Abdominal Complaints in School Age Children Michael A. D’Amico, MD

Abdominal Complaints in
School Age Children
Michael A. D’Amico, MD
Pediatric Gastroenterology and Nutrition
May 16, 2012
Objectives
• Become familiar with common causes of
abdominal complaints in school age children
• Understand the therapeutic approach to these
conditions
• Know when to make appropriate referrals
• Explore presentation content further with Q & A’s
Statements
• No financial disclosures
• I may be discussing off-label use of some
medications
Common Abdominal Complaints
• Developmental level of child
– introspection
• Comfort level
• Social context
Often difficult to express or verbalize
precise sensation
Common Complaints
(symptoms)
• Pain
– Most common
– Vague
• Don’t feel well, My tummy hurts, Hunger, Nausea
• Upset stomach
• Constipation
– Hard to go, takes a long time going
• Diarrhea
Common Complaints
• Vomiting
• Dysphagia
– Difficulty swallowing
• “Accidents”
– Stool incontinence
– Encopresis
• Blood in stool
– hematochezia
Classification of Abdominal Pain
• Organic
• Non-organic
– Aka:
“Functional” abdominal pain
– Avoid terms like psychogenic, nervous stomach
or “its all in your head”
Organic Causes of Chronic
Abdominal Pain
•
Gastrointestinal
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Esophagitis
Gastritis/Peptic Ulcer
Malrotation/adhesions
Duplications
Hernias
IBD
Constipation
Parasitic infection/infestation
Bezoar or foreign body
Carbohydrate intolerance
Intussusception
Tumor
Ischemic
•
–
•
•
Chronic hepatitis
Cholelithiaisis/Cholecystitis
Choledochal cyst
Chronic pancreatitis/pseudocyst
UPJ obstruction/hydronephrosis
Nephrolithiasis
Recurrent pyelo/cystitis
Hematocolpos
Mittleshmerz
Endometriosis
Metabolic/Hematologic
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•
Infection, inflammation or tumor near
diaphram
Genitourinary
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Hepatobiliary/pancreatic
–
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Respiratory
Porphria
Hereditary angioedema
DM
Lead poisoning
Sickle cell disease
Collagen vascular disease
Musculoskeletal
–
Trauma, tumor, infection
Suggestive of Organic Cause of
Chronic Abdominal Pain
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< 5 yrs
Constitutional Sx: fever, wt loss, rash, joint pain
Emesis (bilious, hematemesis)
Pain that awakens from sleep
Pain well localized away from umbilicus
Referred pain
Family Hx of IDB, PUD, etc
Perianal disease
Occult or gross blood in stool
Abnormal testing
Constipation
• Likely the most common cause of
complaints of abdominal pain in school age
children
• Will spend the most time on this today
Constipation
• Chronic constipation is a very
common pediatric problem
• Accounts for 3 – 5% of visits to
primary provider
• Up to 25% of referrals to pediatric
GI
• Male to female ratio is 6:1
• Parental anxiety/stress
Constipation in children with
disabilities
• More common
– 75 – 90% with neuromuscular and
developmental disabilities
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Delay in diagnosis and treatment
Longer therapy
More medications and interventions
More tests (x-ray, barium enema,
manometry, colonscopy)
Constipation: Definition
• Passage of fewer than 3 stools per week or
• Passage of painful, large hard stools
regardless of frequency
– Children may have fecal impaction with
frequent small bowel movements “around” the
impacted mass -- OVERFLOW
• Subjective
“Normal” stooling patterns
• Frequency varies with age
– Highly variable in early infancy depending on
feeding source (breast-fed vs. formula)
– By 4 months most infants average 2 stools/day
(range 1 – 7/day in 93%)
– Toddlers and school-age children average 1.2
bowel movements/day
• Adults range from 3/day to 3/week
Defecation
• Fecal filling of the rectum
• Reflex relaxation of the
tonically contracted
internal anal sphincter
• Voluntary contraction of
external anal sphincter
• “Fecal continence”
Defecation
• Voluntary relaxation of
external anal sphincter and
puborectalis muscle
“opens” and “straightens”
passage
• Straining (Valsalva
maneuver), increasing
intra-abdominal pressure
and rectal contractions
helps propel stool outside
body
• Coordinated by sensory
epithelium of anorectal
mucosa
The Colon
• Stores and desiccates liquid stool received
from the ileum
• Propulsive contractions stimulated by
– Eating (gastro-colic reflex)
– Distension (bulk)
• Transit time increases with age and varies
with nutritional (dietary) components of
stool – mostly FIBER
Constipation can be caused by
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Insufficient fiber intake
Insufficient water intake
Tumors, fractures or lesions
Spinal cord/disc disease
Large bowel nervous disorders
Neuromuscular disorders/motility disorder
– Paradoxical puborectalis contraction
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Metabolic or endocrine disorders
Dehydration
Medications
Behavioral problems
→ usually multifactorial
Withholding
• Most common cause of constipation in
children is withholding of stool
– Usually because of a prior painful bowel
movement (?associated anal fissure)
• Subconscious
• Initiates habit cycle of stool retention
– Stretches rectum and later proximal colon
– Reabsorption of fluid and electrolytes
Withholding
• Self-perpetuating
– Larger and harder stools are more difficult to
pass
– Reinforcement of painful experience and
further withholding
• Leads to fecal impaction
– Further stretching and so on and so on and……
→ overflow incontinence (ENCOPRESIS)
Pediatr Clin North Am 1982;29:315-30
Who’s affected?
Encopresis
• “Soiling”
• Less common
• Most commonly due to constipation
– “Retention encopresis”
– “Overflow incontinence”
• Reported frequency varies
– 1 – 8% of school-age children
Encopresis
• Involuntary leakage of liquid or semiformed stool around the constipated fecal
mass is the usual trigger to bring patients to
medical attention
• Chronic rectal distension from fecal
retention decreases sensation of stool
volume which formerly caused the “urge”
to defecate
Medications
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Narcotic or opioid pain medications
Anesthetics
Anticholinergics/anti-spasmodics
Anticonvulsants/ketogenic diets
Antipsychotics/antidepressants/stimulants
Barium
Minerals: calcium, iron, lead, aluminum, bismuth
Nonsteroidal anti-inflammatory agents
Clinical Signs and Symptoms
• Frequency of BM’s with chronic constipation may
NOT be a reliable indicator
• Other signs & symptoms such as abdominal pain
and distension develop
• Clogging the toilet
• Frequent soiling or leaking may be confused as
diarrhea or over treatment with stool softeners
• Cyclic appetite blunting with periods of poor
weight gain, followed by remarkable response to
therapy
Clinical signs and symptoms
• Efforts to withhold may may be
misinterpreted as attempts to strain or
defecate
• Common withholding maneuvers
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Posturing
Scissoring of the legs
Dancing back & forth, from leg to leg
Occasionally resembling seizures
Clinical signs and symptoms
• Urinary incontinence
– ~30% diurnal enuresis
– 35% nocturnal
• Recurrent urinary tract infection (~10%)
• Physical exam
– Abdominal mass
– Peri-anal fissures, hemorrhoids
So what can we do?
A few basic tenets
• Soften the stool
• Provide a secure, conducive environment to
sit, sit, sit
Goals for Stooling
• Soft, but formed stool
• Upright position with knees/hips bent to
maximize Valsalva
• Feet securely planted on firm surface
• Appropriately sized seat
Treatment
Maintenance
• Keep the colon “clean”
• Osmotic agents
– Lactulose
– Docusate (Colace)
– Miralax
• Mineral oil
– Softener and emollient (lubricates)
Maintenance
• Bulking agents
– Fiber
• Stimulants
– Senna (Sennakot)
– Bisacodyl (Dulcolax)
– Lose effect with time (tachyphylaxis)
• Motility agents
– Metoclopramide (Reglan)
– Serotoninergic agonists
Other Therapies
• Biofeedback
– Electromyography
– Manometry
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Reward systems
Individual or family therapy
Pyschotherapy
Pyschopharmacotherapy
Patience
Time
Support and encouragement
Prognosis
• Generally good
– The colon can and will return to normal caliber
and function
• Muscular
• Sensory
• Directly correlates with
– ability to adhere to regimen and toileting
– Retraining and resolution of withholding
GERD
The Antireflux Barrier
Pathogenic Factors in GERD
Pharynx
UES
Mechanisms of Esophageal Complications
• Impaired esophageal clearance
• Defective tissue resistance
• Noxious composition of refluxate
Esophagus
Crural
diaphragm
Pylorus
Mechanisms of GER
• Transient LES relaxation
•
Intra-abdominal pressure
• Reduced esophageal capacitance
•
Gastric compliance
• Delayed gastric emptying
Angle
of His
LES
Stomach
Mechanisms of Airway Complications
• Vagal reflexes
• Impaired airway protection
Presenting Symptoms and Signs
of GERD
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Recurrent vomiting
Poor weight gain
Irritability in infant
Heartburn
Esophagitis
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Dysphagia or feeding
refusal
Apnea or ALTE
Asthma
Recurrent pneumonia
Upper airway symptoms
Differential Diagnosis of Vomiting in Infants
and Children
GI Obstruction
• Pyloric stenosis
• Malrotation
• Intermittent
intussusception
Infections
• Sepsis
• Meningitis
• Urinary tract infection
Allergic
• Dietary protein
intolerance
GI Disorders
• Achalasia
• Gastroparesis
• Gastroenteritis
Neurologic
• Hydrocephalus
• Subdural hematoma
• Intracranial
hemorrhage
Metabolic/Endocrine
• Galactosemia
• Fructose intolerance
• Urea cycle defects
Renal
• Obstructive uropathy
• Renal insufficiency
Toxic
• Lead
Cardiac
• Congestive heart
failure
Adapted from Rudolph et al, J Pediatr Gastroenterol Nutr 2001;32:S1
Pharmacotherapy
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Antacids
Histamine-2 receptor antagonists
Proton pump inhibitors
Prokinetic agents
Surface agents
Goals of Pharmacotherapy
• Control symptoms
• Promote healing
• Prevent complications
• Improve health-related quality of life
• Avoid adverse effects of treatment
Principles of Antireflux Surgery
Restore intraabdominal segment
of esophagus
Approximate
diaphagmatic
crurae
Reduce
hiatal hernia
when present
Wrap fundus
around LES to
reinforce
antireflux barrier
Peptic Disease
• PUD – peptic ulcer disease
– Very uncommon in children
• H. pylori gastritis
– Acid-loving bacteria
– Uncommon in young children
Dietary Intolerance
• Carbohydrate Intolerance
– Most common form is Lactose Intolerance
– Deficiency (primary or secodary) in small
bowel enzyme LACTASE
• Food allergy
– Many possibilities
• Cow/soy protein, nuts, fish, shell fish, wheat
Dietary Intolerance
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Celiac disease
Aka – Celiac sprue, Gluten sensitivity
Autoimmune disease
Environmental trigger
Complex genetics
Treatment: GFD (gluten free diet)
Inflammatory Bowel Disease
• Crohn’s Disease
– Possibly entire GI tract
• Ulcerative colitis
– Restricted to large intestine (colon)
Parasitic Infections
• Giardia
– Most common
– Usually associated with diarrhea, weight loss
• Round worms (nematodes)
– Ascaris
– Enterobius vermicularis (pinworms)
Others (rare)
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Hepatitis
Choledocholithiasis (gallstones)
Kidney stones
Pancreatitis
Eosinophilic esophagitis
Foreign bodies
– (ie. bezoar)
Chronic Recurrent Abdominal Pain
• Chronic
• Recurrent
• Abdominal
• Pain
– Aka – Functional
abdominal pain
- Functional GI Disorders -
Functional Abdominal Pain
• Chronic or recurrent if at least 1 episode of
pain occurs each month of 3 consecutive
months AND is severe enough to interfere
with functioning
• ~10 to 15% of school age kids
• More recently – up to 20% of middle & high
school students report pain daily or weekly
Functional Abdominal Pain
• What is it? →→ Dysfunctional
• What is it NOT?
– Psychogenic
– Imaginary
– Malingering
Functional Abdominal Pain
• Genuine pain
• Cannot be explained on the basis of
structural or biochemical abnormalities
• Generally localizable
– Commonly periumbilical
– Can be diffuse
Epigastric FAP
• Associated with nausea, vomiting, bloating,
belching, early satiety
• Confused with GERD, gastritis
• Commonly “Non-ulcer dyspepsia”
Periumbilical FAP
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Usually no associated symptomatology
No change in bowel patterns
No patterns or discernible triggers to pain
Most common
Infraumbilical FAP
• Associated with cramps, distension,
bloating
• Altered bowel movements
– Constipation
– Diarrhea
• Irritable Bowel Syndrome (IBS)
Clinical Characteristics of FAP
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> 5 yrs
Paroxysms of abd pain
Location: periumbilical (epigastric, infraumbilical)
Pain characterization: vague, non-localizing or
radiating
• Poor temporal correlation with activity, meal,
bowel pattern
• Interferes with normal activity
– Direct relationship with time missed in school/work
• Normal PE, laboratory/other studies
Cyclic Vomiting Syndrome
• Not rare –estimated ~1.9% incidence in
children
– Less common in adults
• Diagnosis – average 9.6 years
• Onset of Sx 5.3 years
– Delay in diagnosis
• F:M 1.2:1
• Cycles 4 -12/year
CVS
CVS
• Likely a heterogeneous group of disorders
• Most commonly linked to migraines
– ? share a common pathophysiologic process
• Also linked to food allergy, mitochondrial,
metabolic, and endocrine disorders
CVS and migraines
• Linked to both migraine headaches and abdominal
migraines
– Abdominal migraines similar with core symptom pain
– Both with high incidence of headache
• Discreteness of episodes – normal health in
between
• Progression of cyclic vomiting to migraine
headaches
• Strong family history (~80%)
• Response to antimigraine therapy
CVS
• Triggers – stress, illness, caffeine/foods,
menstruation (catamenial)
• Autonomic imbalance
– Severe tachycardia, hypertension, and/or
orthostasis during episodes
– Autonomic imbalance with enhanced
sympathetic and diminished parasympathetic
vagal modulation (71%)
To J, et al. J Pediatr 1999 Sep;135(3):363-6
The Brain-Gut Axis
Brain-Gut Connection:
Corticotropin Releasing Factor
• Paraventricular nucleus (hypothalamus)
• Dorsal vagal complex
– Endogenous brain CRF mediates psychological,
physical, somatovisceral, and immunological stressinduced delayed gastric emptying in rats.
• Postoperative gastric ileus is prevented by
peripheral injection of CRF antagonists.
• CVS is precipitated by stimulation of CRF release
– resulting endocrine, autonomic, and visceral changes
are indicative of central CRF activation.
Tache Y. Dig Dis Sci 1999 Aug;44(8 Suppl):79S-86S.
Emotional Motor System
• Overlap of brain regions concerned with
processing visceral afferent innervation
(mainly colon) with central autonomic
regulation of GI motility and secretion
• Rostral portion of the anterior cingulate
cortex (ACC) is the visceromotor cortex
– Projects to hypothalamic nuclei, amygdala,
periaqueductal grey and brainstem nuclei
Summary of FGIDs
What can be done?
Pharmacotherapy
• Anti-spasmodics
– (anti-cholinergics, anti-histamines)
– Dicyclomine (Levsin, Bentyl)
– Hycosamine
• Serotoninergics
– Agonist: Tegaserod (Zelnorm)
– Antagonist: Alosetron (Lotronex)
Antidepressants
Tricyclics
– 3° - Amitriptyline, Imipramine
– 2° - Nortriptyline, Desipramine
Lower doses than anti-depressant use provide:
• anxiolytic effects
• anti-nociceptive properties and facilitate central pain
tolerance
• peripheral analgesic effects at the level of visceral
mechanoreceptors and afferent nerve fibers
Antidepressants
• SSRIs
– Equivocal beneficial effects
– Many due to anti-anxiety effects
• SNRIs
– No randomized trials in FGIDs (adults or kids)
– Many open label studies and anecdotal data to
suggest promise with less side effects than
TCAs
Non-pharmacologic Therapy
• Cognitive Behavioral Therapy
• Interpersonal dynamic psychotherapy
• Deep muscle relaxation
• Stress reduction techniques
• Biofeedback
CBT more effective in IBS than TCA and antispasmodics (~80%)
Drossman DA, et al. Gastroenterology 2003
Psychosocial
• Psychosocial aspects can not be underscored
enough
• “Continued symptoms coupled with negative
work-ups (lack of definitive tests or marker), lack
of understanding of parents and patients, and
incomplete or ambivalent explanations from
providers can lead to constant worry, fear and
anxiety, thus perpetuating symptoms and
influencing healthcare-seeking behavior
adversely”.
Syed IM, et al. Gastroenterology and Hepatology, 2006
Factors Influencing Long-Term
Prognosis
Factor
Better Prognosis Worse Prognosis
Sex
Female
Male
Age of Onset
> 6 yrs
< 6 yrs
Family
Normal
“Painful”
Duration of Sx
< 6 months
> 6 months
Education level
> High school
completed
Socioeconomic class Middle-upper
Lower
Surgery
Frequent
Infrequent
< High school
Summary of FGID
• FGIDs are a spectrum of biopsychosocial
disorders that lack a diagnostic marker
• Involve altered GI function, with
dysfunction of brain-gut axis regulation
• Focus should be a return to normal function,
not complete resolution of pain.
Take Home Message
• Abdominal complaints are common in
school age children
• Many may be a symptom of underlying
organic or functional disease
• Some may be attempts at distraction from
school work or attendance
• Early referral for evaluation is important in
cases of associated symptoms or significant
academic or social dysfunction