Diagnosis Of Functional Abdominal Pain Research Articles

Flexible Sigmoidoscopy Utility in the Diagnosis of Pediatric Gastrointestinal Disorders.

Although flexible sigmoidoscopy (FS) is utilized in children for the diagnosis of pediatric gastrointestinal conditions, such as inflammatory bowel disease and juvenile polyp disorders, the diagnostic yield of FS in pediatric patients is unknown. We retrospectively reviewed FS cases in children under 18 years of age over a five-year period at our institution.Indications for the procedure, endoscopic visual findings, histologic findings, final diagnosis, and any management changes based on FS findings were included. A total of 354 cases were included in the analysis for which 40 cases (11.3%) had abnormal visual findings, 48 cases (13.6%) had abnormal histologic findings, and 13 cases (3.7%) had both abnormal endoscopic visual and histologic findings.Of the 88 cases with abnormal visual and/or histologic abnormalities, only the results of 34 of these FS cases led to a change in management based on endoscopic findings (9.6%).Most patients with a non-diagnostic FS had a final diagnosis of functional abdominal pain; most patients with a diagnostic FS had a final diagnosis of colitis, not otherwise specified. Our findings suggest that FS is not a helpful diagnostic endoscopic intervention in pediatric patients, especially in children with reassuring history and physical exam findings.

Sex Moderates the Relationship Between Nausea Severity and Heart Rate Variability in Adolescents and Young Adults.

Nausea is a common complaint among children and is particularly prevalent in children with functional abdominal pain (FAP), with nearly half of children with FAP also endorsing nausea. Dysfunction of the autonomic nervous system, which can be indexed by heart rate variability (HRV), leads to abnormalities in gastric electrical activity that are associated with GI symptoms. To evaluate that relationship between nausea severity and HRV in adolescents and young adults with a history of FAP and to assess for sex differences. Participants were pediatric patients with a diagnosis of FAP who were recruited from a pediatric GI clinic between 1993 and 2007 for a prospective study of the course of FAP. Study analyses focused on the cross-sectional relationship between HRV, indexed by standard deviation of the R-R interval (SDRRI) and high-frequency (HF) power, and nausea severity collected during a follow-up visit in late adolescence and young adulthood. Controlling for age and BMI, a significant nausea by sex interaction emerged for both SDRRI and HF power. Tests of conditional effects of nausea by sex showed that the inverse relation between nausea severity and both SDRRI and HF was significant for females but not for males. This is the first study to evaluate the relationship between nausea severity and HRV. Greater nausea severity was associated with lower HRV in females but not in males. Further validation of these results may provide insight into novel treatment approaches for females with nausea that target vagal tone.

Higher prevalence of obesity among children with functional abdominal pain disorders

BackgroundFunctional abdominal pain (FAP) disorders are one of the most common gastrointestinal disorders in children. We aimed to define the association between obesity and functional abdominal pain (FAP) disorders and to assess differences between overweight/obese children and normal weight children with FAP disorders.MethodsWe conducted a retrospective study of children (2–18 years old) with a clinical diagnosis of FAP who were followed-up in our pediatric gastroenterology unit between 1/2016–10/2018. FAP disorders were defined according to the ROME IV criteria. Body mass index (BMI) percentiles were defined by CDC standards. Patients with BMIs ≥85th percentile were designated as being overweight/obese. A population control group was obtained from the 2015–2016 Israel national health survey.ResultsData from 173 children with FAP disorders (median age 11.5 years, 114 females) were included. Seventy-one children (41%) were classified as having functional abdominal pain-NOS, 67 (38.7%) as having irritable bowel syndrome (IBS), and 35 (20.2%) has having functional dyspepsia. Fifty-three children (30.6%) were classified as being overweight/obese.Adolescents with FAP disorders had a significantly higher prevalence of overweight/obesity compared to controls (39.5% vs. 30%, respectively, p = 0.04). Children with FAP and overweight were older [12.4 (range 9.8–15.3) vs. 10.8 (7.4–14.1) years, p = 0.04] and had more hospitalizations due to FAP (20.8% vs. 7.6%, p = 0.01) compared to Children with FAP and normal weight.ConclusionsAdolescents with FAP had higher prevalence of overweight/obesity compared to controls. Future studies are warranted to raise awareness of weight issues in FAP and determine the effect of weight loss on FAP.

Probiotics for paediatric functional abdominal pain disorders: A rapid review.

Functional abdominal pain disorders (FAPD) are prevalent in the paediatric population, however, there is currently no consensus regarding best practices for treatment. The use of probiotics is becoming popular to treat FAPD. The goal of this rapid review is to synthesize the best evidence on the use of probiotics in children with FAPD. Searches were conducted on five main databases. Randomized controlled trials (RCTs) of probiotic use in children (0 to 18 years) with FAPD were searched. Populations of interest were patients with functional abdominal pain (FAP), irritable bowel syndrome (IBS), and functional dyspepsia (FD), recruited based on Rome criteria. Outcomes of interest were changes in abdominal pain severity, frequency, and duration. Eleven RCTs with 829 participants with the diagnosis of FAP (n=400), IBS (n=329), FD (n=45), and mixed population (n=55) were included. Of six studies of children with FAP, two (n=103) used Lactobacillus rhamnosus GG (LGG) and reported no significant effects on pain, and four (n=281) used Lactobacillus (L) reuteri DSM 17938, of which three (n=229) reported significant positive effects on either severity or frequency of pain. Of six trials of children with IBS, four (n=219) used LGG, of which three (n=168) reported a positive effect. One (n=48) used bifidobacteria and one used VSL #3 (n=59), both demonstrating positive effects with probiotics. Two studies of FD reported no benefit. No adverse events were attributed to probiotics. There is preliminary evidence for use of probiotics, particularly LGG, in reducing abdominal pain in children with IBS. There are inconsistent positive effects of other probiotics, including L. reuteri DSM 17938, in reducing pain in patients with FAP, IBS, or FD. More RCTs with rigorous methodology using single or combination probiotics are warranted.

Parents’ experience when their child has chronic abdominal pain: a qualitative study in Norway

ObjectiveFunctional abdominal pain occurs frequently in children and adolescents. It is an exclusion diagnosis; somatic diseases have to be ruled out. However little explanation is given for why the child...

Emergency department visits related to functional abdominal pain in the pediatric age group

To analyze visits to and admissions from the emergency department (ED) in children with a primary diagnosis of functional abdominal pain (FAP). This was a cross-sectional study using data from...

Restless Legs Syndrome in Adolescents with Functional Abdominal Pain

Aim: We aimed to investigate the insidence of restless leg syndrome (RLS) in adolescents with functional abdominal pain (FAP). Materials: Seventy-nine adolescent patients following with the diagnosis of FAP ranging from 12 to 17 years of age in our clinic and 92 age-matched and sex-matched healty adolescents as a control group were studied. A semistructured interview guided by a questionnaire about RLS was applied to all of the participants. Results: Sixteen (20.2%) of the patients with FAP and 4 (4.3%) patients in the control group had RLS. The prevalence of RLS was higher in patients with FAP, compared to the control group (p<0,01). Discussion: The prevalence of RLS was higher in adolescent FAP patients than it was in the control group.

Childhood functional abdominal pain: mechanisms and management.

Chronic abdominal pain is one of the most common clinical syndromes encountered in day to day clinical paediatric practice. Although common, its definition is confusing, predisposing factors are poorly understood and the pathophysiological mechanisms are not clear. The prevailing viewpoint in the pathogenesis involves the inter-relationship between changes in hypersensitivity and altered motility, to which several risk factors have been linked. Making a diagnosis of functional abdominal pain can be a challenge, as it is unclear which further diagnostic tests are necessary to exclude an organic cause. Moreover, large, well-performed, high-quality clinical trials for effective agents are lacking, which undermines evidence-based treatment. This Review summarizes current knowledge regarding the epidemiology, pathophysiology, risk factors and diagnostic work-up of functional abdominal pain. Finally, management options for children with functional abdominal pain are discussed including medications, dietary interventions, probiotics and psychological and complementary therapies, to improve understanding and to maximize the quality of care for children with this condition.

Electrocardiograms changes in children with functional gastrointestinal disorders on low dose amitriptyline.

To study the effects of low dose amitriptyline on cardiac conduction in children. Secondary analysis of data obtained from a double-blind, randomized placebo-controlled trial, evaluating low dose amitriptyline in children with a diagnosis of functional abdominal pain, functional dyspepsia, and irritable bowel syndrome according to the Rome II criteria. Children 8-17 years of age were recruited from the pediatric gastroenterology clinics of 6 tertiary care centers in the United States. The electrocardiograms (EKGs) done prior to initiation of amitrityline and 1 mo after initiation of amitriptyline were examined. The changes in cardiac conduction were evaluated in patients and controls. Thirty children were included in the study. There were 12 patients, ages 9-17 years of both genders, in the amitriptyline treatment group and 18 patients, ages 9-17 years of both genders, in the placebo treatment group. None of the patients had any baseline EKG abnormality. Amitriptyline use was associated with an increase in heart rate (P = 0.024) and QTc interval (P = 0.0107) as compared to pre-EKGs. Children in the placebo group were also noted to present a statistically significant increase in QTc interval (P = 0.0498). None of the patients developed borderline QTc prolongation or long-QT syndrome after they were started on amitriptyline. The study findings suggest that once patients with functional gastrointestinal disorders have been screened for prolonged QTc interval on baseline EKG, they probably do not need a second EKG for reevaluation of cardiac conduction after starting low dose amitriptyline.

Zaburzenia wchłaniania fruktozy u dzieci jako przyczyna dolegliwości dyspeptycznych – opis dwóch przypadków

Chronic abdominal pain, bloating, diarrhea, and eating disorders are common causes of children reporting to a doctor. Despite many studies the causes of these problems have not been established and a diagnosis of functional abdominal pain is usually given. Fructose malabsorption is a disease entity in which there are such symptoms but has been, however, neglected in the literature as well as pediatric practice. Such a diagnosis may be made on a clinical picture and positive hydrogen breath test after an oral loading of fructose. Proper diet is an effective way of treatment in such. This paper describes two children who were diagnosed with fructose malapsorption.

Hypnosis for Functional Abdominal Pain

Chronic abdominal pain is a common pediatric condition affecting 20% of the pediatric population worldwide. Most children with this disorder are found to have no specific organic etiology and are given the diagnosis of functional abdominal pain. Well-designed clinical trials have found hypnotherapy and guided imagery to be the most efficacious treatments for this condition. Hypnotic techniques used for other somatic symptoms are easily adaptable for use with functional abdominal pain. The author discusses 2 contrasting hypnotic approaches to functional abdominal pain and provides implications for further research. These approaches may provide new insights into this common and complex disorder.

Audio-Recorded Guided Imagery Treatment Reduces Functional Abdominal Pain in Children: A Pilot Study

This study was designed to develop and to test a home-based, guided imagery treatment protocol, using audio and video recordings, that is easy for health care professionals and patients to use, is inexpensive, and is applicable to a wide range of health care settings. Thirty-four children, 6 to 15 years of age, with a physician diagnosis of functional abdominal pain were assigned randomly to receive 2 months of standard medical care with or without home-based, guided imagery treatment. Children who received only standard medical care initially received guided imagery treatment after 2 months. Children were monitored for 6 months after completion of guided imagery treatment. All treatment materials were reported to be self-explanatory, enjoyable, and easy to understand and to use. The compliance rate was 98.5%. In an intention-to-treat analysis, 63.1% of children in the guided imagery treatment group were treatment responders, compared with 26.7% in the standard medical care-only group (P = .03; number needed to treat: 3). Per-protocol analysis showed similar results (73.3% vs 28.6% responders). When the children in the standard medical care group also received guided imagery treatment, 61.5% became treatment responders. Treatment effects were maintained for 6 months (62.5% responders). Guided imagery treatment plus medical care was superior to standard medical care only for the treatment of abdominal pain, and treatment effects were sustained over a long period.

This Month in Gastroenterology

This Month in Gastroenterology

Nausea Reports as an Indicator of Morbidity

Purpose: Pediatric patients with functional disorders often report nausea, but little has been reported about the significance of this symptom to overall pathology. Therefore, this study sought to determine whether children with chronic abdominal pain and nausea have more psychological and medical morbidity than children with chronic abdominal pain in the absence of nausea. Methods: As part of data collection for an intervention study, 132 parents and their children age 7–17, who reported at least three episodes of abdominal pain over a 3-month period interfering with the child's activities, and a medical diagnosis of functional abdominal pain, were administered a battery of questionnaires. These included the MASC (Multidimensional Anxiety Scale for Children), the CDI (Child Depression Inventory), the FDI (Functional Disability Inventory), and the PRI (Pain Response Inventory-catastrophizing subscale). Parents also provided data on school absences in the past three months, and children rated the extent to which they had experienced nausea in the past week. Results: 53 children reported experiencing no or a little nausea (categorized as low nausea). 77 children reported experiencing some, a lot or a whole lot of nausea (categorized as high nausea). Unpaired t-tests were used to compare groups as a function of nausea category. Children who experienced higher versus lower levels of nausea evidenced greater disability (as seen in functional disability scores M = .93 vs. 48, P < .000 and school days missed: M = 4.18 vs. 2.87, P < .034). They also reported greater anxiety (M = 13.73 vs.12.27, P < .048), depression (M = 10.43 vs. 7.63, P < .011), and maladaptive coping (M = 1.67 vs. 1.35, P < .028). These analyses were repeated using gender- and age-based subgroups. Results were stronger for all children aged 7–11, especially younger girls. Conclusion: Children with chronic abdominal pain who report higher nausea are at risk for disability, negative affect and maladaptive coping. This information should be incorporated into the clinical evaluation and medical treatment of these patients. [Supported by NIH Grant R01HD36069 awarded to Dr. Levy.]

Estudo prospectivo de pacientes pediátricos com dor abdominal crônica

OBJETIVO: Classificar a dor abdominal crônica em crianças e adolescentes por meio dos critérios de Roma II e definir o desfecho diagnóstico em três anos de seguimento. MÉTODOS: Durante um ano, 71 pacientes com dor abdominal crônica foram atendidos como casos novos num ambulatório terciário de gastroenterologia pediátrica. Causas orgânicas foram excluídas por bases clínicas e laboratoriais, e relatos clínicos foram avaliados especificamente quanto à possibilidade de preencherem os Critérios de Roma II para dor abdominal em crianças. Para estabelecer o diagnóstico definitivo, os pacientes foram seguidos por três anos, em média. RESULTADOS: A alocação dos 71 pacientes segundo Roma II foi: doença orgânica (n=12), remissão dos sintomas após a primeira consulta (n=7), ou preencheram os critérios para dor funcional (n=52). Dos 12 pacientes de doença orgânica, nove foram diagnosticados como intolerantes à lactose, mas foram re-alocados para doença funcional no seguimento, visto que a dieta de isenção não aliviou a queixa. Dos 52 pacientes com doença funcional (idade mediana=9,3 anos, 50% meninos), nove, que inicialmente preencheram o critério para dor abdominal funcional, foram re-alocados no diagnóstico de constipação funcional e 43 mantiveram o diagnóstico funcional: 24 com dispepsia funcional, 18 com dor abdominal funcional e um com síndrome do intestino irritável. CONCLUSÕES: Dentre os casos de dor abdominal crônica, a dor do tipo funcional foi mais comum que as causas orgânicas e, dentre os seus subgrupos, a dispepsia funcional foi mais freqüente. O seguimento em longo prazo permitiu estabelecer o diagnóstico definitivo da origem da dor abdominal nessas crianças.

The value of the abdominal radiograph in children with functional gastrointestinal disorders

Functional gastrointestinal disorder is a common problem in childhood. The symptoms vary from a relative mild gastrointestinal problem such as abdominal pain or infrequent defecation to severe problems with fecal impaction and fecal incontinence. The aim of this review is to describe and evaluate the value of the different existing methods to assess fecal loading on an abdominal radiograph with or without the use of radio-opaque markers in the diagnosis of functional abdominal pain, functional constipation and functional non-retentive fecal incontinence. In our opinion, the abdominal radiograph has limited value in the diagnostic work-up of children with functional gastrointestinal disorders.

Management of Functional Abdominal Pain.

The diagnosis of functional abdominal pain should be made based on the Rome II symptom criteria with only limited testing to exclude other disease. During physical examination the clinician may look for evidence of pain behavior which would be supportive of the diagnosis. Reassurance and proper education regarding the clinical entity of functional abdominal pain is critical for successful treatment and good patient satisfaction. Education should include validation that symptoms are real, and that other individuals experience similar symptoms. No further treatment may be required for those with mild symptoms. For patients with more severe symptoms, a long-term management plan of either pharmacological or psychological treatments is warranted. This will require a commitment by both the patient and the physician to engage in a partnership with active involvement and responsibility by both individuals. The goal of treatment--to decrease pain and increase function over time, not to cure the disorder-- should be explained. Strong consideration should be made for the use of an antidepressant to treat analgesic effects. Tricyclic antidepressants are the mainstay of therapy for functional pain disorders. The analgesic effect is generally quicker in onset and occurs at a lower dose than their effect on mood. To maximize patient compliance, patients should be told the rationale behind their use, warned of the potential side effects, and reassured that many of the side effects will disappear with time. Choice of an antidepressant should be based on the presence of concomitant symptoms (eg, depression), cost, and physician familiarity with specific agents. All patients with functional abdominal pain should be screened for underlying psychiatric disturbance as an untreated mood disorder will adversely affect response to treatment. If a concurrent mood disorder is found, it should be treated by either using a higher dose of the tricyclic antidepressant or by adding another antidepressant agent. Psychological interventions such as cognitive behavioral therapy may be important as adjuvant therapy or as an alternative to treatment with antidepressants for those patients who find antidepressants ineffective or are intolerant to them. Narcotics and benzodiazepines should not be used to treat chronic abdominal pain due to the high risk of physical and psychological dependence.

P0849 DETRIMENTAL EFFECTS OF CONSUMERISM IN MEDICINE: LESSONS FROM CHILDREN WITH FUNCTIONAL ABDOMINAL PAIN

Introduction: Functional abdominal pain (FAP) in childhood as defined by the Rome II criteria is commonly associated with unrecognised psychological factors and a degree of parent–child enmeshment. We hypothesised that the increasingly consumeristic approach to medicine advocated by governments and medical professional bodies alike might be counterproductive in enmeshed families who lack insight into the origins of their child’s FAP. Methods: 23 consecutive referrals (11M, 12F median age 14 years) of children with FAP to a single gastroenterologist at a tertiary referral centre were studied retrospectively. All had been investigated according to standard clinical service guidelines and a positive diagnosis of FAP made. Predictors of outcome were analysed using Fisher’s exact test Results: 15/23 had already had >2 Consultant opinions and 14/15 were dissatisfied with such opinions. 9/23 were frankly hostile towards the medical profession at first consultation in GOSH. 12/23 had complained about some aspect of their child’s care (9/12 at GOSH) and 8/12 complaints were overt attempts to manipulate some facet of their child’s care (for example further referral or inappropriate investigation). Investigation via the formal Hospital complaints procedure did not find the physician at fault in any instance. In 12/13 of the families who accepted psychological referral there was evidence of family conflict / dysfunction and poor insight into the child’s illness. Poor outcome (defined as pain lasting > 12 months and failure to return to normal levels of functioning) was associated with lack of insight into psychosocial influences upon the illness (P<0.001, RR 7.49), refusal to engage with psychological services (P<0.05, RR 4.55), involvement of > 3 consultants (P<0.05, RR 7.00) and lodging of a manipulative complaint (P<0.05, RR 3.25). Conclusion: Healthcare consumerism in families lacking insight is deleterious for the child with FAP. Robust systems are necessary to protect the child (and their physician) from the consequences of consumerism in medicine

Pressure measurements from biliary and pancreatic segments of sphincter of oddi

Using a minimally compliant infusion system and a triple-lumen pressure recording catheter, we obtained endoscopic manometric measurements from both the common bile duct and pancreatic duct segments of the sphincter of Oddi (SO) in 58 patients. Fifteen patients (ages 27-69) had the diagnosis of functional abdominal pain, 19 patients (ages 30-76) had partial biliary obstruction, and 24 patients (ages 15-80) had idiopathic acute recurrent pancreatitis. Resting ductal pressure was similar in the common bile duct and pancreatic duct in all patient groups. In the group with functional pain, basal SO pressure was similar, whether obtained from the common bile duct or pancreatic duct sphincteric segment. Eight of 19 patients with partial biliary obstruction had elevated basal SO pressure. Five of these eight patients had elevated basal SO pressure confined exclusively to the common bile duct segment of the sphincter, while three patients had elevated basal SO in both segments. Conversely seven of 24 patients with acute recurrent pancreatitis had an elevated basal SO pressure, with five patients having pressure elevation only in the pancreatic duct segment while two patients had abnormal basal SO pressure in both segments. We conclude that selective cannulation of the common bile duct and/or the pancreatic duct during manometric study of the SO is necessary in order to diagnose segmental SO dysfunction responsible for partial biliary obstruction or episodes of acute recurrent pancreatitis.

Use of imagery to describe functional abdominal pain as an aid to diagnosis in a pediatric population.

Abdominal pain is a common presenting complaint among children and adolescents. Although psychological factors may be involved, their role is not clear and a diagnosis of functional pain is often made only after extensive investigations. Specific psychological characteristics have been associated with abdominal pain in children, but little is known about the nature of the pain itself. A retrospective study was undertaken to characterize the subjective experience and description of abdominal pain in patients hospitalized for investigation of abdominal pain. Thirty subjects with proven inflammatory bowel disease (IBD) and 32 diagnosed as having functional abdominal pain (FAP) were studied. The age, sex distribution, and duration of the pain in these groups were similar. Seven (23%) patients with IBD used imagery to describe their pain in contrast to 25 (78%) of those with FAP (P less than 0.01). Neither age nor duration of pain was associated with the use of imagery. The use of imagery was significantly associated with the diagnosis of FAP (P less than 0.01). A more detailed characterization of the way patients describe abdominal pain might assist in diagnosing its etiology.