Functional and organic diseases of digestive tract. Etiology

Functional and organic diseases of digestive tract. Etiology

Functional and organic diseases
of digestive tract. Etiology,
pathogenesis, clinical features,
diagnostics, treatment and
prevention.
Lecturer:
Sakharova I.Ye., MD, PhD
Chronic abdominal pain
Frog position in severe crampy
abdominal pain
Is it a problem?
• Prevalence 0.5%-19% in community
• 13-17% middle/high school students
weekly pain
• 2-4% of paediatric office visits
• Considerable morbidity, missed school
days
• Difficult, time-consuming and expensive
to manage because of diagnostic
uncertainty, chronicity and increasing
parental anxiety
What I’ll talk about
• Definitions of functional abdominal
pain
• Cause of functional abdominal pain
• Differentiating organic vs functional
pain
• Management of functional abdominal
pain
Rome III criteria, 2006
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Functional dyspepsia
Irritable bowel syndrome
Functional abdominal pain
Functional abdominal pain syndrome
Abdominal migraine
- No evidence of an inflammatory, anatomical,
metabolic or neoplastic process
- Criteria fulfilled at least once a week for at least
two months before diagnosis
Functional dyspepsia
• Persistent or recurrent pain or
discomfort centred in the upper
abdomen (above the umbilicus)
• Not relieved by defecation or
associated with the onset of a
change in stool frequency or stool
form
Recurrent abdominal pain (Apley and
Naish, 1958)
• Waxes and wanes
• 3 episodes in 3 months
• Severe enough to affect activities
Irritable bowel syndrome
Abdominal discomfort (uncomfortable
sensation not described as pain) or pain
associated with two or more of the
following at least 25% of the time:
• Improved with defecation
• Onset associated with a change in
frequency of stool
• Onset associated with a change in form
(appearance) of stool
Functional abdominal pain
• Episodic or continuous abdominal
pain
• Insufficient criteria for other
functional gastrointestinal disorders
Functional abdominal pain syndrome
Must include functional abdominal pain at
least 25% of the time and one or more of
the following:
• Some loss of daily functioning
• Additional somatic symptoms such as
headache, limb pain, or difficulty in
sleeping
Abdominal migraine
• Paroxysmal episodes of intense, acute periumbilical
pain that lasts for one or more hours
• Intervening periods of usual health lasting weeks to
months
• The pain interferes with normal activities
• The pain is associated with two or more of the
following:
- Anorexia
- Nausea
- Vomiting
- Headache
- Photophobia
- Pallor
Criteria fulfilled two or more times in the preceding 12
months
What causes it?
• Biopsychosocial model
• Visceral sensation, disturbances in GI motility,
hormonal changes, inflammation
• Psychological factors
• Family dynamics
• Brain-gut axis
• Sexual abuse – longer duration of symptoms
• Parental anxiety in first year of life associated
with chronic abdo pain before age 6
• GI problems in parents
Chronic abdo pain in OPD
• Organic vs functional pain
• Organic pain 5% in general
population, 40% in paediatric
gastroenterology OPD.
Organic vs functional pain
• No diagnostic tools to differentiate
• Presence of alarm symptoms or
signs increases the probability of an
organic disorder and justifies further
tests
History and examination
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Analysis of the pain
GI symptoms including bowel habit
Genitourinary symptoms
Effect on daily living
Family history – GI problems,
migraine
Alarm symptoms
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Involuntary weight loss
Deceleration of linear growth
Gastrointestinal blood loss
Significant vomiting
Chronic severe diarrhoea
Unexplained fever
Persistent right upper or right lower
quadrant pain
• Family history of inflammatory bowel
disease
Organic pain - differential
GI tract
• Chronic constipation
• Lactose intolerance
• Parasite infection (Giardia)
• Excess fructose/sorbitol ingestion
• Crohns
• Peptic ulcer
• Reflux esophagitis
• Meckels diverticulum
• Recurrent intussusception
• Hernia – internal, inguinal, abdominal wall
• Chronic appendicitis
Organic pain - differential
Gallbladder and pancreas
• Cholelithiasis
• Choledochal cyst
• Recurrent pancreatitis
Genitourinary tract
• UTI
• Hydronephrosis
• Urolithiasis
Miscellaneous causes
• Abdominal epilepsy
• Gilberts syndrome
• Familial Mediterranean fever
• Sickle cell crisis
• Lead poisoning
• HSP
• Angioneurotic edema
• Acute intermittent porphyria
Diagnostic Tools
• Rome III Criteria
• Essential Investigations : according to symptoms
e.g.
- CBC
- U A , Stool exam
- LDG, Amylase ,lipase
- Ultrasound
- Barium study
- Gastric emptying time test ,Intestinal transit time
,Colonic transit time test
- Hydrogen breath test: lactose ,lactulose,glucose
- Endoscopy
- Skin Prick test
- Urea Breath test
Recommendation of North American
Society for Pediatric
Gastroenterology, Hepatology and
Nutrition
• Additional diagnostic evaluation is
not required in children without
alarm symptoms
• Testing may be carried out to
reassure children and their parents
What are the predictive values of diagnostic
tests?
• There is no evidence to suggest that the use of
ultrasonographic examination of the abdomen
and pelvis in the absence of alarm symptoms has
a significant yield of organic disease (evidence
quality C).
• There is little evidence to suggest that the use of
endoscopy and biopsy in the absence of alarm
symptoms has a significant yield of organic
disease (evidence quality C).
• There is insufficient evidence to suggest that the
use of esophageal pH monitoring in the absence
of alarm symptoms has a significant yield of
organic disease (evidence quality C).
Treatment
• Deal with psychological factors
• Educate the family (an important part of
treatment)
• Focus on return to normal functioning
rather than on the complete
disappearance of pain
• Best prescribe drugs judiciously as part of
a multifaceted, individualised approach, to
relieve symptoms and disability
Treatment
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Medicines:
Acid lowering agents
Mucoprotective drugs
Motility regulators
Laxatives
Analgesics
Probiotics
Gas adsorbants
Dietary and life style change
Psychotherapy
• Pharmacologic treatment
approach
A. Antacids
B. H2- receptor antagonist
C. Proton pump inhibitors
D. Sucralfate
E. Prokinetics
Treatment of Acid-related disorders
• H2-receptor Antagonists:
Ranitidine (2-4 mg/kg/d up to 150 mg bid),
Famotidine (1-1.2 mg/kg/d up to 20 mg bid)
• PPI:
Omeprazole (0.8 mg/kg/d;effective dose
range of 0.3-3.3 mg/kg/d),
Lansoprazole (0.8 mg/kg/d)
• Cytoprotective Agents:
Sucralfate(40-80 mg/kg/d up to 1 g qid)
Rabemipride ( 1 x 3 )
Prognosis
• Majority of children mild symptoms and managed
in primary care
• Studies of prognosis are mainly in referred
patients
• Systematic review
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29.1% of children had on-going abdo pain
(follow-up ranged 1-29 yrs)
• May develop irritable bowel synd as adults
• Risk of later emotional symptoms and psychiatric
disorders, particularly anxiety disorders
Success is not final,
failure is not fatal.
It is the courage to
continue that counts.
Winston Churchill