abdominal pain in the pediatric clinic
TRANSCRIPT
Abdominal Pain in the Pediatric Clinic
Amanda Lee MD
Doernbecher Children’s Hospital
Oregon Health & Science University
Division of Pediatric Gastroenterology
OHSU
Objectives
• Elicit the history for a pediatric patient with abdominal pain• Focus on chronic abdominal pain (> 2 months)
• Identify alarm signs and symptoms to prompt further work-up
• Initiate the work-up for a pediatric patient with abdominal pain
• Manage common causes of abdominal painOHSU
Abdominal Pain
• One of the most common childhood complaints
• Many causes, often self-limited and benign
• Rule out life-threatening causes• Bowel obstruction, perforation, hemorrhage
• Consider non-gastrointestinal causes• Urologic, musculoskeletal, infectiousOHSU
History
• Pain Characteristics• Onset, duration, location, quality, aggravating and alleviating factors
• Associated Symptoms• Nausea, vomiting, dysphagia, anorexia
• Bowel Movements• Diarrhea, constipation, hematochezia, melena
• Review of Systems• Weight loss, fatigue, fevers, headaches, mouth sores, rashes, jaundice,
arthralgias, urinary symptoms, menstrual history in females
• Psychosocial
OHSU
Case 1: History
• Pain Characteristics• Periumbilical, cramping • Began 6 months ago, progressing in severity and frequency
• Associated Symptoms• Poor appetite, nausea when pain is severe
• Bowel Movements• Loose, 4-5 per day, urgency, nocturnal stools 3 times per week for the last month• No pain relief after stooling
• Review of Systems• 10 lb unintentional weight loss, fatigue
• Family History notable for father with ulcerative colitis
OHSU
Case 1: History
• Pain Characteristics• Periumbilical and lower abdomen, cramping • Began 6 months ago, progressing in severity and frequency
• Associated Symptoms• Poor appetite, nausea when pain is severe
• Bowel Movements• Loose, 4-5 per day, urgency, nocturnal stools 3 times per week for the last month• No pain relief after stooling
• Review of Systems• 10 lb unintentional weight loss, fatigue
• Family History notable for father with ulcerative colitis
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Physical Exam
? Vital Signs including height, weight, BMI
? General Appearance: body habitus, pallor, development
? HEENT: presence of aphthous ulcers
? Abdomen: focal tenderness, distension, hepatomegaly, splenomegaly, masses
? Perianal/rectal: skin tags, fissure, fistula
? Skin: rashes, jaundice
? Musculoskeletal: arthritis
? Lymphadenopathy
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Case 1: Physical Exam
• Growth: 10 lb weight loss since well check one year ago, decline in height percentiles from 75th to 50th
• General: thin, tired-appearing, mild pallor, pre-pubertal
• Abdomen: soft, non-distended, +mild tenderness to palpation diffusely, no masses or hepatosplenomegaly
• Perianal: irregular, non-tender perianal skin tag at 7 o’clock OHSU
Red Flags
• Bilious or severe, intractable vomiting
• Blood in stool• Chronic diarrhea
• 3+ loose stools/day > 2 weeks
• Symptoms wake patient from sleep
• Localized pain (RLQ, RUQ, LLQ)• Dysphagia or odynophagia• Frequent infections
• Unexplained fevers• Delayed puberty• Unintentional weight loss• Decrease in height velocity• Physical exam findings
• Oral ulcers• Arthritis• Rashes• Focal abdominal tenderness or mass• Organomegaly• Perianal: deep fissure, fistula, large or
inflamed skin tag
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Further Evaluation
• Complete blood count with differential (CBC)
• Comprehensive metabolic panel (CMP)• Electrolytes, glucose, BUN, creatinine, AST, ALT, bilirubin, albumin, total protein
• Erythrocyte sedimentation rate (ESR)
• C-reactive protein (CRP)
• Celiac serologies• Anti-tissue transglutaminase IgA, total IgA
• Stool studies to consider • Fecal calprotectin• Stool infectious studies • Fecal occult blood
OHSU
Case 1: Further Evaluation
• CBC notable for hemoglobin 11.2 g/dL (normal 12-16 g/dL), normal MCV
• CMP notable for albumin 3.3 g/dL (normal 3.4-5.4 g/dL)
• CRP 15 mg/L (normal < 1)
• ESR 42 mm/hr (normal < 30)
• Anti-TTG IgA negative
• Stool negative for infectious pathogens
• Fecal calprotectin elevated to 750 μg/g
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Case 1: Summary
• Chronic, progressive periumbilical and lower abdominal pain
• Chronic diarrhea with nocturnal symptoms
• Unintentional weight loss
• Delayed puberty
• Family history of inflammatory bowel disease
• Normocytic anemia, hypoalbuminemia, elevated serum and stool inflammatory markers
• Presentation concerning for inflammatory bowel disease
• Peds GI referral
OHSU
Case 2: History
• Pain Characteristics• Onset 6 months ago after the family had a stomach bug
• Sharp periumbilical pain
• Occurs 2-3 times per week, often post-prandial, lasts 30 minutes to 2 hours
• Alleviated by listening to music, sleep, passing stool
• Exacerbated by stress (ex. school exams) and eating fast foodOHSU
Case 2: History
• Bowel Movements• Vary from firm and difficult to pass to loose; 1-3 times daily; no blood; no
nocturnal stooling
• Associated Symptoms• Occasional nausea
• Review of Systems• Positive: fatigue, occasional tension-type headaches, anxiety
• Negative for fevers, mouth sores, vision/eye problems, joint pain or swelling, rashes, unintentional weight loss, urinary changes; normal menses
OHSU
Case 2: Physical Exam
• Growth: normal, gaining weight and height at 75th percentiles
• Unremarkable physical examOHSU
Functional Gastrointestinal Disorders (FGID)Disorders of Gut-Brain Interaction (DGBI)
Alteration in the Brain-Gut Axis• Central, autonomic, and
enteric nervous systems• Neuroendocrine system• Immune system• MicrobiotaChanges in • Visceral sensitivity• Motility• CNS processing
Mayer and Tillisch, 2011
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Biopsychosocial Model of Pain
Environmental
Gut microbiota
Medications
Infections
Diet
Psychosocial
Coping skills
Social support
Reinforcement
Distraction
Response
Biological
Genes
Motility
Visceral sensitivity
Mucosal function
Immune system
Allergies
Inflammation
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FGID / DGBI
• Introduce concept early
• NOT diagnoses of exclusion
• Rome IV criteria• Functional abdominal pain (not otherwise specified)• Irritable bowel syndrome• Functional dyspepsia• Abdominal migraine
• Validate their pain, build rapport, educate• NOT “all in your head,” but rather a disturbance in the complex brain-gut axis
• Further evaluation warranted if any red flags
• Pediatric GI referral more than welcome
OHSU
True or False?
You must rule out organic etiologies of abdominal pain
before diagnosing a functional GI disorder.
False
Functional and organic disorders can co-exist.
True
Psychological comorbidities are common in both organic and functional disorders.
True
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Rome IV Criteria for Functional Abdominal Pain Disorders
Functional Dyspepsia
• 1 or more of the following, at least 4 days per month
• Post-prandial fullness
• Early satiety
• Epigastric pain or burning not associated with defecation
• Criteria fulfilled for at least 2 months before diagnosis
Irritable Bowel Syndrome
• Abdominal pain at least 4 days per month associated with 1 or more:
• Related to defecation• A change in frequency of stool• A change in form/appearance of stool
• If constipated, pain does not resolve with resolution of constipation
• Criteria fulfilled for at least 2 months before diagnosis
Abdominal Migraine
• Paroxysmal episodes of intense, acute periumbilical, midline, or diffuse abdominal pain lasting 1 hour or more
• Episodes separated by weeks to months
• Incapacitating pain
• Stereotypical pattern
• Associated with 2 or more: anorexia, nausea, vomiting, headache, photophobia, pallor
• Criteria fulfilled at least 6 months before diagnosis
Functional Abdominal Pain NOS
• Episodic or continuous abdominal pain that does not occur solely during physiologic events
• Insufficient criteria for FD, IBS, AM
• Criteria fulfilled for at least 2 months before diagnosis
After appropriate evaluation, the symptoms cannot be fully explained by another medical condition.
OHSU
FGID/DGBI: Management
• Behaviors• Participation in rather than avoidance of activities• Sleep• Exercise
• Psychological• Coping skills, stress management• Clinical hypnosis• Cognitive behavioral therapy
• Diet• Avoid triggers, ex. lactose, excess fructose
• Medications• Regulate stools (laxatives, fiber)• Anti-spasmotics, ex. enteric-coated peppermint, hyoscyamine• Target visceral hypersensitivity, ex. amitriptyline • Others: cyproheptadine, probiotics, herbals, acid suppression
OHSU
Case 3: History
• Pain Characteristics• Began 3 months ago when he started kindergarten• Periumbilical and lower abdomen• 4 days per week, variable timing • Improves after stooling
• Bowel Movements• 2-3 per week, hard, sometimes large caliber• Toilet-trained but withholds at school and during play• Fecal smearing 1-2 times/week• Blood on toilet paper noted twice
• Associated Symptoms, Review of Systems• Overweight, normal development, good appetite but dislikes vegetables, active
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Case 3: Constipation
• Education• Pathophysiology of functional constipation• Rare to have underlying pathologic cause
• Behaviors• Avoid withholding• Post-prandial toilet sitting• Foot support
• Diet• Fiber (age + 5-10 grams)• Fluid
• Medications• Bowel clean-out if long-standing constipation• Maintenance regimen• Wean slowly
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Imaging
• Utility depends on suspected diagnosis
• Abdominal x-ray • Not needed to diagnose constipation
• Ultrasound• Cholelithiasis, ovarian pathology, hydronephrosis, mass
• CT• Urgent evaluation for acute process or concerning exam,
ex. abscess, perforation, mass
OHSU
Case 4: History
• Pain Characteristics• 3 months of symptoms• Periumbilical, dull• Occurs all the time, increase in frequency to daily • Exacerbated by eating, particularly with dairy• No relief with acid suppression
• Bowel Movements• Soft, sometimes loose, 1-2 daily, no blood
• Associated Symptoms, Review of Systems• Decreased energy, occasional headaches• No weight gain in 6 months, decrease in height percentiles from 50th to 25th
OHSU
Case 4
• Further workup due to poor growth • CBC: microcytic anemia
• CMP: normal
• Elevated anti-tissue transglutaminase IgA
• CRP, ESR normal
• Concern for celiac disease
• Refer to pediatric GI
• Continue gluten in the diet until celiac diagnosis confirmed with endoscopy with duodenal biopsies.
OHSU
Case 5: History
• Pain Characteristics• 2 months, burning, post-prandial epigastric pain, exacerbated by greasy and spicy
foods
• Associated Symptoms• Early satiety, burning chest pain, acid brash • A few episodes of nausea with vomiting after a heavy meal• No dysphagia or odynophagia
• Bowel Movements• Soft, easily passed, 1-2 times daily, no melena or hematochezia
• Review of Systems• Positive for headaches, taking ibuprofen 3 times per week • Negative for weight loss, fevers, fatigue; onset of menses 4 months ago
OHSU
Pain LocationEpigastrico Gastritis o Peptic ulcero GERDo Esophagitiso Pancreatitiso Hepatobiliary (or RUQ)
RLQo Appendicitiso Mesenteric adenitiso Crohn’s disease
Periumbilicalo Constipationo Irritable bowel
syndrome (IBS)o Abdominal migraineo Functional
abdominal paino Celiac diseaseo IBDo HSP, Volvulus, early
appendicitis, gastroenteritis, DKA, Strep
Lower Abdomen or Pelvico IBSo Colitiso Constipationo Testicular torsiono Ovarian torsiono Dysmenorrheao Ectopic pregnancy
Acute cholecystitis scapulaPancreatitis back
Visceral pain receptors: not well-localized
Abdominal Wallo Musculoskeletalo HerniaOHSU
Epigastric Pain
• Gastroesophageal reflux disease (GERD)
• Functional dyspepsia
• Peptic ulcer disease• NSAIDs
• Gastritis
• H. pylori
• Esophagitis• Eosinophilic esophagitis, esp. if atopic
• Hepatobiliary • Consider ultrasound
OHSU
Epigastric Pain
• Histamine-2 receptor antagonists• Fast acting, tachyphylaxis
• Proton pump inhibitors• Better acid suppression than H2RA• 30 minutes before a meal• CYP2C19 variable metabolism
• Cyproheptadine• Good for nausea, early satiety
• Referral to GI• Refractory to acid suppression, hematochezia or melena, high suspicion for H. pylori
(household contact, endemic region), any red flag or otherwise
OHSU
Take-Home Points
• Many causes of abdominal pain • Benign to life-threatening
• Non-gastrointestinal etiologies
• Elicit pain characteristics, bowel movements, associated symptoms
• Look for red flags that warrant additional workup• Growth
• Functional gastrointestinal disorders are most common• Education, psychological, diet, medications
• Referrals to pediatric GI welcome
OHSU