GI contrast study • Esophageal pH probe monitoring • Impedance monitoring • Upper endoscopy and biopsy • Nuclear scintigraphy study

  47. Hiatal hernia diaphragm stomach

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