Functional Gastrointestinal Disorders

Functional
Gastrointestinal
Disorders
Suma Raju, MD
Pediatric Gastroenterology
Headline Goes Here
I have no relevant financial
relationship or conflicts to
disclose.
What is FGID?
• Chronic and recurrent symptoms not
explained by known biochemical and
structural abnormalities
What are FGID?
• Functional Dyspepsia
• Irritable Bowel Syndrome
• Abdominal Migraine
• Functional Abdominal Pain
Prevelance
• 2-4% of all pediatric office visits
• 15% of middle and high school students
have weekly abdominal pain
• 8% see a physician for this
Why do kids get it?
Family History
Familial clustering has been seen
Infections
• Post infectious dysmotility
Early Life Events
• 20% of patients with FGID report
– Neonatal respiratory distress, infection, colic,
surgery or congenital hydronephrosis
• As a neonate noicceptive neuronoal
circuits are being formed
– Exposure to noxious stimuli may result in
lower pain threshold later in life
Diagnosis
HISTORY, HISTORY,
HISTORY!
History
•
•
•
•
Talk directly to patient
Ask patient to point to site of pain with one finger
Quality, intensity, timing, and duration
Associated symptoms
– Nausea, vomiting, dysphagia, diarrhea, constipation,
encoporesis, blood in stools, fever, weight loss, joint pain,
rashes, dysuria, oral ulcers, perianal discharge, menstrual cycle
•
•
•
•
•
Aggravating factors
Relieving factors
Does it interfere with daily activity
Stressors
Medicines that have helped or worsened symptoms
Red Flags
•
•
•
•
•
•
•
•
Involuntary weight loss
Slowed linear growth
Severe vomiting
Gastrointestinal blood loss
Fever
Chronic severe diarrhea
Night time stooling
Localized RUQ or RLQ pain
Physical Exam
• Patients demeanor
– What does the patient look like when you walk
in the room?
• How does the patient interact with others?
• How does the patient react to the exam?
– Stethoscope test
Organic Causes
• Gastrointestinal
–
–
–
–
–
–
–
–
–
–
–
–
–
Inflammtory Bowel Disease
Celiac Disease
Intermittent volvulus
Recurrent Intussusception
Chronic Constipation
Esophagitis
Gastritis
Peptic ulcer disease
Hernia
Malabsorption
Foreign body
Parasitic infection
Tumor
• Hepatobiliary/pancreatic
–
–
–
–
–
–
Cholelithiasis
Cholecystitis
Pancreatitis
Sphincter of Oddi Dysfunction
Biliary dyskinesia
Chronic hepatitis
• Renal/Urologic
–
–
–
–
Nephrolithiasis
Hydronephrosis
UPJ obstruction
Recurrent Pyelonephritis
• Pelvic
– Endometriosis
– Mittelschmerz
Types of FGID
Functional Dyspepsia
Rome III Criteria
• Must include 1-3, weekly for > 2 months
1. Persistent or recurrent pain above the
umbilicus
2. Not relieved by defecation or associated
with change in stool frequency or form
3. No evidence of inflammatory, anatomic,
metabolic, or neoplastic process that
explains the symptoms
Functional Dyspepsia
• Prevalence in 4-18 year olds is 15%
• Often follows a viral illness
• EGD is indicated if
– Dysphagia is present
– Symptoms persist despite use of acid
reducing medications
– Symptoms recur on cessation of medication
– Ruling out H pylori
Irritable Bowel Syndrome
Rome III criteria
• Must include 1-2, weekly for > 2 months
1. Abdominal discomfort/pain associated with 2
or more of the following 25% of the time
– Improved with defecation
– Associated with change in frequency of stools
– Associated with change in consistency of stools
2. No evidence of inflammatory, anatomic, metabolic,
or neoplastic process that explains the symptoms
IBS - Symptoms
• >4 stools per day or <2 stools per week
• Loose/watery stools or Lumpy/hard stools
• Straining, urgency, feeling of incomplete
evacuation
• Mucus in stool
• Bloating, abdominal distension
IBS
• 6% of middle school students
• 14% of high school students
IBS
• Antecedent
–
–
–
–
Inflammation
Trauma
Allergy
Infection
• Induces visceral hypersensitivity & altered
motility
• Normal exam & growth & no alarm symptoms
– No further investigation initially
Abdominal Migraine
Rome III Criteria
• Must include 1-5, >twice in 12 months
1. Paroxysmal, episodic, intense, acute periumbilical
pain that lasts >1 hour
2. Intervals of weeks to months of usual health
3. Pain interferes with normal activity
4. Pain is associated with >2 of the following:
anorexia, nausea, vomiting, headache,
photophobia, pallor
5. No evidence of inflammatory, anatomic, metabolic,
or neoplastic process that explains the symptoms
Abdominal Migraine
• 5% of children
• Females > Males
• Abdominal migraines, cyclic vomiting
syndrome and migraine headaches are
likelyl manifestations of the same disorder
• When appropriate rule out
– urologic obstruction, GI obstruction, biliary
disorder, pancreatits, intracranial lesions,
metabolic disorders
Functional Abdominal Pain
Rome III Criteria
• Includes 1-3, weekly for at least 2 months
1. Episodic or continuous abdominal pain
2. Insufficient criteria for other FGID
3. No evidence of inflammatory, anatomic,
metabolic, or neoplastic process that
explains the symptoms
Evaluation
Evaluation
• HISTORY, HISTORY, HISTORY
• Alarm signs
–
–
–
–
–
–
–
–
Weight loss
Growth retardation
Vomiting
Significant diarrhea
GI blood loss
Extraintestinal symptoms
Consistent RUQ or RLQ pain
Abnormal physical exam
Evaluation
If alarm symptoms consider further workup.
•
•
•
•
•
•
•
CBC
CMP
ESR
CRP
UA with culture
Stool hemoccult
Stool studies(O&P,
culture, C diff)
•
•
•
•
•
Amylase, lipase
Celiac panel
Thyroid screen
KUB
Abdominal ultrasound
– Better than CT
• UGI
• Referral to GI
To Scope or Not To Scope
•
•
•
•
•
•
•
•
•
•
Dysphagia
Continued symptoms despite therapy
Recurrence with cessation of therapy
GI Bleeding
Diarrhea
Iron deficiency anemia
Weight loss
Poor growth
Elevated CRP or ESR
Concerns for IBD, H pylori or Celiac Disease
Treatment
Treatment
• Important aspects to emphasize to families:
– Not a diagnosis of exclusion, based on Rome
Criteria
– Pain is real although there is no organic etiology
– No “cure” but we can try to improve quality of life
– Goals
• Resume normal activity
• Minimize symptoms
• Set reasonable goals to achieve this
– Family support is critical
Acid reducing medication
• Zantac
– BID dosing
• PPI
– Must take 1st thing in the morning
– On an empty stomach
– Eat 20 minutes later
• Use prn tums, maalox, mylanta until PPI
has time to work, 2-4 weeks
Antispasmodics
•
•
•
•
Levsin
Bentyl
Periactin
Amitriptyline
– EKG
– Antispasmodic, Noradrenergic & Serotonergic
effect
– Decreases GI transit time
– Relaxes fundus
– Restores normal sleep pattern
– Analgesic effect on pain receptors
Peppermint Oil
• Relaxes intestinal smooth muscle
• Colpermin
– Enteric coated peppermint oil capsule
Miralax
• Treatment of constipation
• Keys to using miralax successfully
– Mix in ratio of 17 grams to 8 oz
– Drink mixture in 5-10 minutes
– Take daily
– Use it as long as you need it
Narcotics
Therapy
• If stress seems to be playing a role
• 50% of patients get better within 2 months
of diagnosis