Functional and organic diseases of gastro-duodenal zone and intestine.Lecturer: Sakharova I.Ye., MD, PhD

Chronic abdominal pain

Frog position in severe crampyabdominal pain

Is it a problem?Prevalence 0.5%-19% in community13-17% middle/high school students weekly pain2-4% of paediatric office visitsConsiderable morbidity, missed school daysDifficult, time-consuming and expensive to manage because of diagnostic uncertainty, chronicity and increasing parental anxiety

What Ill talk aboutDefinitions of functional abdominal painCause of functional abdominal painDifferentiating organic vs functional painManagement of functional abdominal pain

Rome III criteria, 2006

Functional dyspepsiaIrritable bowel syndromeFunctional abdominal painFunctional abdominal pain syndromeAbdominal migraine

- No evidence of an inflammatory, anatomical, metabolic or neoplastic process- Criteria fulfilled at least once a week for at least two months before diagnosis

Functional dyspepsiaPersistent or recurrent pain or discomfort centred in the upper abdomen (above the umbilicus)Not relieved by defecation or associated with the onset of a change in stool frequency or stool form

Recurrent abdominal pain (Apley and Naish, 1958)

Waxes and wanes3 episodes in 3 monthsSevere enough to affect activities

Irritable bowel syndrome

Abdominal discomfort (uncomfortable sensation not described as pain) or pain associated with two or more of the following at least 25% of the time:

Improved with defecationOnset associated with a change in frequency of stoolOnset associated with a change in form (appearance) of stool

Functional abdominal painEpisodic or continuous abdominal painInsufficient criteria for other functional gastrointestinal disorders

Functional abdominal pain syndrome

Must include functional abdominal pain at least 25% of the time and one or more of the following:

Some loss of daily functioningAdditional somatic symptoms such as headache, limb pain, or difficulty in sleeping

Abdominal migraineParoxysmal episodes of intense, acute periumbilical pain that lasts for one or more hoursIntervening periods of usual health lasting weeks to monthsThe pain interferes with normal activitiesThe pain is associated with two or more of the following:- Anorexia- Nausea- Vomiting- Headache- Photophobia- PallorCriteria fulfilled two or more times in the preceding 12 months

What causes it?Biopsychosocial modelVisceral sensation, disturbances in GI motility, hormonal changes, inflammationPsychological factorsFamily dynamicsBrain-gut axisSexual abuse longer duration of symptomsParental anxiety in first year of life associated with chronic abdo pain before age 6GI problems in parents

Chronic abdo pain in OPD

Organic vs functional pain

Organic pain 5% in general population, 40% in paediatric gastroenterology OPD.

Organic vs functional pain

No diagnostic tools to differentiatePresence of alarm symptoms or signs increases the probability of an organic disorder and justifies further tests

History and examination

Analysis of the painGI symptoms including bowel habitGenitourinary symptomsEffect on daily livingFamily history GI problems, migraine

Alarm symptoms

Involuntary weight lossDeceleration of linear growthGastrointestinal blood lossSignificant vomitingChronic severe diarrhoeaUnexplained feverPersistent right upper or right lower quadrant painFamily history of inflammatory bowel disease

Organic pain - differentialGI tractChronic constipationLactose intoleranceParasite infection (Giardia)Excess fructose/sorbitol ingestionCrohnsPeptic ulcerReflux esophagitisMeckels diverticulumRecurrent intussusceptionHernia internal, inguinal, abdominal wallChronic appendicitis

Organic pain - differentialGallbladder and pancreas CholelithiasisCholedochal cystRecurrent pancreatitisGenitourinary tract UTI Hydronephrosis Urolithiasis

Miscellaneous causesAbdominal epilepsyGilberts syndromeFamilial Mediterranean feverSickle cell crisisLead poisoningHSPAngioneurotic edemaAcute intermittent porphyria

Diagnostic Tools

Rome III CriteriaEssential 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 transit time test- Hydrogen breath test: lactose ,lactulose,glucose- Endoscopy- Skin Prick test- Urea Breath test

Recommendation of North American Society for Pediatric Gastroenterology, Hepatology and NutritionAdditional diagnostic evaluation is not required in children without alarm symptomsTesting may be carried out to reassure children and their parents

What are the predictive values of diagnostic tests?There is no evidence to suggest that the use of ultrasonographic examination of the abdomen and pelvis in the absence of alarm symptoms has a significant yield of organic disease (evidence quality C).There is little evidence to suggest that the use of endoscopy and biopsy in the absence of alarm symptoms has a significant yield of organic disease (evidence quality C).There is insufficient evidence to suggest that the use of esophageal pH monitoring in the absence of alarm symptoms has a significant yield of organic disease (evidence quality C).

Treatment

Deal with psychological factorsEducate the family (an important part of treatment)Focus on return to normal functioning rather than on the complete disappearance of painBest prescribe drugs judiciously as part of a multifaceted, individualised approach, to relieve symptoms and disability

Treatment

Medicines:Acid lowering agentsMucoprotective drugsMotility regulatorsLaxatives AnalgesicsProbiotics Gas adsorbantsDietary and life style changePsychotherapy

Pharmacologic treatment approachA. AntacidsB. H2- receptor antagonistC. Proton pump inhibitorsD. SucralfateE. Prokinetics

Treatment of Acid-related disordersH2-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 of 0.3-3.3 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 )

Prognosis

Majority of children mild symptoms and managed in primary careStudies of prognosis are mainly in referred patientsSystematic review 29.1% of children had on-going abdo pain (follow-up ranged 1-29 yrs)May develop irritable bowel synd as adultsRisk of later emotional symptoms and psychiatric disorders, particularly anxiety disorders

Success is not final, failure is not fatal. It is the courage tocontinue that counts.

Winston Churchill