Functional abdominal pain in childhood

รศ.พญ. วรนช จงศรสวสด ภาควชากมารเวชศาสตร

คณะแพทยศาสตร จฬาลงกรณมหาวทยาลย

Recurrent abdominal pain (RAP)

Organic VS functional cause????

Endoscopy in RAP

• Normal findings 48.4 % (n=62)

Prapun Aanpreung, et al. J Med Assoc Thai

1997;80:22-25.

• Normal findings 50 % (n=42)

Orawan Louthrenoo, et al. J Med Assoc Thai

2010; 93:1379-84.

Alarm symptoms

Weight loss/FTT

Anemia

GI bleed

Nocturnal symptoms

Chronic diarrhea

Persistent emesis

Delayed puberty

Oral ulcer

Alarm symptoms

Symptoms including • Diarrhea • Constipation • Nocturnal awakening • Pain related to meals could not differentiate between organic and functional cause

Prapun Aanpreung, et al. J Med Assoc Thai 1997;80:22-25.

Adult

B. Functional Gastroduodenal Disorders

C. Functional Bowel Disorders

D. Functional Abdominal Pain Syndrome

E. Functional Gallbladder and Sphincter of Oddi

Disorders

Children

G4. Infant Colic

H2. Abdominal pain-related FGIDs

Gastroenterology 2006;130:1519-26.

Adult

B1. Functional Dyspepsia

C1. IBS

C2. Functional Bloating

D. Functional Abdominal Pain

Syndrome

H2. Abdominal pain-related FGIDs

H2a. Functional Dyspepsia

H2b. IBS

H2c. Abdominal Migraine

H2d. Childhood Functional Abdominal

Pain

H2d1. Childhood Functional Abdominal

Pain Syndrome Gastroenterology 2006;130:1519-26.

Infant colic Must include all of the following in infants

from birth to 4 mo:

• Paroxysms of irritability, fussing or crying that starts and stops without obvious cause

• Episodes lasting 3 hours/day and occurring at least 3 days/wk for at least 1 week

• No failure to thrive

อาการโคลคในทารกเปนอาการทพบไดบอย

• สามารถพบได 40 % ในทารก1

• พบไดทงในทารกทไดรบนมแมและนมผสม 1,2,3

• มกเรมพบในชวงเดอนแรก ๆ ตงแตทารกอายประมาณ 2-3 สปดาหแรก

• 25% ของปญหาทมาปรกษากมารแพทย1

1. Lucassen PL, et al. Arch Dis Child 2001; 84:398-403. 2. Brazelton TB. Pediatrics 1962: 29; 579-88. 3. Iacono G, et al. Dig Liver Dis 2005; 37:432-8.

Symptom of colic

Colic Flushing

Abdominal bloating

Abdominal pain

Intense & prolonged

crying

Sleeplessness, exhaustion

โคลคในทารกพบมากทสดในทารกอาย 5-6 สปดาห

Barr RG, et al. Child Abuse & Neglect 2006; 30: 7-16.

ชวงเวลาทรองมากทสด คอ หกโมงเยนถงสองทม

Brazelton TB. Pediatrics 1962; 29: 579-88.

Cause of colic

Cause of colic: multi-factorials

GI

- Immaturity

- GERD

- Gut flora imbalance

- Lactose intolerance

Behavioral/

Psychological

- Disturbance of

parent-child

interaction

Dietary

- Reaction to

cow’s milk or

other food

constituents

Cause of inconsolable, crying young infant

Functional Dyspepsia

Must include all of the following:

1.Persistent or recurrent pain or discomfort centered in the upper abdomen

2.Not relieved by defecation or associated with the onset of a change in stool frequency or stool form

3.No evidence of an inflammatory, anatomic, metabolic or neoplastic process that explains the subject’s symptoms

* Criteria fulfilled at least once per week for at least 2 months prior to diagnosis

Irritable Bowel Syndrome

Must include both of the following:

1. Abdominal discomfort** or pain associated with 2 of the following at least 25% of the time:

a. Improvement with defecation

b. Onset associated with a change in frequency of stool

c. Onset associated with a change in form (appearance) of stool

2. No evidence of an inflammatory, anatomic, metabolic, or neoplastic process that explains the subject’s symptoms

* Criteria fulfilled at least once per week for at least 2 months prior to diagnosis

** “Discomfort” means an uncomfortable sensation not described as pain

Diseases mimicking IBS

• Parasitic infestation: Giardia

• UTI

• Lactose intolerance

• Encopresis

• Gynecologic diseases

• IBD: ulcerative colitis, Crohn disease

Abdominal migraine

Must include all of the following:

1.Paroxysmal episodes of intense, acute periumbilical pain that lasts for 1 hour

2.Intervening periods of usual health lasting weeks to months

3.The pain interferes with normal activities

4.The pain is associated with 2 of the following: Anorexia, N/V, headache, photophobia, pallor

5.No evidence of an inflammatory, anatomic, metabolic, or neoplastic process considered that explains the subject’s symptoms

* Criteria fulfilled 2 times in the preceding 12 months

Childhood Functional Abdominal Pain

Must include all of the following:

1.Episodic or continuous abdominal pain

2.Insufficient criteria for other FGIDs

3.No evidence of an inflammatory, anatomic, metabolic, or neoplastic process that explains the subject’s symptoms

* Criteria fulfilled at least once per week for at least 2 months prior to diagnosis

Childhood Functional Abdominal Pain Syndrome

Must satisfy criteria for childhood FAP and have at least 25% of the time 1 of the following:

1. Some loss of daily functioning

2. Additional somatic symptoms such as headache, limb pain, or difficulty sleeping

* Criteria fulfilled at least once per week for at least 2 months prior to diagnosis

Functional abdominal pain

Psychosocial factors

Altered motility Abnormal

visceral perception

Which investigation should be done in RAP?

RAP: investigations (first stage)

• CBC with differential

• ESR

• Stool tests for parasite & occult blood

• Urinalysis

• Trial of lactose-free diet

Impact of RAP

• Parents: figure out

• What is causing the pain

• Whether it is serious

• Child: at risk for

• Increased psychological problems such as depression

• Missing out on activities and school

• Decreased quality of life

–

Goals of treatment

• Reassure that the patient’s pain is real, not faked, and not caused by organic diseases

• Relieve discomfort and anxiety

• Return child to active, normal life

(including school) as soon as

possible

Psychosocial assessments

• Cognitive-behavioral therapy

• Determining precipitating stress

• Teaching stress management skills to the child and family

• Elimination of secondary gains

• Advising the child to participate in normal activities as possible

Cognitive behavioral therapy

• Several sessions with a trained therapist in which the child and parents learn ways to think about and cope with pain

• Learning to relax during times of pain and approaches for the child to stay involved in school and regular activities

Recommendation Children

• Attempt to reduce threat and/or catastrophic thinking about their pain

• Promote relaxation strategies

Parents

• Attempt to reduce threat and/or catastrophic thinking about their child's pain

• Train in alternative ways of responding to illness behaviour that encourage wellness

Pain Res Manage 2012;17(6):413-417.

Prognosis of RAP

• Pain resolves completely in 30-50 % by 2-6 weeks after Dx

• More long-term studies suggest that

30-50 % experience pain as adults

Prognosis of RAP

• 64 children with RAP

-26.6 % had severe symptoms which

affected their regular school attendance

- 20 % had symptoms mimicking PU

• Long-term follow-up

- 63 % were free of pain

- 31 % were better

- 6 % had no change

เสกสต โอสถากล และคณะ. Thai Journal of Pediatrics 35,2 (เม.ย.-ม.ย. 2539) 103-10.

Thank you for your attention