Recurrent abdominal pain of childhood: new insights

1. Recurrent abdominal pain of childhood: new insights Professor Mike Thomson Centre for Paediatric Gastroenterology Sheffield Children’s Hospital and Portland Hospital, London www.paediatricgastroenterologist.com

2. Chronic abdominal pain of childhood • ‘The Received Wisdom’ • ‘The New Vantage Point’ • A practical diagnostic/therapeutic approach

3. Chronic abdominal pain of childhood • ‘The Received Wisdom’ • ‘The New Vantage Point’ • A practical diagnostic/therapeutic approach

4. Chronic abdominal pain: ‘The Received Wisdom’ • Apley and Naish 1958 • “Chronic intermittent abdominal pain between the ages of 4 and 16 years lasting for more than 3 months and interfering with normal daily activity” • Apley J, Naish N. Arch Dis Child. 1958;50:429-36.

5. Chronic abdominal pain • 10-15% all <16 years fulfil this definition • Further 10-15% experience pain but does not interfere with normal daily activities • ‘Recurrent abdominal pain’ (RAP) • ‘Functional’

6. y

9. No warning signs

10. Warning signs

12. STRESS Substance P Impaired Intestinal Barrier Function Mast cells Macromolecular Ag absorption CRH Eosinophil NK1 and NK2 PAIN Induction of inappropriate inflammaiton

18. ‘Functional’ RAP • ‘Nearer the umbilicus’ rule • GENUINE pain • Altered GI motility and visceral hypersensitivity • Not necessarily a diagnosis of exclusion • NOT if < 4 years, and less common if >14 years

19. ‘Functional’ RAP : THE FALLACY! • ‘the high achieving perfectionist constantly worrying daughter of a demanding father in a highly stressful school environment’ • Nevertheless…..

20. ‘Functional’ RAP: characteristics • Evidence of physical or psychological stressful stimuli • Environmental reinforcement of pain behaviour • Normal physical examination • Normal first line lab evaluation (FBC, ESR, CRP, urinalysis, urine culture, faecal MCS OCP)

21. ‘Functional’ RAP: make a positive diagnosis • Paroxysmal (variable in severity) • Clustering of pain episodes (weeks-months) • Begins gradually • Peri-umbilical or mid-epigastric • Inability to describe nature of pain • No temporal association with meals, exercise, but often happens at same time of day • Interrupts normal activity

22. Chronic abdominal pain of childhood • ‘The Received Wisdom’ • ‘The New Vantage Point’ • A practical diagnostic/therapeutic approach

23. ‘The New Vantage Point’Apley’s “rules” can now be questioned • GI motility studies • Helicobacter pylori • GI food allergy • Brain-gut axis • Development of paediatric endoscopy and other investigations • Abdominal migraine • Disaccharidase deficiencies

24. Apley’s “rules” now questioned • GI motility studies • Helicobacter pylori • GI food allergy • Brain-gut axis • Development of paediatric endoscopy and other investigations • Abdominal migraine • Disaccharidase deficiencies

25. ? Organic basis for recurrent abdominal pain in childhood • “Abnormal gastroduodenal motility in children and adolescents with recurrent functional abdominal pain” Pineiro-Carrero et al. J Ped 1988 Abnormal patterns of motility: • ineffective propagation of luminal contents • segmental distension of small bowel • stimulation of proprioceptors in bowel wall

26. ? Organic basis for recurrent abdominal pain in childhood • “Abnormalities of Gastrointestinal Motility in Children with Non-ulcer dyspepsia” • Cucchiara et al. Dig Dis Sci 1991 Abscence of antral phase III • delayed gastric emptying Non-propagated uncoordinated s.i. motility • increased duodeno-gastric reflux

27. Electrogastrography

28. Apley’s “rules” now questioned • GI motility studies • Helicobacter pylori • GI food allergy • Brain-gut axis • Development of paediatric endoscopy and other investigations • Abdominal migraine • Disaccharidase deficiencies

31. Lymphonodular hyperplasia

32. H pylori gastric ulcer

33. Urea breath test

34. ? Helicobacter pylori and recurrent abdominal pain in childhood. FOR: 1. Raymond et al J Clin Microbiol Aug 1994 abdominal painFH of PU HP +ve n=77 63.3% ns14% ns HP -ve n=74 48.6% ns5% ns • 75% of HP +ve group WITH abdo pain had NORMAL gastric mucosa / no PU

35. ? Helicobacter pylori and recurrent abdominal pain in childhood. FOR: 2. Chong et al Pediatrics Aug 1995 HP +vePU RAP n=218 17.4%4% (4/14 HP +ve) No RAP n=238 10.5%0% (p<0.05) (only 111/218 with RAP were endoscoped)

36. ? Helicobacter pylori and recurrent abdominal pain in childhood. AGAINST: 1. van der Meer et al Eur J Ped Oct 1993 HP serology +ve RAP n=82 8.5% Control n=39 5.1% (ns)

37. ? Helicobacter pylori and recurrent abdominal pain in childhood. AGAINST: 2. McCallion et al J Ped Surg Mar 1995 RAP HP +ve n=127 17.3% Fasting serum HP -ve n=312 16.3% gastrin measured

38. ? Helicobacter pylori and recurrent abdominal pain in childhood. AGAINST: 3. Macarthur et al JAMA Mar 1995 meta-analysis of 45 studies H Pylori and: Antral gastritis / DU...strong association GU.............................weak association RAP...........................very weak / no association

42. CLA resistance or prior CLA therapy? H. pylori algorithm Symptoms 1 EGD with biopsies (& culture *) No Yes 12 2 H. pylori with PUD and/or gastritis Treat without CLA: PPI AMO MET 2 wks or bismuth based tx. FISH for CLA on paraffin slides of first biopsies EGD with Culture and CLA-testing 14 3 CLA resistance?* 13 15 Yes 4 No Unknown Treat according to result of CLA testing PPI-AMO-MET# or PPI-AMO-CLA# or Bismuth-AMO-MET or Sequential therapy 6 16 PPI AMO CLA PPI AMO MET 6 7 5 Noninvasive test for eradication Noninvasive test for eradication 17 8 HP eradicated? HP eradicated? Assess + Encourage compliance No Yes 11 Yes No 9 18 Observe Consider: other antibiotic bismuth quadruple therapy higher dosage CLA resistance or prior CLA therapy? Observe 10 19 12 EGD= Esophagogastroduodenoscopy PUD = Peptic ulcer disease CLA= Clarithromycin • = area with >20% CLA resistance rate • # according to background of child 20

43. Apley’s “rules” now questioned • GI motility studies • Helicobacter pylori • GI food allergy • Brain-gut axis • Development of paediatric endoscopy and other investigations • Abdominal migraine • Disaccharidase deficiencies

44. RAP and food allergy • GOR and upper GI dysmotility • Intestinal hurry and enteropathy • Constipation • Strong personal/FH of atopy/autoimmunity

45. RAP and food allergy • GOR and upper GI dysmotility • Intestinal hurry and enteropathy • Constipation • Strong personal/FH of atopy/autoimmunity

46. Allergic oesophagitis

47. RAP and food allergy • GOR and upper GI dysmotility • Intestinal hurry and enteropathy • Constipation • Strong personal/FH of atopy/autoimmunity

50. RAP and food allergy • GOR and upper GI dysmotility • Intestinal hurry and enteropathy • Constipation • Strong personal/FH of atopy/autoimmunity