Abdominal Pain in Children

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Abdominal Pain in Children
Modified from a lecture by Dr. John Snyder, CNMC
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Objectives

• Know the differential diagnosis of recurrent
  abdominal pain
• Recognize the clinical manifestations of chronic
  recurrent abdominal pain
• Plan the evaluation of a patient with chronic
  recurrent abdominal pain
• Understand the role of Helicobacter pylori in
  chronic recurrent abdominal pain

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Self Quiz

• Organic cause in 10-15 of cases of abdominal
  pain
• Over-achievers and worries have more recurrent
  abdominal pain
• Recurrent abdominal pain is more common in
  females lt 10 years old
• Serology is a good test for H. pylori
• H. pylori is an important cause of abdominal pain
• Prevalence of celiac disease in US is 1/2500
• Serology is a good test for celiac disease

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Self Quiz So how did you do?
TRUE FALSE FALSE FALSE FALSE FALSE TRUE

• Organic cause in 10-15 of cases of abdominal
  pain
• Over-achievers and worries have more recurrent
  abdominal pain
• Recurrent abdominal pain is more common in
  females lt 10 years old
• Serology is a good test for H. pylori
• H. pylori is an important cause of abdominal pain
• Prevalence of celiac disease in US is 1/2500
• Serology is a good test for celiac disease

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Apley Recurrent Abdominal Pain (RAP)

• 3 or more episodes occuring in 3 months
• Severe enough to affect routine activity and
  daily function
• Absence of organic pain

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Apley Criteria

• Pros
• Well known
• Provides frame of reference
• Cons
• Based on about 1000 English students
• 1950s data
• Limited evaluations performed
• Few validated assessment tools in children

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Rome Criteria for Abdominal Pain

• 5 categories based on adult criteria
• Functional dyspepsia pain above umbilicus
• Irritable bowel syndrome improved with stooling
• Functional abdominal pain doesnt fit other
  categories
• Functional abdominal pain (FAP) syndrome some
  loss of daily functioning and somatic complaints
  (ie. headache, limb pain)
• Abdominal migraine severe perimbilical pain and
  headache, photophobia, vomiting or nausea

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Rome Criteria

• Intended as a research framework
• Not clear how useful in the outpatient setting
• Does allow for comparison and perspective
• Offers families a more concrete diagnosis
• May be more practical to focus on treating
  symptoms

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Recurrent Abdominal PainEpidemiology

• 10-15 of school age children seek help
• 10-15 more have symptoms but never seek medical
  attention
• 10 have an organic cause
• Femalesgtmales
• Higher in gt 10 years old
• Prevalence increases during school, not vacations

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MYTHS

• NOT associated with
• Super-intellect
• Perfectionist
• Over-achiever
• Constant worrier

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Differential Diagnosis

• GI
• Constipation
• Parasites
• Lactose Intol
• Peptic Disease
• IBD
• Gallstones
• Pancreatitis
• Allergy
• ?H. pylori
• ?Celiac Dis.

GU UTI Renal Stones Ovarian PID
OTHER Medications HSP Sickle Cell Lymphoma Fam
Med Fever Porphyria Lead Poisoning Rheumatologic
FUNCTIONAL Functional Dyspepsia IBS FAP Functional
Ab Pain Abdominal Migraine
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Feeling like this yet?
Dont despair!
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The Dilemma

• This is a very common problem
• 10 of cases have an organic etiology
• So the question you have to answer is
• How many causes should be excluded?
• What are the clues to an organic cause?

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EASY 8 QuestionsTo Separate Functional from
Organic

• When did it start? Document duration
• F Concurrent stressful event in life
• O Trauma or travel
• Where is it located and where does it go?
• F Peri-umbilical or epigastric
• O Well localized away from umbilicus

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EASY 8 QuestionsTo Separate Functional from
Organic

• How long does it last?
• F Prolonged duration with no clear signs
• O Variable signs raise the ante
• What does the pain feel like?
• F Vague, gradual onset, variable severity
• O Isolated, sudden onset

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EASY 8 QuestionsTo Separate Functional from
Organic

• What makes the pain better?
• F No relationship to interventions
• O Sometimes medications or position change help
• What makes the pain worse?
• F Reinforcement from parents
• Is the pain intermittent or constant
• F Constant
• O - Intermittent

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EASY 8 QuestionsTo Separate Functional from
Organic

• Association with other signs or symptoms?
• F Signs of anxiety (mottled skin, nail biting),
  family history of irritable bowel, migraines
• O Association with hematachezia, fever, rash,
  weight loss, growth faltering, family history of
  ulcers or IBD

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1st Visit

• Emphasize the pain is real but the cause may be
  hard to find
• Exclude the functional 5
• Chronic UTI (especially in females)
• Giardia
• Lactose Intolerance
• Stooling problems constipation or irregular
  stool pattern (IBS)
• Consider Celiac Disease

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Physical Examination

• Growth evidence of faltering?
• Abdomen
• guarding?
• degree of pain vs. softness
• Tubular masses in LLQ
• Distractability
• Rectal - nature of stool, guaiac
• Consider Gyn examination vs abdominal ultrasound
  when appropriate

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Red Flags Rapid Work-Up

• Systemic signs hematachezia, fever, rash,
  weight loss, growth faltering
• Historical clues family history of ulcers or
  IBD
• Prolonged school absence
• Use of narcotic pain medication
• Positive exam findings
• If present hurry up!!!!

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1st Line Evaluation

• Urine UA, /- culture
• Stool guaiac, EIA antigen test (Giardia)
• Blood CBC, /- ESR, other tests indicated by
  history or examination
• Therapeutic trial high fiber and lactose free
  diet

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What about H. pylori?

• Circumstantial evidence against a major role for
  H. pylori
• Eradication does not always result in
  improvement of pain
• Serology is NOT an accurate screener

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H. Pylori

• Over 3000 patients in 7 studies of abdominal
  pain
• H. pylori found in 10-15 of patients
• Prevalence is the same in patients with pain and
  without pain
• No randomized, controlled studies

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H. Pylori Serology in Children

• Low sensitivity in young children
• Lower antibody titers
• Immunodominant proteins differ from adults
• Antibodies persist long after eradication
• Maternal antibodies often found in infants

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Now to Celiac..

• Prevalence 1/250 (sero screening)
• Children at increased risk
• GI clinic symptomatic children 1/57
• Type I diabetic 5-8
• Down Syndrome 1-2
• Results similar to those in Europe
• ONLY 5 of US cases are diagnosed!

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Which Test for Celiac?
Antibody Test Sensitivity Specificity PPV NPV
Gliadin IgG 65 60 30 50
Gliadin IgA 70 75 40 80
Endomysial IgA 90 98 95 85
tTG human IgA 95 99 99 95
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Medications for Abdominal Pain

• Empiric trials for acid suppression often done
• Many also use homeopathy
• For pain of unknown cause
• Use of narcotics is an indication for admission
  and evaluation

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Medications for Abdominal Pain
Drug Action EtOH Death
Mylicon Anti-flatulence None No
Bentyl Anti-spasmodic None Yes
Levsin AS, sedation, anti-cholinergic 20 Yes
Donnatol AS, sedation, anti-cholinergic 24 Yes
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Ready to Apply Your Knowledge?
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Case Study

• 12.5 year old, previously well, hispanic female
  arrives in your clinic with a 6 month history of
  severe, intermittent abdominal pain. Travels to
  Mexico frequently to see family.
• Pain peri-umbilical or epigastric, crampy or
  sharp, variable frequency and duration
• No emesis, diarrhea, weight loss, fever,
  hematachezia
• Intermittent hard stools
• Normal menstrual periods
• Missed 3.5 weeks of school fair student who
  does not like school
• Family intact, no home stressors
• Meds Mylanta, Tylenol, Ibuprofen, Ginseng

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Case Study

• Diet heavy on fast foods and diet coke
• PE remarkable for
• Ht 153 cm (25-50), Wt 59 kg (gt90), BMI 26
  (gt95)
• ABD obese, soft, pain on deep palpation of mid
  abdomen, no guarding, rebound, masses or
  hepatosplenomegaly
• Rectal normal anus and tone hard, heme
  negative stool

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Remember the EASY 8 Questions
Functional Organic
1. Start? Trip to Mexico X
2. Location? Peri-umbilical X
3. Duration? Variable X
4. Description? Vague X
5. Improvement? No relief on Rx X
6. Worsens? School Absence X
7. Intermittent? Variable X
8. Signs/Sx? None X
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Real Story Gone Bad

• What was done a battery of tests including CT,
  US, treatment for H. pylori, ultimately a
  cholecystectomy was done.
• The patient did not get better

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• Finally started on therapy for constipation by
  gastroenterologist and began counseling for
  chronic pain

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Lessons to be learned from case

• H. pylori is usually not the simple solution
• Gallstones in the absence of specific signs and
  symptoms, are rarely the cause of vague abdominal
  pain

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Remember to complete the questions related to
this topic!