Functional Gastrointestinal Disorders(FGIDs) in Children:

A Developing Country

Insight.

Eyad Altamimi, MD

Pediatric Gastroenterologist

Associate Professor of Pediatrics

Mu’tah University

Functional Gastrointestinal Disorders (FGIDs)

include a variable combination of age-

dependent, chronic or recurrent

gastrointestinal symptoms not otherwise

explained by structural or biochemical

abnormalities

Gastroenterology,2006

The term functional emphasizes that many

of the symptoms may accompany normal

development (eg, infant regurgitation) or

may be a response to otherwise normal

internal or external cues (eg, constipation

following painful stooling)

Gastroenterology,2006

Etiology & Pathophysiology

Despite the availability of isolated findings

and hypothesis the etiology of most of

FGIDs still need to be determined

J Pediatr Gastroenterol Nutr,2013

J Pediatr, 2015

The pathophysiology

of FGID is thought to

involve

abnormalities in the

relationship

between the enteric

and central nervous

systems

In Adult Gut:

- 100 million neurons located along the gut

which produce various neurotransmitters,

regulating mood and satiety N Engl J Med,1996

- 95% of the body`s total serotonin is

located in the gut ACS Chem Neurosci,2013

There is a high prevalence of psychiatric

disorders in FGID patients(anxiety and

depression)

Patients with internalizing psychiatric

disorders are found to have a higher

prevalence of pain predominant FGID

Diagnosis:

Physician’s lack of understanding

or appreciation of the illness

Absence of reliable biologic

markers and specific diagnostic

tests

Curr Pediatr Rep ,2013

Approach of FGID symptoms

Historical Background:

Apley`s Define RAP

Pediatric Working

Team met in Rome

ROME II Criteria

published

ROME III Criteria

published

ROME IV Criteria

published

1958

1997

1999

2006

2016

Rome criteria

The process involved group consensus

using:

- clinical experience

- extensive review of the literature

Goals:

- Diagnostic tool (accurate and definitive)

- Research tool ( facilitate and

advancement)

Rome criteria Symptom-based ( not organ related)

Symptom characteristics

Presence of associated symptoms

Impairment of daily activities

Age-specification:

- Patient– reporting

- Parents – reporting

Presence of alarming symptoms/signs

Cyclic Vomiting

Must include all of the following:

1. Two or more periods of intense

nausea and unremitting

vomiting or retching lasting hours

to days

2. Return to usual state of health

lasting weeks to months

Intense

Normal in between

Functional Constipation

Must include 2 or more of the following in a

child with a developmental age of at least 4

years with insufficient criteria for diagnosis of

IBS:

1. Two or fewer defecations in the toilet per

week

2. At least 1 episode of fecal incontinence per

week

3. History of retentive posturing or excessive

volitional stool retention

4. History of painful or hard bowel movements

5. Presence of a large fecal mass in the rectum

6. History of large diameter stools that may

obstruct the toilet

*Criteria fulfilled at least once per week for at

least 2 months before diagnosis

Infrequent, painful, large-

diameter with retentive

posturing

Treatment:

BIOPSYCHOSOCIAL MODEL

Takes into account the physical and psychosocial

components of the illness

The main goal

of the therapy

for children

with a FGID is to

re-establish a

normal daily

life for both the

patient and the

family

Most Important Part

Establishing connection with the patient

and family

Addressing the concerns

Tailor the work-up according to patient

condition

Explanation and reassurance

Medications to restore age appropriate

activities

Therapeutic Interventions:

Psychological and

cognitive behavioral

therapy

Diet manipulation

Hypnotherapy

Acupuncture

Bulking agents

Pro- and prebiotics,

Pharmacotherapy:

- Antispasmodics

- Tricyclic antidepressants

- Anti- diarrheals

- Stool softeners

- Antibiotics

- Melatonin

- Chloride channel

agonists

Reassurance and Placebo

Explaining the benign nature of the pain

Use familiar terms (e.g. IBS)

Compare to familiar symptom(e.g.

Headache)

Address any catastrophic thinking(patient

& family)

Discourage symptom re- enforcement

(missing school)

Explain the role of emotion

60% of patients improve with placebo

Curr Pediatr Rep , 2013

Addressing Mental Health Disorders

one-third of children presenting to general

practice for evaluation of abdominal pain,

anxiety and depressive problems persisted

during 1 year of follow-up Scand J Prim Health Care,2012

It may be reasonable to involve psychiatrist

early on

It was concluded that there was no evidence that

fiber supplements or lactose-free diets were effective

in the management of children with intermittent or

chronic abdominal pain

In childhood IBS, a

low FODMAP diet

decreases

abdominal pain

frequency.

Gut microbiome

biomarkers may be

associated with low

FODMAP diet

efficacy.

Aliment Pharmacol Ther ,2015

Tricyclic Antidepressants Used effectively in chronic pains

Analgesic effect is separate from the anti-

depressant effect

Used in small doses

Need weeks to feel the effect

Side effects with therapeutic implications:

- Increased sleepiness

- Delayed intestinal motility

ECG monitoring is recommended

Probiotics

The use of Lactobacillus rhamnosus GG

moderately increases treatment success in

children with pain-predominant FGID,

particularly among children with IBS

Aliment Pharmacol Ther, 2011

Probiotics

Despite evidence that changes in enteric

flora may play a role in childhood IBS there

is currently little agreement on when, for

how long, and which probiotic to use in

children with FGID

Cyproheptadine

Widely used in children with

dyspeptic symptoms, poor

appetite and as prophylaxis

of cyclic vomiting and

abdominal migraine

episodes

86% response rate in children

with Functional Abdominal

Pain

Minerva Pediatr, 2008

Montelukast

Used based on the

finding of duodenal

eosinophilia in children

with FD

Two studies showed a

significant clinical

benefit in children

receiving montelukast

Burden of FGIDs:

Recent Metanalysis:

A Worldwide pooled

prevalence for functional

abdominal pain disorders

13.5%(95% CI 11.8-15.3)

South America (16.8%)

Asia (16.5%)

Europe (10.5%)

Burden of Constipation:

The worldwide prevalence

varies between 0.7% and

29.6%

Pediatrician visit: 3% to 5%

Ped.GI consults: 25%

What about Jordan?

I will present briefly two studies :

- one clinic based (childhood

constipation)

- Community- based (FGIDs

prevalence)

At our clinic, 25.9% of clinic consults are due to chronic constipation

Males comprise 54.8% Most common age group were the Pre-schoolers 43.7%

Fecal incontinence affected 28.6 %

ARABIC TRANSLATION OF THE ROME III CRITERIA IS NOW AVAILABLE

Eyad M. Altamimi,MD & Mohammad Al Safadi,MD

Pediatric Department, Mu'tah University, Alkarak, Jordan

Introduction

Functional gastrointestinal disorders affect children of

all ethnic groups. Rome criteria are symptom-based

criteria allow a positive diagnosis of functional

gastrointestinal disorders (FGIDS).

The symptom based questionnaires are dependent

on the understanding of the questions and

expressions, which mandate these questionnaires

being addressed in the patient`s mother language.

As for Arabic speaking children there was no Arabic

version of these questionnaires. This was depriving

those children and their treating physicians from this

very important diagnostic tool. So, we decided to

translate the ROME III questionnaires into Arabic.

Methods

The Rome Foundation was contacted. Our interest in

translating the criteria was expressed. The foundation

permission was obtained. The process was

performed according to the translation guidelines

prepared by the foundation. The final validated Arabic

version get the foundation recognition and approval

on 12th of June,2012.

Conclusion We are so happy to denote that Arabic

translation of ROME III criteria is now

available for usage, through the Rome

Foundation website at:

http://www.romecriteria.org/translations/.

We believe this validated translation will

be of tremendous value in diagnosis of

(FGIDS) in Arabic speaking children.

Discussion

The major issues during the translation

process were the cultural sensitivity of

the topic and the availability of

simple terms describing the symptoms.

These problems were solved by using the

predetermined standardized

method of translation, the enthusiasm of

the working team and the help of the

foundation translation supervisor.

References

Appendix E: Rome III Diagnostic Questionnaire for

the Pediatric Functional GI Disorders

(http://www.romecriteria.org/questionnaires/)

Rome criteria translation Guidelines

(http://www.romecriteria.org/translations/guidelines.

cfm)

Prevalence Of Functional

Gastrointestinal Disorders In

Jordanian Children

The project is supported by a network grant from the European

Society for Pediatric Gastroenterology, Hepatology and Nutrition

(ESPGHAN), to study Prevalence Of Functional Gastrointestinal

Disorders In The European- Mediterranean Area

Methods: The prevalence of FGIDs has been

assessed using the Arabic version of the

questionnaires on pediatric GI symptoms

based on Rome III Criteria (QPGS-RIII)

The parent-report form has been used for

subjects aged between 4-10 years (Group

A), while the self-report form has been

used for subjects aged between 11-18

years (Group B)

Children and adolescents have been

enrolled in schools distributed throughout

the national territory

Results: A total of 815 children recruited. Males

comprise 46 % male. Median age was

14.9 years (range 10-18 years). A total of

322 subjects (39.5%) met criteria for a

FGID. Abdominal pain predominant FGIDs

were the most common affecting 18% of

the children followed by defecation

disorders. Functional constipation was

diagnosed in 15.3%.

Results:

A total of 773 subjects (49 % male, median

age 7.9 years, range 4-10 years)

completed our study

A total of 192 subjects (24.8%) met criteria

for a FGID. Defecation disorders were the

most common group of FGIDs

Functional constipation was diagnosed in

12.2 %. Abdominal pain predominant

FGIDs were seen in 7%. Abdominal

migraine and Irritable bowel syndrome

were the most common 3.6 and 3.2

respectively.

Table 1: Prevalence of FGIDs in Jordanian

children 4-10 yrs. of age

Disorder Prevalence Estimate [95%

C.I.) (x100)

Functional Dyspepsia 0.131 [0.003 to 0.728]

Irritable Bowel Syndrome 3.19 [2.033 to 4.748]

Abdominal Migraine 3.607 [2.274 to 5.41]

Cyclic Vomiting Syndrome 1.374 [0.63 to 2.592]

Functional Abdominal Pain Syndrome- Lower 0.135 [0.003 to 0.751]

Functional Abdominal Pain Syndrom Upper 0 [0 to 0.482]

Functional Abdominal Pain Lower 0.41 [0.085 to 1.195]

Functional Abdominal Pain Upper 0.531 [0.145 to 1.353]

Functional Constipation 12.242 [9.948 to 14.848]

Non retentive fecal incontinence 0.707 [0.23 to 1.643]

Rumination Syndrome 0.149 [0.004 to 0.828]

Aerophagia 5.037 [3.513 to 6.968]

Table 2: Prevalence of FGIDs in Jordanian

children 10-18 yrs. of age

Disorder Prevalence Estimate [95%

C.I.) (x100)

Functional Dyspepsia 6.23 [2.02 to 14.47]

Irritable Bowel Syndrome 4.545 [3.186 to 6.265]

Abdominal Migraine 6.3 [4.666 to 8.29]

Cyclic Vomiting Syndrome 2.714 [1.642 to 4.206]

Functional Abdominal Pain Syndrome- Lower 0.127 [0.003 to 0.706]

Functional Abdominal Pain Syndrom Upper 0.124 [0.003 to 0.69]

Functional Abdominal Pain Lower 0.385 [0.079 to 1.12]

Functional Abdominal Pain Upper 1.124 [0.515 to 2.122]

Functional Constipation 15.259 [12.733 to 18.067]

Non retentive fecal incontinence 0.446 [0.092 to 1.297]

Adolescent Rumination Syndrome 0.306 [0.037 to 1.102]

Aerophagia 6.006 [4.325 to 8.089]

Conclusion:

Functional constipation is the most common

disorder in Jordanian children 4-10 yrs.

Abdominal pain-predominant Functional

gastrointestinal disorders are the most

common followed by functional

constipation in Jordanian children 10-18yrs.