Lecturer: Sakharova I.Ye., MD, PhD

1. Functional and organic diseases of digestive tract. Etiology, pathogenesis, clinical features, diagnostics, treatment and prevention. Lecturer: Sakharova I.Ye., MD, PhD

2. Chronic abdominal pain

3. Frog position in severe crampy abdominal pain

4. Is it a problem? • Prevalence 0.5%-19% in community • 13-17% middle/high school students weekly pain • 2-4% of paediatric office visits • Considerable morbidity, missed school days • Difficult, time-consuming and expensive to manage becauseof diagnostic uncertainty, chronicity and increasing parentalanxiety

5. What I’ll talk about • Definitions of functional abdominal pain • Cause of functional abdominal pain • Differentiating organic vs functional pain • Management of functional abdominal pain

6. Rome III criteria, 2006 • Functional dyspepsia • Irritable bowel syndrome • Functional abdominal pain • Functional abdominal pain syndrome • Abdominal migraine - No evidence of an inflammatory, anatomical, metabolic orneoplastic process - Criteria fulfilled at least once a week for at least two monthsbefore diagnosis

7. Functional dyspepsia • Persistent or recurrent pain or discomfort centred in theupper abdomen (above the umbilicus) • Not relieved by defecation or associated with the onset of achange in stool frequency or stool form

8. Recurrent abdominal pain (Apley and Naish, 1958) • Waxes and wanes • 3 episodes in 3 months • Severe enough to affect activities

9. Irritable bowel syndrome Abdominal discomfort (uncomfortable sensation notdescribed as pain) or pain associated with two or more of thefollowing at least 25% of the time: • Improved with defecation • Onset associated with a change in frequency of stool • Onset associated with a change in form (appearance) of stool

10. Functional abdominal pain • Episodic or continuous abdominal pain • Insufficient criteria for other functional gastrointestinaldisorders

11. Functional abdominal pain syndrome Must include functional abdominal pain at least 25% of thetime and one or more of the following: • Some loss of daily functioning • Additional somatic symptoms such as headache, limb pain, ordifficulty in sleeping

12. Abdominal migraine • Paroxysmal episodes of intense, acute periumbilical pain that lasts forone or more hours • Intervening periods of usual health lasting weeks to months • The pain interferes with normal activities • The pain is associated with two or more of the following: - Anorexia - Nausea - Vomiting - Headache - Photophobia - Pallor Criteria fulfilled two or more times in the preceding 12 months

13. What causes it? • Biopsychosocial model • Visceral sensation, disturbances in GI motility, hormonalchanges, inflammation • Psychological factors • Family dynamics • Brain-gut axis • Sexual abuse – longer duration of symptoms • Parental anxietyin first year of life associated with chronicabdo pain before age 6 • GI problems in parents

14. Chronic abdo pain in OPD • Organic vs functional pain • Organic pain 5% in general population, 40% in paediatricgastroenterology OPD.

15. Organic vs functional pain • No diagnostic tools to differentiate • Presence of alarm symptoms or signs increases theprobability of an organic disorder and justifies further tests

16. History and examination • Analysis of the pain • GI symptoms including bowel habit • Genitourinary symptoms • Effect on daily living • Family history – GI problems, migraine

17. Alarm symptoms • Involuntary weight loss • Deceleration of linear growth • Gastrointestinal blood loss • Significant vomiting • Chronic severe diarrhoea • Unexplained fever • Persistent right upper or right lower quadrant pain • Family history of inflammatory bowel disease

18. Organic pain - differential GI tract • Chronic constipation • Lactose intolerance • Parasite infection (Giardia) • Excess fructose/sorbitol ingestion • Crohns • Peptic ulcer • Reflux esophagitis • Meckels diverticulum • Recurrent intussusception • Hernia – internal, inguinal, abdominal wall • Chronic appendicitis

19. Organic pain - differential Gallbladder and pancreas • Cholelithiasis • Choledochal cyst • Recurrent pancreatitis Genitourinary tract • UTI • Hydronephrosis • Urolithiasis

20. Miscellaneous causes • Abdominal epilepsy • Gilberts syndrome • Familial Mediterranean fever • Sickle cell crisis • Lead poisoning • HSP • Angioneurotic edema • Acute intermittent porphyria

21. Diagnostic Tools • Rome III Criteria • Essential Investigations : according to symptoms e.g. - CBC - U A , Stool exam - LDG, Amylase ,lipase - Ultrasound - Barium study - Gastric emptying time test ,Intestinal transit time ,Colonic transittime test - Hydrogen breath test: lactose ,lactulose,glucose - Endoscopy - Skin Prick test - Urea Breath test

22. Recommendation of North American Society forPediatric Gastroenterology, Hepatology and Nutrition • Additional diagnostic evaluation is not required in childrenwithout alarm symptoms • Testing may be carried out to reassure children and theirparents

23. What are the predictive valuesof diagnostic tests? • There is no evidence to suggest that the use ofultrasonographic examination of the abdomenand pelvisin the absence of alarm symptoms has a significant yieldof organic disease(evidence quality C). • There is little evidence to suggest that the use ofendoscopy and biopsy in the absence of alarmsymptoms has a significant yield of organic disease (evidence quality C). • There is insufficient evidence to suggest that the use ofesophageal pH monitoring in the absence of alarmsymptoms has a significant yield of organic disease(evidence quality C).

24. Treatment • Deal with psychological factors • Educate the family (an important part of treatment) • Focus on return to normal functioning rather than on thecomplete disappearance of pain • Best prescribe drugs judiciously as part of amultifaceted, individualised approach, to relievesymptoms and disability

25. Treatment • Medicines: • Acid lowering agents • Mucoprotective drugs • Motility regulators • Laxatives • Analgesics • Probiotics • Gas adsorbants • Dietary and life style change • Psychotherapy

26. Pharmacologic treatmentapproach A. Antacids B. H2- receptor antagonist C. Proton pump inhibitors D. Sucralfate E. Prokinetics

27. Treatment of Acid-related disorders • H2-receptor Antagonists: Ranitidine (2-4 mg/kg/d up to 150 mg bid), Famotidine (1-1.2 mg/kg/d up to 20 mg bid) • PPI: Omeprazole (0.8 mg/kg/d;effective dose range of0.3-3.3 mg/kg/d), Lansoprazole (0.8 mg/kg/d) • Cytoprotective Agents: Sucralfate(40-80 mg/kg/d up to 1 g qid) Rabemipride ( 1 x 3 )

30. Prognosis • Majority of children mild symptoms and managed in primarycare • Studies of prognosis are mainly in referred patients • Systematic review • 29.1% of children had on-going abdo pain (follow-up ranged 1-29 yrs) • May develop irritable bowel synd as adults • Risk of later emotional symptoms and psychiatric disorders, particularly anxiety disorders

31. Success is not final, failure is not fatal. It is the courage to continue that counts. Winston Churchill

32. THANKS FOR ATTENTION