Chronic Abdominal Pain in the Adolescent: Is it Irritable Bowel Syndrome? : Chronic Abdominal Pain in the Adolescent: Is it Irritable Bowel Syndrome? Brock J. Doubledee, D.O
Pediatric Gastroenterology
Recurrent Abdominal Pain (RAP) : Recurrent Abdominal Pain (RAP) Is responsible for 2-4% of pediatric office visits.
Affects 7-25% of school-aged children and adolescents.
Prevalence of RAP increases with increasing age into adolescence.
Gender ratio is equal in early childhood but becomes female predominant in late childhood and adolescence. Pace et al. World J Gastroenterol 2006; 12(24): 3874-3877
Red Flags in Pediatric Abdominal Pain : Red Flags in Pediatric Abdominal Pain Persistent right upper or right lower quadrant pain
Pain that wakes the child from sleep
Dysphagia
Arthritis
Persistent vomiting
Perirectal disease
Gastrointestinal blood loss Involuntary weight loss
Nocturnal diarrhea
Deceleration of linear growth
Family history of inflammatory bowel disease, celiac disease, or peptic ulcer disease
Delayed puberty
Unexplained fever Drossman D, Corazziari E, Spiller R, Talley N, Thompson W, Whitehead W, eds. Rome III.
The Functional Gastrointestinal Disorders. 3rd ed. McLean, VA 2006
Testing : Testing History
Physical
Lab
Stool
Serum
Radiology
Nuclear Medicine
Functional gastrointestinal disorders (FGIDs) : Functional gastrointestinal disorders (FGIDs) Functional dyspepsia
Irritable bowel syndrome
Abdominal migraine
Childhood functional abdominal pain
Childhood functional abdominal pain syndrome Drossman D, Corazziari E, Spiller R, Talley N, Thompson W, Whitehead W, eds. Rome III.
The Functional Gastrointestinal Disorders. 3rd ed. McLean, VA 2006
Functional Dyspepsia : Functional Dyspepsia Must include all of the following:
1.Persistent or recurrent pain or discomfort centered in the upper abdomen (above the umbilicus)
2.Not relieved by defecation or associated with the onset of a change in stool frequency or stool form (ie, not IBS)
3.No evidence of an inflammatory, anatomic, metabolic, or neoplastic process that explains the subject’s symptoms Drossman D, Corazziari E, Spiller R, Talley N, Thompson W, Whitehead W, eds. Rome III. The Functional Gastrointestinal Disorders. 3rd ed. McLean, VA 2006
Abdominal Migraine : Abdominal Migraine Must include all of the following:
1.Paroxysmal episodes of intense, acute periumbilical pain that lasts for 1 hour or more
2.Intervening periods of usual health lasting weeks to months
3.The pain interferes with normal activities
4.The pain is associated with 2 or more of the following:
a.Anorexia
b.Nausea
c.Vomiting
d.Headache
e.Photophobia
f.Pallor
5.No evidence of an inflammatory, anatomic, metabolic, or neoplastic process considered that explains the subject’s symptoms Drossman D, Corazziari E, Spiller R, Talley N, Thompson W, Whitehead W, eds. Rome III. The Functional Gastrointestinal Disorders. 3rd ed. McLean, VA 2006
Childhood Functional Abdominal Pain : Childhood Functional Abdominal Pain Must include all of the following:
1. Episodic or continuous abdominal pain
2. Insufficient criteria for other FGIDs
3. No evidence of an inflammatory, anatomic, metabolic, or neoplastic process that explains the subject’s symptoms Drossman D, Corazziari E, Spiller R, Talley N, Thompson W, Whitehead W, eds. Rome III. The Functional Gastrointestinal Disorders. 3rd ed. McLean, VA 2006
Childhood Functional Abdominal Pain Syndrome : Childhood Functional Abdominal Pain Syndrome Must include childhood functional abdominal pain at least 25% of the time and 1 or more of the following:
1. Some loss of daily functioning
2. Additional somatic symptoms such as headache, limb pain, or difficulty sleeping Drossman D, Corazziari E, Spiller R, Talley N, Thompson W, Whitehead W, eds. Rome III. The Functional Gastrointestinal Disorders. 3rd ed. McLean, VA 2006
Irritable Bowel Syndrome : Irritable Bowel Syndrome Must include all of the following:
1. Abdominal discomfort (an uncomfortable sensation not described as pain) or pain associated with 2 or more of the following at least 25% of the time:
a. Improved with defecation
b. Onset associated with a change in frequency of stool
c. Onset associated with a change in form (appearance) of stool
2. No evidence of an inflammatory, anatomic, metabolic, or neoplastic process that explains the subject’s symptoms Drossman D, Corazziari E, Spiller R, Talley N, Thompson W, Whitehead W, eds. Rome III. The Functional Gastrointestinal Disorders. 3rd ed. McLean, VA 2006
The Bristol Stool Form : The Bristol Stool Form Seven categories defined
Form depends upon colon transit time
Lumpier stools correlate with longer colon transit
Often used in studies
Subjective
Categorical variable
Should not average results Davies G et al. Gut 1986;27:164–9 Type 1 Type 2 Type 3 Type 4 Type 5 Type 6 Type 7
Prevalence of IBS Across the World : New Zealand
IBS: 17% UK
IBS: 22% Australia
IBS: 12% USA
IBS: 9–20% Scandinavia
IBS: 13% Prevalence of IBS Across the World
Overlapping Upper GI Symptoms in Patients with IBS : Overlapping Upper GI Symptoms in Patients with IBS Talley et al. Am J Gastroenterol 2003;98:2454–9
IBS Subtypes : IBS Subtypes Drossman D, Corazziari E, Spiller R, Talley N, Thompson W, Whitehead W, eds. Rome III. The Functional Gastrointestinal Disorders. 3rd ed. McLean, VA 2006
Conceptual mechanisms interacting in the development of FGIDs and IBS : Conceptual mechanisms interacting in the development of FGIDs and IBS Camilleri et al. Aliment Pharmacol Ther 1997; 11: 3 Disordered motility Genes/ Environment Abnormal sensation
Heritability of IBS and FGIDs: the evidence : Heritability of IBS and FGIDs: the evidence IBS and FGID runs in families. 1
Genetic? 2
Similar psychosocial factors may contribute to clustering in families? 3 1 Morris-Yates et al. Am J Gastroenterol 1998;93:1311–7 2 Levy et al. Gastroenterology 2001;121:799–804 3 Locke et al. Mayo Clin Proc 2000;75:907–12
Familial association in FGIDs : Familial association in FGIDs GERD Diarrhea Constipation Dyspepsia IBS Locke et al. Mayo Clin Proc 2000;75:907-912 2.5
2.0
1.5
1.0
0.5
0 Odds
ratio
Evidence for Visceral Hypersensitivity in IBS : 1 Munakata et al, Gastroenterology 1997; 122: 55
2 Mertz et al, Gastroenterology 1995; 109: 40
3 Mayer et al, Am J Med 1999; 107: 12S Evidence for Visceral Hypersensitivity in IBS Decreased pain and discomfort thresholds to rectal balloon distension compared to controls1,2
Altered viscerosomatic referral areas. 1,2
Increased intensity of sensations. 2
Increased responses in terms of arousal, emotion and perceived stress. 3
Regional GI Tract Visceral Hypersensitivity in IBS : Rectum Colon Ileum Jejunum Duodenum Esophagus 80
60
40
20
0 Patients (%) Regional GI Tract Visceral Hypersensitivity in IBS Trimble et al. Dig Dis Sci 1995;40:1607–13
Development of IBS After Infectious Diarrhea : Gwee et al. Gut 1999;44:400–406 109 94 completed 22 IBS (23%) Alternating 2 Constipation 2 Diarrhea 18 30 declined 3 months post discharge Acute gastroenteritis (hospitalized): No prior history of any bowel disorder 15 withdrew Development of IBS After Infectious Diarrhea
Common Pathophysiologic Mechanisms : Common Pathophysiologic Mechanisms
Treatments : Treatments Unfortunately there are few treatments with any overwhelming success
Based on symptoms some pharmacologic treatments may be effective in selected patients
Psychological and behavioral interventions have shown varied success
IBS Drugs for Dominant Symptom : IBS Drugs for Dominant Symptom Drossman D, Corazziari E, Spiller R, Talley N, Thompson W, Whitehead W, eds. Rome III. The Functional Gastrointestinal Disorders. 3rd ed. McLean, VA 2006