chronic abdominal pain amanpreet dhaliwal july 23, 2015
TRANSCRIPT
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Chronic Abdominal PainAMANPREET DHALIWAL
JULY 23, 2015
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Learning Objectives1. To learn what aspects are important in medical history (present illness, past
family and personal history)
2. To establish a differential diagnosis for chronic abdominal pain
3. To recognize red flags in children with chronic abdominal pain
4. To review the management and basic investigations pertinent to children with chronic abdominal pain
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Bidirectional Gut-Brain Axis
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DefinitionChronic abdominal pain is defined as
A. Continuous or intermittent abdominal discomfort lasting for atleast 6 months
B. 3 episodes of severe pain in a child >3 years old for atleast 3 months
C. Pain of more than 2 weeks duration
D. Severe pain in a child >3 years old for more than 3 months
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DefinitionChronic abdominal pain is defined as
A. Continuous or intermittent abdominal discomfort lasting for atleast 6 months
B. 3 episodes of severe pain in a child >3 years old for atleast 3 months
C. Pain of more than 2 weeks duration
D. Severe pain in a child >3 years old for more than 3 months
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Remember the Rule of 3s 3 episodes of severe pain
Child >3 yr old
Over 3 month period
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Key History Questions Present Illness
Past Family History
Personal History
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Key History Questions Present Illness
◦ Description of pain- location, quality, frequency, duration and timing of episodes
◦ Associated symptoms
Past Family History◦ Recurrent abdominal pain◦ Peptic ulcer◦ IBS/IBD◦ Food allergies◦ Lactose intolerance◦ Gall bladder disease
◦ Kidney stones◦ Migraine headaches◦ Mediterranean descent
Personal History◦ Travel history◦ Congenital or acquired immunodeficiencies◦ Intra-abdominal surgeries◦ Dietary history◦ Medications◦ Sexual activity◦ Menses
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Case A 9-year-old girl is brought to your office with a 6-month history of peri-umbilical pain. Characteristics of pain are described as follows: it occurs mainly after eating, lasts from 10 minutes to one hour, frequency varies since there might be times when she complains of pain twice a day but there are other times when she is symptom free for a month. She described the pain as if someone was “punching” her belly. Her symptoms worsen at school but acknowledge she eats a lot of junk food. There is no history of nocturnal pain but halitosis has been noticed. Her weight, appetite and energy level have been stable. Further history revealed BMs every 3 days and stools are hard and some intermittent soiling. Mild headaches have been associated. Her family history revealed migraines and irritable bowel syndrome on the mother.
There were no abnormalities on exam; anthropometrics plotted her on the 25th percentile.
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Back to case A 9-year-old girl is brought to your office with a 6-month history of peri-umbilical pain. Characteristics of pain are described as follows: it occurs mainly after eating, lasts from 10 minutes to one hour, frequency varies since there might be times when she complains of pain twice a day but there are other times when she is symptom free for a month. She described the pain as if someone was “punching” her belly. Her symptoms worsen at school but acknowledge she eats a lot of junk food. There is no history of nocturnal pain but halitosis has been noticed. Her weight, appetite and energy level have been stable. Further history revealed BMs every 3 days and stools are hard and some intermittent soiling. Mild headaches have been associated. Her family history revealed migraines and irritable bowel syndrome on the mother.
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Physical Exam OSCE Station Vitals are vital
Growth parameters: weight, height, growth velocity
Inspection◦ General Appearance and level of comfort or discomfort
Abdominal Exam◦ Auscultate◦ Percuss Palpation (to assess enlarged organs or masses)◦ Carnett sign (differentiate visceral from abdominal wall pain
DRE ◦ Impacted stool, perinanal fistuals or deep fissures
±Pelvic Exam if history suggests
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Red Flags
Adapted from Uptodate
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Red Flags
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Differential Diagnosis Ask yourself is this ORGANIC or FUNCTIONAL?◦ Think about information
gathered from history and physical
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Differential Diagnosis Organic
◦ Many but to name a few◦ Gastritis◦ Duodenal ulcer◦ Pancreatitis◦ Hepatitis◦ Celiac◦ IBD◦ SLE
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Differential Diagnosis Functional
◦ Rome-III Diagnostic Categories ◦ H1. Vomiting and Aerophagia
◦ H1a. Adolescent Rumination Syndrome ◦ H1b. Cyclic Vomiting Syndrome ◦ H1c. Aerophagia
◦ H2. Abdominal Pain-related Functional GI Disorders ◦ H2a. Functional Dyspepsia ◦ H2b. Irritable Bowel Syndrome ◦ H2c. Abdominal Migraine ◦ H2d. Childhood Functional Abdominal Pain ◦ H2d1. Childhood Functional Abdominal Pain Syndrome
◦ H3. Constipation and Incontinence ◦ H3a. Functional Constipation ◦ H3b. Non-retentive Fecal Incontinence
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Differential Diagnosis Functional
◦ Rome-III Diagnostic Categories ◦ H1. Vomiting and Aerophagia
◦ H1a. Adolescent Rumination Syndrome ◦ H1b. Cyclic Vomiting Syndrome ◦ H1c. Aerophagia
◦ H2. Abdominal Pain-related Functional GI Disorders ◦ H2a. Functional Dyspepsia ◦ H2b. Irritable Bowel Syndrome ◦ H2c. Abdominal Migraine ◦ H2d. Childhood Functional Abdominal Pain ◦ H2d1. Childhood Functional Abdominal Pain Syndrome
◦ H3. Constipation and Incontinence ◦ H3a. Functional Constipation ◦ H3b. Non-retentive Fecal Incontinence
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Irritable Bowel Syndrome Rome III Criteria
Must include all of the following:◦ Within the preceding two months, at least weekly occurrence of:◦ Abdominal discomfort or pain associated with ≥2 of the following:
◦ Relieved with defecation, and/or◦ Onset associated with a change in frequency of stool, and/or◦ Onset associated with a change in form (appearance) of stool
◦ No evidence of inflammatory, anatomic, metabolic, or neoplastic process to explain the symptoms
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Abdominal Migraine◦ Must include ALL of the following criteria, fulfilled two or more times in the preceding 12 months:◦ Paroxysmal episodes of intense, acute periumbilical pain that lasts for 1 hour or more. ◦ Intervening periods of usual health lasting weeks to months. ◦ The pain interferes with normal activities. ◦ The pain is associated with ≥2 of the following:
◦ a. Anorexia. ◦ b. Nausea.◦ c. Vomiting. ◦ d. Headache. ◦ e. Photophobia. ◦ f. Pallor.
◦ No evidence of an inflammatory, anatomic, metabolic, or neoplastic process considered that explains the subject’s symptoms.
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Functional Constipation◦ Must include ≥ 2 of the following:
◦ Straining during at least 25% of defecations ◦ Lumpy or hard stools in at least 25% of defecations ◦ Sensation of incomplete evacuation for at least 25% of defecations ◦ Sensation of anorectal obstruction/blockage for at least 25% of defecations ◦ Manual maneuvers to facilitate at least 25% of defecations (e.g., digital evacuation, support of the pelvic
floor) ◦ Fewer than three defecations per week
◦ Loose stools are rarely present without the use of laxatives ◦ Insufficient criteria for irritable bowel syndrome ◦ * Criteria fulfilled for the last 3 months with symptom onset at least 6 months prior to
diagnosis
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Bristol Stool Chart
*Encopresis
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Case A 9-year-old girl is brought to your office with a 6-month history of peri-umbilical pain. Characteristics of pain are described as follows: it occurs mainly after eating, lasts from 10 minutes to one hour, frequency varies since there might be times when she complains of pain twice a day but there are other times when she is symptom free for a month. She described the pain as if someone was “punching” her belly. Her symptoms worsen at school but acknowledge she eats a lot of junk food. There is no history of nocturnal pain but halitosis has been noticed. Her weight, appetite and energy level have been stable. Further history revealed BMs every 3 days and stools are hard and some intermittent soiling. Mild headaches have been associated. Her family history revealed migraines and irritable bowel syndrome on the mother.
There were no abnormalities on exam; anthropometrics plotted her on the 25th percentile.
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Investigations Pick 5 of the following investigations you would order as initial workup1. CBC2. Lytes3. ESR4. Amylase, lipase5. Urinalysis6. Abdominal US7. Stools for O&P, C&S, occult blood8. AXR9. CXR10. CT abdo11. Barium upper GI series12. Endoscopy13. Colonoscopy
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Investigations Pick 5 of the following investigations you would order as initial workup1. CBC2. Lytes3. ESR4. Amylase, lipase5. Urinalysis6. Abdominal US7. Stools for O&P, C&S, occult blood8. AXR9. CXR10. CT abdo11. Barium upper GI series12. Endoscopy13. Colonoscopy
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Follow up Evaluation Can use the following one or more investigations if warning signs, abnormal lab results, or specific or persistent symptoms
CT abdo with oral, rectal, IV contrast
Celiac disease serology
Barium upper GI series
Endoscopy
Colonscopy
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Management Approach Combination of
◦ Therapeutic relationship
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Management Approach Combination of
◦ Therapeutic relationship◦ Patient Education
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Management Approach Combination of
◦ Therapeutic relationship◦ Patient Education◦ Return to school
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Management Approach Combination of
◦ Therapeutic relationship◦ Patient Education◦ Return to school◦ Behavior modification
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Management Approach Combination of
◦ Therapeutic relationship◦ Patient Education◦ Return to school◦ Behavior modification◦ Improved coping
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Management Approach Combination of
◦ Therapeutic relationship◦ Patient Education◦ Return to school◦ Behavior modification◦ Improved coping◦ Managing Triggers
◦ Lactose, fructose free diet
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Management Approach Combination of
◦ Therapeutic relationship◦ Patient Education◦ Return to school◦ Behavior modification◦ Improved coping◦ Managing Triggers◦ Managing Symptoms
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Managing Symptoms Abdominal pain
◦ Probiotics◦ Fiber◦ Peppermint oil (↓ smooth muscle spasms)
Dyspepsia◦ Small frequent meals◦ Avoidance of food that aggravate symptoms◦ Trial of H2 blocker or PPI for 4-6 weeks
Constipation
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ConstipationDisimpaction
GoLYTELYPEG Enema
Sodium phosphateSalineMineral oil
Digital disimpaction
MaintenancePolyethylene glycolMagnesium hydroxide (milk of magnesia)LactuloseMineral oil
Behaviour ModificationToilet sittingReward systemMonitoring
Diary, log the bowel movements
Dietary changesFiberTrial of 2 weeks of eliminating all cow’s milk protein from diet
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Prognosis Pain resolves in 30-50% of kids within 2-6 weeks of diagnosis
30-50% of kids with recurrent abdominal pain will have functional pain as adults.
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Follow up Bring them back in 2-3 months initially
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Management Which of the following has shown to be most effective in treating abdominal pain in children
A. CBT
B. Famotidine
C. Dietary changes (↑ fiber, food avoidance)
D. Peppermint oil
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Management Which of the following has shown to be most effective in treating abdominal pain in children
A. CBT
B. Famotidine
C. Dietary changes (↑ fiber, food avoidance)
D. Peppermint oil
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Case A 9-year-old girl is brought to your office with a 6-month history of peri-umbilical pain. Characteristics of pain are described as follows: it occurs mainly after eating, lasts from 10 minutes to one hour, frequency varies since there might be times when she complains of pain twice a day but there are other times when she is symptom free for a month. She described the pain as if someone was “punching” her belly. Her symptoms worsen at school but acknowledge she eats a lot of junk food. There is no history of nocturnal pain but halitosis has been noticed. Her weight, appetite and energy level have been stable. Further history revealed BMs every 3 days and stools are hard and some intermittent soiling. Mild headaches have been associated. Her family history revealed migraines and irritable bowel syndrome on the mother.
There were no abnormalities on exam; anthropometrics plotted her on the 25th percentile.
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