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OSVALDO BORRELLI

Department of Paediatric Gastroenterology, Head

Division of Neurogastroenterology & Motility

Great Ormond Street Hospital (GOSH)

London, UK

Novità su dolori addominali

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GASTRO-OESOPHAGEAL

REFLUX DISEASE

BACKGROUND: DEFINITION

GER: the passage of gastric contents into the

esophagus with or without regurgitation and

vomiting.

GERD: when GER leads to troublesome symptoms and/

or complications.

Responsive GERD GERD responding to optimal treatment

Refractory GERD: GERD not responding to optimal treatment after 8

weeks.

Optimal Therapy: Maximum pharmacologic and/or nonpharmacologic

therapy based on the region of practice of the

subspecialist

INFANT REGURGITATION

(OR UNCOMPLICATED GOR)

• Daily regurgitation (occasionally vomiting)

• Normal growth pattern (“happy spitting out”)

• Parental anxiety – Doctor shopping

• Frequent formula changes

• Failure of empiric therapy

• Spontaneous resolution around 12 months

Must include all of the following in otherwise healthy infants 3 weeks to 12

months of age:

1. Regurgitation 2 or more times per day for 3 or more weeks

2. No retching, hematemesis, aspiration, apnea, failure to thrive,

feeding or swallowing difficulties, or abnormal posturing

Hyman et al Gastroenterol 2006;130:1519–1526

Infant with Suspicion of GERD

HISTORY AND PHYSICAL

EXAMINATION WARNING SIGNALS

JPGN 2018;66: 516–554

Warning signals requiring investigation in infants

with regurgitation or vomiting

Vandenplas 2017

Bilious vomiting

GI bleeding

– Hematemesis, Hematochezia

Consistently forceful vomiting

Onset of vomiting after 6 months of life

Failure to thrive

Diarrhoea, Constipation

Fever

Lethargy

Hepatosplenomegaly

Bulging fontanelle, Macro/microcephaly, Seizures

Abdominal tenderness or distension

Documented or suspected genetic/metabolic syndrome


EXAMINATION WARNING SIGNALS EVALUATE FURTHER

SYMPTOMS/SIGNS OF GOR DISEASE

no

yes

JPGN 2018;66: 516–554


SYMPTOMS AND SIGNS SUGGESTIVE OF GORD

JPGN 2018;66: 516–554




FUNCTIONAL REGURGITATION

UNCOMPLICATED GOR

NO TESTS - PARENTAL REASSURANCE, OBSERVATION,

LIFE-STYLE CHANGES, EXCLUDE OVERFEEDING

CONSIDER

• REFERRAL TO PEDIATRIC

GI

• TREATMENT

EVALUATE FURTHER

yes

no yes

no

JPGN 2018;66: 516–554

yes

THICKENED FORMULA

POSITION TREATMENT

ALGINATE

OBSERVE

no

OBSERVE

CONSIDER

HYDROLYSATE (2-4 WEEKS)


JPGN 2018;66: 516–554

CONSIDER HYDROLYSATE

(2-4 WEEKS)


CONTINUE MANAGEMENT

AND DISCUSS MILK PROTEIN

REINTRODUCTION AT

FOLLOW UP

Improved Not Improved

REFERRAL TO

PAEDIATRIC GI

Referral not

Possible

CONSIDER 4-8 WEEEK TRIAL

OF ACID SUPPRESSION

THEN WEAN IF SYMPTOMS

IMPROVED

Referral

REVISIT THE DIFFERENAL

DIAGNOSES, CONSIDER TESTING

AND/OR SHORT MEDICATION

TRIAL

NO FURTHER

TREATMENT

Symptoms not

Improved or Recur

Successful Weaning




LIFE-STYLE CHANGES –

DIETARY EDUCATION

ACID

SUPPRESSION

FOR 4-8 WEEKS

REFERRAL TO

PAEDIATRIC GI

EVALUATE FURTHER

yes

no yes

no

JPGN 2018;66: 516–554

yes

CONTINUE FOR 4-8

WEEKS AND THEN

ATTEMPT WEAN

OBSERVE

ENDOSCOPY

Child with Typical Symptoms of GERD

no

REFER TO

PEDIATRIC GI

JPGN 2018;66: 516–554

ENDOSCOPY

TREAT

APPROPRIATELY

pH-MII or pHMETRY

NERD

NO SYMPTOM

CORRELATION

POSITIVE SYMPTOM

CORRELATION

CONTINUE PPI FOR

RESPONSIVE

SYMPTOMS WITH

PERIODIC

WEANING ATTEMPTS

No Erosions,

Persistent

symptoms

despite PPI

ABNORMAL ACID EXPOSURE NORMAL ACID EXPOSURE

FUNCTIONAL

HEARTBURN

REFLUX

HYPERSENSITIVITY

Child with Typical Symptoms of GERD

OMEPRAZOLO:

1 mg/kg/die

(adulto 20-40 mg),

LANSOPRAZOLO :

Dose iniziale: 1.5 mg/kg/die

(adulto 30-60 mg)

ESOMEPRAZOLO

0.5-1 mg/kg/die

(adulto 20-40 mg)

30-45 min prima della colazione/cena.

Romano C et al Current Clinical Pharmacology, 2011;6:41-47

Gli Inibitori di Pompa Protonica nelle Malattie Acido-correlate

Prevalence of PPI use by year in infants

< 12 months

Pre

vale

nce o

f P

PI

use /

100,0

00

insure

d infa

nts

Barron et al JPGN 2007; 45: 421-427

Concerns about long-term therapy with PPIs

in children

De Bruyne et al Arch Dis Child 2018;103:78–82

Gli Inibitori di Pompa Protonica nelle Malattie Acido-correlate

• Give PPIs to children with acid-

related GERD symptoms

• Regularly reassess the child’s

response to PPIs and taper off

dose with the aim to wean after

8 weeks of treatment

• Substitute PPIs with other

antireflux medications when it

is difficult to wean off

(H2-receptor antagonists or

alginates)

Nikaki Nat Rev Gastr Hepatol 2016

DO

• Do not prescribe PPIs in

infants without proven acid-

related GERD symptoms

• Do not abruptly stop PPIs;

taper dose down to avoid

rebound hyperacidity

• Do not continue to represcribe

PPIs; question their use and

aim to wean off

• Do not treat children with

atypical or extraoesophageal

symptoms with PPIs unless

there is an increased

oesophageal acid exposure

DO NOT

L’uso appropriato – MRGE Considerazioni generali

FUNCTIONAL

ABDOMINAL PAIN

………..

BURDEN OF THE ILLNESS

• Prevalence 0.3-19%

• Bi-modal peak

•Age 4-6

•Age 8-12

• Female preponderence

• 2%-4% of all office visits

Chitkara et al Am J Gastro, 2005

15%

9%

0.3-19%

23%

DEFINITIONS

• Recurrent abdominal pain

• Chronic abdominal pain

• Non-organic abdominal pain

• Psychogenic abdominal pain

• FUNCTIONAL ABDOMINAL PAIN DISORDERS

FUNCTIONAL DYSPEPSIA

Must include 1 or more of the following

bothersome symptoms at least 4 days/month:

1. Postprandial fullness

2. Early satiation

3. Epigastric pain or burning not associated

with defecation

4. After appropriate evaluation, the symptoms

cannot be fully explained by another medical

condition.

*Criteria fulfilled for at least 2 months before diagnosis.

Hyams et al Gastroenterology 2016

Postprandial distress syndrome

Epigastric pain syndrome

IRRITABLE BOWEL SYNDROME (IBS) Must include all of the following:

1. Abdominal pain at least 4 days per month

associated with one or more of the following:

• related to defecation

• a change in frequency of stool

• a change in form (appearance) of stool

2. In children with constipation, the pain does

not resolve with resolution of the constipation

(children in whom the pain resolves have

functional constipation, not IBS)

3. After appropriate evaluation, the symptoms

cannot be fully explained by another medical

condition

*Criteria fulfilled for at least 2 months before diagnosis. Hyams et al Gastroenterology 2016

ABDOMINAL MIGRAINE

Must include all of the following at least twice

1. Paroxysmal episodes of intense, acute

periumbilical pain, midline or diffuse pain ≥1 hr

(should be the most severe/distressing symptom)

2. Episodes are separated by weeks to months

3. The pain is incapacitating and interferes with

normal activities

4. Stereotypical pattern and symptoms in the

individual patient

5. The pain is associated with ≥2 of the following:

a. Anorexia b. Nausea c. Vomiting

d. Headache e. Photophobia f. Pallor

6. After appropriate evaluation, the symptoms cannot

be fully explained by another medical condition.

*Criteria fulfilled for at least 6 months before the diagnosis Hyams et al Gastroenterology 2016

FUNCTIONAL ABDOMINAL PAIN

NOT OTHERWISE SPECIFIED

Must be fulfilled at least 4 times per month

and include all of the following:

1. Episodic or continuous abdominal pain

that does not occur solely during

physiologic events (eg eating, menses)

2. Insufficient criteria for irritable bowel

syndrome, functional dyspepsia,

or abdominal migraine

3. After appropriate evaluation, the

abdominal pain cannot be fully explained

by another medical condition

*Criteria fulfilled for at least 2 months before diagnosis. Hyams et al Gastroenterology 2016

The clinical problem

La bambina mi sembra stia benissimo

Dr Borrelli…..il prossimo paziente è uno di quelli

con dolori addominali ricorrenti

Il papà è grosso ed

alto 1.90 cm

La mamma mi sembra molto

preoccupata

Adesso passerà tutto il pomeriggio a parlare!

Oh…Yippy…Yippy….il mio paziente preferito

Forse chiedo al mio specializzando di vederla

Richiederò direttamente degli esami bioumorali

e una ecografia

identificare un possibile trigger

Discriminare tra una patologia organica e funzionale

Identificare la terapia con maggiore possibilità di successo

Classificare il sottotipo di DFGI

Capire le loro preoccupazione ed aspettative

DIAGNOSTIC ALGORITHM

CHRONIC ABDOMINAL PAIN HISTORY AND PHYSICAL EXAMINATION

PRESENCE OF ALARM SIGNS

ALARM SIGNS IN ABDOMINAL PAIN

Historical findings

• Persistent right upper or right

lower quadrant pain

• Persistent vomiting

• Gastrointestinal blood loss

• Chronic severe diarrhoea

• Dysphagia

• Involuntary weight loss

• deceleration of linear growth

• Delayed puberty

• Unexplained fever

• Family history of IBD, CD or

familial Mediterranean fever

• Deceleration of linear growth

• Uveitis

• Oral lesions

• Skin rashes

• Icterus

• Anaemia

• Hepatomegaly/Splenomegaly

• Arthritis

• Costovertebral angle tenderness

• Tenderness over the spine

• Perianal abnormalities

ALARM SIGNS IN ABDOMINAL PAIN

Examination findings

DIAGNOSTIC ALGORITHM

CHRONIC ABDOMINAL PAIN HISTORY AND PHYSICAL EXAMINATION

PRESENCE OF ALARM SIGNALS EVALUATE

FURTHER

FULFILLS CRITERIA

OF CONSTIPATION

TREAT

CONSTIPATION

WORKING DIAGNOSIS OF FUNCTIONAL

ABDOMINAL PAIN DISORDERS

DIAGNOSIS ACCORDING

ROME IV CRITERIA

Pain alone: Functional abdominal pain (NOS)

Pain in upper abdomen Functional dyspepsia

Pain + abnormal bowel habit IBS

Paroxysmal episodes of Pain Abdominal Migraine

DIAGNOSTIC TESTS

FBC, ESR, CRP

Coeliac screening

Food Allergy

Urinalysis

Calprotectin

Stool O&P

Stool H. Pylori antigen

EVALUATE

FURTHER

APPROPRIATE

TREATMENT

yes

yes

yes no

no

no

BIOPSYCHOSOCIAL MODEL OF CARE

REASSURANCE

• Prevalence of FGID

• Benign clinical course

• Therapeutic approach directed to entire family

• Effective physician-family relationship

• Emphasize normal growth

• Genuine pain

SET REALISTIC THERAPEUTIC GOAL

• Decrease stress and tension

• Improvement of daily symptoms and quality of life

IDENTIFY AND ADDRESS OBSTACLES RELATED TO SCHOOL ATTENDANCE

• How much school has been missed

• Working with school teachers

• Initial reduction of home work

MDT APPROACH

Pediatrician, Psychologist, Psychiatrist, Dietitian, Social worker, Paediatric Gastroenterologist

DIAGNOSIS OF ABDOMINAL PAIN

RELATED FGID

Reassurance and education

Lifestyle and food habits

Discuss expectations

Abdominal pain diary Evaluate after 2-3 weeks

? intervention effective

Stop therapy and evaluate

after 2 months

Start therapy

Dependent on subtype and

preference of patient and parents

Pharmacological

Antispasmodics

Antireflux agents

Antihistaminic agents

Antidepressants

Nonpharmacological

Hypnotherapy

CBT

Probiotics

Evaluate after 2-3

weeks

Intervention effective?

Evaluate after 2-3 months


Continue or adjust therapy

Taper medication after 2–6 months

Change therapy

reconsider diagnosis

Continue

Evaluate effect


yes

yes yes yes

Korterinket al. Nat. Rev. Gastroenterol. Hepatol 2015:12:159–171

no

no

no

no no

yes

ANTIDEPRESSANTS FOR FUNCTIONAL

ABDOMINAL PAIN

Amitriptyline

Saps et al Gastroenterology 2009

90 children,

5 centers,

4 wks Rx,

5 years to complete it

CBT aims to change attitudes, cognitions, and

behavior that may play a role in generating or

maintaining symptoms

• Child

• Family

COGNITIVE BEHAVIOURAL THERAPY

GUT-BRAIN AXIS

Medial Pain System

(Spinoreticular Tract)

• Painful sensation

• Motivational –

Affective component

(suffering, anger,

response planning)

Prefrontal Cortex

(Pain Memory,

Interpretation,

Response)

Lateral Pain System

(Spinothalamic Tract)

• Non painful sensation

• Sensory – emotional

component

(location, intensity,

nature of pain)

COGNITIVE-BEHAVIORAL THERAPY FOR CHILDREN WITH

FUNCTIONAL ABDOMINAL PAIN AND THEIR PARENTS

DECREASES PAIN AND OTHER SYMPTOMS

An intervention aimed at reducing protective

parental responses and increasing child coping

skills is effective in reducing children’s pain

and symptom levels compared with an

educational control condition.

Levy et al Am J Gastroenterol 2010

CONSTIPATION

FUNCTIONAL CONSTIPATION : DEFINITION

Gastroenterology 2016;130:1519–1526

ALLARM

SYMPTOMS/SIGNS?

Constipation:

Delayed or difficult defecation >4 weeks

History, physical examination

MANAGEMENT OF CONSTIPATION IN INFANTS

AND CHILDREN

ALARM SIGNS AND SYMPTOMS IN CONSTIPATION

Constipation starting very early in life (<1 month)

Passage of meconium > 48 hours

Family history of Hirschsprung’s disease

Ribbon stools

Blood in the stools and no anal fissures

Failure to thrive

Fever

Bilious vomiting

Abnormal thyroid gland

Severe abdominal distension

Perianal fistula

Abnormal position of anus

Absent anal or cremasteric reflex

↓ lower extremity strength/tone/reflex

Tuft of hair on spine

Sacral dimple

Gluteal cleft deviation

Extreme fear during anal inspection

Anal scars

FUNCTIONAL CONSTIPATION


AND CHILDREN

IS THERE FECAL IMPACTION ?

“ GET THEM EMPTY AND

KEEP THEM EMPTY “

ALLARM

SYMPTOM/SIGNS?

Constipation:

Delayed or difficult defecation >4 weeks

History, physical examination

Evaluate further

yes no

Management of Constipation – DISIMPACTION

“FECAL IMPACTION” is defined as either having a hard mass in the lower

abdomen on physical examination, a dilated rectum filled with a large amount

of stool on rectal examination, or excessive stool in the colon on radiography”

CONTINUA….

INFANTS DOSAGE

glycerin suppositories 1 paediatric supp

phoshate enema 6 ml/Kg up to 135 ml

OLDER CHILDREN

Sodium phoshate enema

PEG (oral/NGT lavage)*

PEG 3350**

Mineral oil

Senna

Bisacodyl

2.5 ml/Kg up to 133 ml/dose

25 ml/Kg/hr, up to 1 L/hr until clear

1.5 gr/Kg/day for 3-5 days

15-30 ml/yrs of age up to 240 ml

15 ml every 12 hrs

Suppository: 5 mg every 12 hrs

Tablet 5 – 10 mg every 12 hrs

* Pashankar et al J Pediatr 2004 ** Youssef et al J Pediatr 2002


AND CHILDREN

Intake

Defe

cati

on

fre

qu

en

cy/

wk

(±S

E)

ns ns

*

Disimpaction

Defecation

Enema

PEG

Bekkali et al, J Pediatr 2009


enema vs high dose oral PEG

Bekkali et al, J Pediatr 2009


enema vs high dose oral PEG

Intake Disimpaction

ns *

*

Fecal

inco

nti

nen

ce /

wk

Fecal incontinence

Enema

PEG

Management of Constipation – MAINTENANCE

MEDICATION AGE DOSE

milk of magnesia

lactulose or sorbitol

Mineral Oil

PEG 3350

Senna

sodium picosulphate

Bisacodyl tablet

>6 month

1 month

> 12 months

1 month

2-6 years

6-12 years

> 12 years

1 month-4 years

>4 years

2-10 years

>10 year

1-3 ml/kg/day in 1-2 doses



0.2-0.8 gr/kg/day

2.5-5 mg 1-2 times daily

7.5-10 mg/day

15-20 mg/day

2.5-10 mg 1-2 times daily

2.5-20 mg/day

5 mg daily

5-10 mg daily

Tabbers et al JPGN 2014

Treatment failure?

Intractable constipation

Poor compliance

Wrong treatment

Treatment failure

Poor compliance

Tabbers MM, JPGN 2014

Wrong treatment

Treatment failure

• Re-educate

• Re-assess

• Monitor treatment adherence

Treatment adherence

• Omissions of doses or delays in the timing of doses.

• Patients commonly improve their medication-taking behavior in

the 5 days before and after an appointment with the health care

provider.

Osterberg L, Blaschke T: NEJM 2005

Treatment failure

• Re-educate

• Re-assess

• Monitor treatment adherence

• Change medications

NEWS FROM LITERATURE

Fecal incontinence (with Peristeen®)

≥ 1/week 40 (44.0%)

< 1/week 14 (15.4%)

None 37 (40.7%)

Concomitant medication in 46 (50.5%)

Oral laxatives 38 (82.6)

Enemas 10 (21.7)

Bisacodyl sup 3 (6.5)

~70% of parents reported improvement

TAKE HOME MESSAGES

Disimpact the children before starting the maintenance

treatment

Judicious use of PPI

Role of holistic approach to FGID

Importance of red flags

Role of rectal therapy

Please, refer to a Paediatric GI for the correct diagnosis

ACKNOWLEDGEMENTS

novità su dolori addominali ricorrenti, stipsi e malattia ... fimp 2018... · ricorrenti, stipsi e...

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