func%onal gastrointes%nal disease pediatrics
TRANSCRIPT
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Func%onalGastrointes%nalDiseasePediatrics
SmallGroupSession:March1,2020ChristopheFaure,MD,Professor
DivisionofGastroenterology,HepatologyandNutriCon,UniversitédeMontréal(CHUSainte-JusCne)
ElyanneRatcliffe,MD,AssociateProfessorDivisionofGastroenterologyandNutriCon,McMasterUniversity
(McMasterChildren’sHospital)
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Conflict of Interest Disclosure (over the past 24 months)
• NorelevantrelaConshipswithanycommercialornon-profitorganizaCons
Name: Dr. C. Faure
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Conflict of Interest Disclosure (over the past 24 months)
Commercial or Non-Profit Interest Relationship
American Neurogastroenterology and Motility Society
Member, ANMS Council
Name: Dr. E. Ratcliffe
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✔ Medical Expert (as Medical Experts, physicians integrate all of the CanMEDS Roles, applying medical knowledge, clinical skills, and professional values in their provision of high-quality and safe patient-centered care. Medical Expert is the central physician Role in the CanMEDS Framework and defines the physician’s clinical scope of practice.)
✔ Communicator (as Communicators, physicians form relationships with patients and their families that facilitate the gathering and sharing of essential information for effective health care.)
✔ Collaborator (as Collaborators, physicians work effectively with other health care professionals to provide safe, high-quality, patient-centred care.)
Leader (as Leaders, physicians engage with others to contribute to a vision of a high-quality health care system and take responsibility for the delivery of excellent patient care through their activities as clinicians, administrators, scholars, or teachers.)
✔ Health Advocate (as Health Advocates, physicians contribute their expertise and influence as they work with communities or patient populations to improve health. They work with those they serve to determine and understand needs, speak on behalf of others when required, and support the mobilization of resources to effect change.)
✔ Scholar (as Scholars, physicians demonstrate a lifelong commitment to excellence in practice through continuous learning and by teaching others, evaluating evidence, and contributing to scholarship.)
Professional (as Professionals, physicians are committed to the health and well-being of individual patients and society through ethical practice, high personal standards of behaviour, accountability to the profession and society, physician-led regulation, and maintenance of personal health.)
CanMEDS Roles Covered
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LearningObjecCvesAttheendofthissessionparCcipantswillbeableto:1. RecognizetheconCnuumofclinicalpresentaConsoffuncConal
consCpaConandirritablebowelsyndromeinpediatricpaCents.2. IdenCfypsychosocialfactorsthatplayaroleinthegenesis/
exacerbaConofpediatricIBS.3. Describemanagementapproaches,bothpharmacologicandnon-
pharmacologic,usedinthecareofpediatricpaCentswithIBS.
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Case• 12yearoldfemale• Referredfor“consCpaCon”• 2yearhistory
• Abdominalpain• VomiCng• ConsCpaCon
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Case• MulCpleadmissionsfor“consCpaCon”presenCngwithabdominalpainandvomiCng
• NGinserted;cleanoutwithPEG+electrolytes• Dailybowelmovements;BristolType6• DecreasedappeCte;feels“full”• Abdominalpaindayandnight;moderate4-7onpainscale
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Does she have func-onal cons-pa-on or IBS with cons-pa-on?
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FuncConalConsCpaConRomeIVDiagnos%cCriteriaforFunc%onalCons%pa%on(Child/Adolescent)
Mustinclude2ormoreofthefollowingoccurringatleastonceperweekforaminimumof1monthwithinsufficientcriteriaforadiagnosisofirritablebowelsyndrome
1. 2orfewerdefecaConsinthetoiletperweekinachildofadevelopmentalageofatleast4years
2. Atleast1episodeoffecalinconCnenceperweek3. HistoryofretenCveposturingorexcessivevoliConalstool
retenCon4. Historyofpainfulorhardbowelmovements5. Presenceoflargefecalmassintherectum6. Historyoflargediameterstoolsthatcanobstructthetoilet
AherappropriateevaluaCon,thesymptomscannotbefullyexplainedbyanothermedicalcondiCon.
HyamsJSGastroenterology2016
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IBS–PartofFBDConCnuum
Lacy BE Gastroenterology 2016
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IrritableBowelSyndromeRomeIVDiagnos%cCriteriaforIrritableBowelSyndrome(Child/Adolescent)
Mustincludeallofthefollowing:
1. Abdominalpainatleast4dayspermonthassociatedwithoneormoreofthefollowing:a. RelatedtodefecaConb. Achangeinfrequencyofstoolc. Achangeinform(appearance)ofstool
2. InchildrenwithconsCpaCon,thepaindoesnotresolvewithresoluConofconsCpaCon(childreninwhomthepainresolveshavefuncConalconsCpaCon)
3. AherappropriateevaluaCon,thesymptomscannotbefullyexplainedbyanothermedicalcondiCon.
Criteriafulfilledforatleast2monthsbeforediagnosis.
HyamsJSGastroenterology2016
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PrevalenceofFGIDsaccordingtoRomeIV
RobinetalJPediatr2018
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Case• AddiConalsymptomsofheadaches,blurredvision,dizziness,weaknesses
• Parentsseparated;familystressedbyadmissions/appointmentsandlackofprogress
• DuetoconstellaConofsymptomsandprominenceofabdominalpain–referredtoPediatricChronicPainProgram
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Should we worried be about anything else?
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ClinicalAssessment• EstablishaworkingandtherapeuCcalliancewithpaCentandfamily• TakeCme+++• PaCent’shistory• Painhistory• StressfullepisodeorinfecCousepisodeassociatedwithonsetofsymptoms
• PsychosocialhistoryofpaCentandfamily• FamilyhistoryofGIdisorders• DietaryassociaConwithpainepisodes
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RedFlags:neithersensiCvenorspecific…• Pain
! NocturnalPain! Persistantrightupperorrightlowerquadrantpain
• AssociatedGIsymptoms! PersistentvomiCng! Nocturnaldiarrhea! Dysphagia! Hematochezia! Perirectaldisease
• Generalsymptoms! Fever,arthriCs,apthousulcers! InvoluntaryWeightloss! DeceleraConoflineargrowth,delayedpuberty
• FamilyhistoryofIBD
• Familyhistoryofceliacdisease• FamilyhistoryofpepCculcer
RasquinetalGastroenterology2006
…butthegreaterthenumberpresent,thegreaterthelikelihoodoforganicdisease
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Work-Up?• DirectedbyhistoryofthechildandfamilyandbyphysicalexaminaCon• IniCalscreeningcaninclude:
• CBC,CRP,albumin• IgAtTG• ALT,lipase/amylase• Urianalysis• FecalcalprotecCn• Stoolforovaandparasites
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IBSandCeliacDiseaseIBS:4Cmeshigherriskofhavingceliacdiseasethanthe
generalpediatricpopulaCon(P<.001;oddsraCo,4.19[95%CI,2.03-8.49])
CristoforietalJAMAPediatr2014
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What caused her to be like this?
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FBD–SensiCzingEvents
HyamsJSGastroenterology2016
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Post-infecCousFGID• Norovirus:Nopediatricdata
• IBS(OR11.40;95%CI3.44–37.82;Zaninietal.AmJGastroenterol2012),
• FD,consCpaCon(Porteretal.ClinInfectDis2012)
• Giardia:• IBSRR=3.4(95%CI2.9to3.8)aherinfecCon(Wensaasetal.Gut2012)
• Diarrhea,flatulenceinpreschoolchildren(Mellingenetal.BMCPublicHealth2010)
• CJejuni(IBS,FD)• Salmonella(IBS,FD)• Shigella(IBS)
Spilleretal.Gastro2009Sapsetal.JPediatr2008Futagamietal.APT2015
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But she is not an anxious girl…
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VisceralHypersensiCvityandSymptomSeverity
• PsychologicalcomorbidityiscommoninFGIDs• BarostattesCnginadultIBSandFDcohortsdemonstratedincreasingGIsymptomseveritywithincreasingvisceralhypersensiCvity
• Findingswereindependentofatendencytoreportsymptoms,oranxiety/depressioncomorbidiCes
Simrénetal,Gut.2018Feb;67(2):255-262
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VisceralHypersensitvity:RectalSensoryThresholdforPain(RSTP)
IBS Controls0
10
20
30
40
50
RST
P (m
mH
g)
FaureetalJPediatr2007CasCllouxetalJPGN2008
IBS Controls0
10
20
30
40
50R
STP
(mm
Hg)
85% of the pa-ents = RSTP ≤ 30.8 mmHg
(<5th perc. of Normal Children)
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Psychologicalco-morbidiCesarefrequent
IBS FAP FD50
60
70
80
90
100STAI-C
CampoetalPediatrics2004FaureetalJPediatr2007CasCllouxetalJPGN2008
Anxiety~50% Depression~10%IBS FAP FD
0
10
20
30
40
CDI
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Family-childdynamicsinfluenceseverityofsymptoms
FamilyFactors• Modeling• Psychologicaldistress• ParentalpercepConof:
• Pain• Child’sself-efficacy
• ParentalprotecCveness(e.g.keepinghomefromschoolwhenchildinpain)
• Parentalcatastrophizing
ChildFactors
• Copingstyle/self-efficacy
vanTilburgetal,WorldJGastroenterol2015;21(18):5532-41DuPennetal,Children2016;3(15)
Cunninghametal,JPGN2014;59:732–738
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So, how do we treat this?
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Treatmentshouldbetailoredto…
• IBSsubtype:IBS-D,IBS-C• IBSseverity• Associatedpsychologicalco-morbidiCes• IBSpathophysiologicalmechanism(?)
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ManagementofFGIDs
• PosiCvediagnosis• ProvidepathophysiologicalexplanaCons• Reassurance
• Symptomsarerealbutarenotlife-threatening• Mustlearntolive/copewiththesymptom
• Avoidtriggers
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IBSTreatment:NutriCon• Reducesorbitol,fructose,lactose?• LowFODMAPs• Fibres=age(years)+5g• Avoid:
• Fat• Tea,coffee,Coke• Spicyandacidicfood
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IBS:SymptomaCcTreatments• ConsCpaCon:mineraloil,lactulose,PEG3350• Diarrhea:loperamide(Imodium®),cholestyramine(Questran®)…
• Pain:AnCspasmodics:trimebuCne,dicyclomine,Pepermintoil(KlineJPediatr2001)…
• Gas:simethicone…
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IBS:Non-pharmacologicalTreatments
• ProbioCcs:LactobacillusGG,LactobacillusrhamnosusGGJPGN2010;51:24-30Gut2010;59:325-32
• HypnosisVliegeretal.Gastroenterology2007
• CogniCvebehaviouraltherapy(CBT)Youssefetal.JPGN2004
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IBS:TreatmentofSevereFormsInmostseverecases(schoolabsenteeism)• Amitriptyline0.2to0.4mg/kgHS,10to50mg/day;or
• Imipramine0.2to0.4mg/kgHS,10to50mg/day(lessanCcholinergic)
• Citalopram(5-HTreuptakeinhibitor)10mg/dayto40mgdie
• Mirtazapine7.5to15mgHS
Baharetal.JPediatr2008(RCT)Sapsetal.Gastroenterology2009(RCT)
TeitelbaumJPGN2011(Open)Campoetal.2004(openstudy)RoohafzaetalNGM2014RCT
Hussainetal.JPGN2014
CheckforSuicidalIdeaConandQT
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Placebo
Kaptchuketal.BMJ2010
TheplaceboeffectinIBS(evenwhenplaceboisannounced)
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What’snext?• IBS-C:LinacloCde:Guanylate-cylaseCagonist
• ImprovesvisceralhypersensiCvity;increaseschloridesecreCon• IBS-D:Eluxadoline:mu-opioidreceptoragonistandadelta-opioidreceptorantagonist
• IBS-D:Ondansetron:5-HT3Rantagonist• LarazoCde:sCmulaConofCghtjuncCons• EbasCne(Aerius)(H1antagonist):TRPV1desensibilisaCon(Wouters2016)• Pregabaline(SaitoetalAPT2018)• And…understandwhysomepaCentsrespondtoFODMAPSandothersdonot
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AuricularNeurosCmulaConControls ac-vity of pain areas in the central nervous system par-cularly the amygdala and spinal cord
IB-STIM™
KrasaelapetalClinGastroHepatol2020KovacicetalLancetGastro2017
27IBSadolescents(medianage,15.3y):auricularneurosCmulaCon23IBSadolescents(medianage,15.6y):shamsCmulaCon5days/weekfor4weeks
%with30%improvementinworstpainseverityinPENFSvsshamaher3weeksandatextendedfollow-up8–12weeksaherendoftherapy
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MoayyediPJCAG2019HyamsJSGastroenterology2016
IBSManagement-Pediatrics
Linaclotide: Safety and efficacy study of a range of doses administered orally to children aged 7-17 years, with irritable bowel syndrome with constipation (NCT02559817). Study completion date August 2019. Black box warming for < 6 years.