![Page 1: The teenager with chronic abdominal pain; the teenager with chronic symptoms Oscar Taube, MD Coordinator, Adolescent Medicine The Children’s Hospital at](https://reader036.vdocuments.us/reader036/viewer/2022062421/56649dea5503460f94ae5d59/html5/thumbnails/1.jpg)
The teenager with chronic abdominal pain; the teenager
with chronic symptomsOscar Taube, MD
Coordinator, Adolescent MedicineThe Children’s Hospital at Sinai
September 22, 2009
![Page 2: The teenager with chronic abdominal pain; the teenager with chronic symptoms Oscar Taube, MD Coordinator, Adolescent Medicine The Children’s Hospital at](https://reader036.vdocuments.us/reader036/viewer/2022062421/56649dea5503460f94ae5d59/html5/thumbnails/2.jpg)
Case:17 y.o. female seen multiple times over past year at GPA:
Abdominal Pain: Bilateral lower abd. pain; intermittent; 4/5 pain; constipation alternating with diarrhea; BM’s do not relieve pain; Never sexually active.
Headaches: Mainly frontal; several times/week; not interfering with activity; no vision changes, no vomiting; doesn’t waken her from sleep; no URI complaints; no family hx. of migraine. Rx’d in past for sinusitis with amoxicillin- no relief of pain.
![Page 3: The teenager with chronic abdominal pain; the teenager with chronic symptoms Oscar Taube, MD Coordinator, Adolescent Medicine The Children’s Hospital at](https://reader036.vdocuments.us/reader036/viewer/2022062421/56649dea5503460f94ae5d59/html5/thumbnails/3.jpg)
Case History, continued
• Backache: Chronic lower back pain, not increased with movement.
• Joint pains: Multiple complaints in past 6 months; mostly hip pains; no morning stiffness.
• Social Hx. Patient’s mother recently became pregnant; pregnancy with complications; mother on bed rest.
• Physical Exam: Abdominal Exam: Mild bilateral lower abd. tenderness; no HSM, masses, guarding, rigidity.Otherwise, PE wnl.
• Labs: CBC, CMP, amylase, lipase, urine culture, STD testing, connective tissue disease testing all negative.
![Page 4: The teenager with chronic abdominal pain; the teenager with chronic symptoms Oscar Taube, MD Coordinator, Adolescent Medicine The Children’s Hospital at](https://reader036.vdocuments.us/reader036/viewer/2022062421/56649dea5503460f94ae5d59/html5/thumbnails/4.jpg)
Case History #2Adolescent Consultation Service
Patient• KJ, 19 year old white female w. several
months sharp stabbing upper abdominal pain; sometimes awakens her at night. Decreased appetite. No T, V, D, blood in stools.
• Previous work up: Endoscopy: small gastric/duodenal ulcers; some improvement with PPI’s. CBC/CMP/Amylase-Lipase all normal.
![Page 5: The teenager with chronic abdominal pain; the teenager with chronic symptoms Oscar Taube, MD Coordinator, Adolescent Medicine The Children’s Hospital at](https://reader036.vdocuments.us/reader036/viewer/2022062421/56649dea5503460f94ae5d59/html5/thumbnails/5.jpg)
Case #2, continued
• 10 years complaint of joint pains
• Complaint of significant fatigue, even with adequate sleep.
• Several years of frequent headaches; difficulty with concentration, short term memory.
![Page 6: The teenager with chronic abdominal pain; the teenager with chronic symptoms Oscar Taube, MD Coordinator, Adolescent Medicine The Children’s Hospital at](https://reader036.vdocuments.us/reader036/viewer/2022062421/56649dea5503460f94ae5d59/html5/thumbnails/6.jpg)
Case #2, continued
• Psychosocial: Raped at age 17, never reported. Admits to depressed, self deprecatory, suicidal ideation. Beck Depression Inventory score 48 (severe range= 29-63).
• Physical exam WNL except for + tenderness on 11 of 18 Fibromyalgia tender-point sites.
![Page 7: The teenager with chronic abdominal pain; the teenager with chronic symptoms Oscar Taube, MD Coordinator, Adolescent Medicine The Children’s Hospital at](https://reader036.vdocuments.us/reader036/viewer/2022062421/56649dea5503460f94ae5d59/html5/thumbnails/7.jpg)
Why this combination of topics? (Chronic abd. pain/chronic
symptoms)• The two key symptoms in children and
adolescents with potential somatization disorders are:
• Abdominal pain
• Headaches.
• And chronic fatigue/muscle pain, too.
![Page 8: The teenager with chronic abdominal pain; the teenager with chronic symptoms Oscar Taube, MD Coordinator, Adolescent Medicine The Children’s Hospital at](https://reader036.vdocuments.us/reader036/viewer/2022062421/56649dea5503460f94ae5d59/html5/thumbnails/8.jpg)
Epidemiology-Chronic Abdominal Pain
Hyams et. al. J. Pediatrics, 1996. Community based study of abd. pain complaints of suburban 7th, 10th graders:
Middle School (mean age 12.6 years)
13% pain at least weekly
32% pain > 5x. per year
24% pain severe enough to affect activities
![Page 9: The teenager with chronic abdominal pain; the teenager with chronic symptoms Oscar Taube, MD Coordinator, Adolescent Medicine The Children’s Hospital at](https://reader036.vdocuments.us/reader036/viewer/2022062421/56649dea5503460f94ae5d59/html5/thumbnails/9.jpg)
Epidemiology, continued.
• Hyams study, continued.
• High school (Mean age 15.6 years)
• 17% at least weekly pain
• 37% pain > 5 x/year
• 17% pain severe enough to affect activities.
• Chronic abdominal pain accounts for 2-4% of all pediatric office visits.
![Page 10: The teenager with chronic abdominal pain; the teenager with chronic symptoms Oscar Taube, MD Coordinator, Adolescent Medicine The Children’s Hospital at](https://reader036.vdocuments.us/reader036/viewer/2022062421/56649dea5503460f94ae5d59/html5/thumbnails/10.jpg)
All roads lead to….
![Page 11: The teenager with chronic abdominal pain; the teenager with chronic symptoms Oscar Taube, MD Coordinator, Adolescent Medicine The Children’s Hospital at](https://reader036.vdocuments.us/reader036/viewer/2022062421/56649dea5503460f94ae5d59/html5/thumbnails/11.jpg)
Rome!
• Rome III Criteria for Functional Bowel Disorders Associated with Abdominal Pain or Discomfort in Children and Adolescents– Functional Dyspepsia– Irritable Bowel Syndrome– Childhood Functional Abdominal Pain and
Syndrome
![Page 12: The teenager with chronic abdominal pain; the teenager with chronic symptoms Oscar Taube, MD Coordinator, Adolescent Medicine The Children’s Hospital at](https://reader036.vdocuments.us/reader036/viewer/2022062421/56649dea5503460f94ae5d59/html5/thumbnails/12.jpg)
Functional Dyspepsia
– A. Persistent/recurrent pain centered in upper abdomen, above umbilicus
– B. Pain not relieved by defecation, or assoc. w. onset of change in stool frequency or stool form (i.e., NOT IBS).
– C. No evidence of inflammatory, anatomic, neoplastic process to explain symptoms
– D. Above must be present at least 1x/week, for at least 2 months.
![Page 13: The teenager with chronic abdominal pain; the teenager with chronic symptoms Oscar Taube, MD Coordinator, Adolescent Medicine The Children’s Hospital at](https://reader036.vdocuments.us/reader036/viewer/2022062421/56649dea5503460f94ae5d59/html5/thumbnails/13.jpg)
Irritable Bowel Syndrome
• Recurrent abdominal pain or discomfort at least 3 days per month for the past 3 months, associated with two or more of the following:
• Improvement with defecation
• Onset assoc. w. change in stool frequency
• Onset assoc. w. change in stool form (appearance).
![Page 14: The teenager with chronic abdominal pain; the teenager with chronic symptoms Oscar Taube, MD Coordinator, Adolescent Medicine The Children’s Hospital at](https://reader036.vdocuments.us/reader036/viewer/2022062421/56649dea5503460f94ae5d59/html5/thumbnails/14.jpg)
Childhood Functional Abdominal Pain
• All of the following must be present at least once a week for at least 2 months before diagnosis
• A. Episodic or continuous abdominal pain• B. Insufficient criteria for other functional
GI disorders.• C. No evidence of an inflammatory,
anatomic, metabolic, or neoplastic process that explains the symptoms.
![Page 15: The teenager with chronic abdominal pain; the teenager with chronic symptoms Oscar Taube, MD Coordinator, Adolescent Medicine The Children’s Hospital at](https://reader036.vdocuments.us/reader036/viewer/2022062421/56649dea5503460f94ae5d59/html5/thumbnails/15.jpg)
Childhood Functional Abdominal Pain Syndrome
• Must include Dx. of Childhood Functional Abdominal Pain at least 25% of the time and one or more of the following:
• A. Some loss of daily activity
• B.Additional Somatic symptoms such as headache, limb pain, or difficulty sleeping.
![Page 16: The teenager with chronic abdominal pain; the teenager with chronic symptoms Oscar Taube, MD Coordinator, Adolescent Medicine The Children’s Hospital at](https://reader036.vdocuments.us/reader036/viewer/2022062421/56649dea5503460f94ae5d59/html5/thumbnails/16.jpg)
Differential Dx. Functional Bowel Disorders
• Functional Dyspepsia: GER; Peptic ulcer disease; Biliary tract obstruction/biliary colic; chronic pancreatitis; gastroparesis.
• IBS: Lactose intolerance; IBD; Celiac disease; Infection (e.g. giardiasis); constipation
.
![Page 17: The teenager with chronic abdominal pain; the teenager with chronic symptoms Oscar Taube, MD Coordinator, Adolescent Medicine The Children’s Hospital at](https://reader036.vdocuments.us/reader036/viewer/2022062421/56649dea5503460f94ae5d59/html5/thumbnails/17.jpg)
Differential Dx. Functional Bowel Disorders, continued
• Gynecologic Differential Diagnosis:• Pelvic adhesions- Pelvic inflammatory
disease.• Mittelschmerz• Dysmenorrhea• Endometriosis• Ovarian mass.• UTI
![Page 18: The teenager with chronic abdominal pain; the teenager with chronic symptoms Oscar Taube, MD Coordinator, Adolescent Medicine The Children’s Hospital at](https://reader036.vdocuments.us/reader036/viewer/2022062421/56649dea5503460f94ae5d59/html5/thumbnails/18.jpg)
Differential Dx. of Abdominal Pain by location
• RUQ:Hepatitis/cholecystitis/pneumonia
• RLQ: Appendicitis/IBD/Salpingitis
• Epigastric: Peptic ulcer disease/pancreatitis/pericarditis
• Periumbillical: Early appy/gastroenteritis
• LUQ: Splenic abcess/pancreatitis
• A very partial list!
![Page 19: The teenager with chronic abdominal pain; the teenager with chronic symptoms Oscar Taube, MD Coordinator, Adolescent Medicine The Children’s Hospital at](https://reader036.vdocuments.us/reader036/viewer/2022062421/56649dea5503460f94ae5d59/html5/thumbnails/19.jpg)
Pathogenesis of Functional Bowel Disorders
1.Visceral hypersensitivity or hyperalgesia, with a decreased threshold for pain
2. Altered GI motility3. Psychological stress as a trigger/Genetic
factors/environmental factors4. Other “Medical” factors: Infectious
gastroenteritis as IBS trigger; abnormal serotonergic mechanisms; small intestinal bacterial overgrowth.
![Page 20: The teenager with chronic abdominal pain; the teenager with chronic symptoms Oscar Taube, MD Coordinator, Adolescent Medicine The Children’s Hospital at](https://reader036.vdocuments.us/reader036/viewer/2022062421/56649dea5503460f94ae5d59/html5/thumbnails/20.jpg)
![Page 21: The teenager with chronic abdominal pain; the teenager with chronic symptoms Oscar Taube, MD Coordinator, Adolescent Medicine The Children’s Hospital at](https://reader036.vdocuments.us/reader036/viewer/2022062421/56649dea5503460f94ae5d59/html5/thumbnails/21.jpg)
Approach to Functional GI Disturbances
• CAREFUL, COMPREHENSIVE HISTORY• (Timing, location, radiation, quality, severity, precipitants, relievers
of pain; associated complaints; diet; family hx., etc.)• CAREFUL, COMPREHENSIVE PHYSICAL EXAM. • (Oral exam; Pubertal stage; abd. Exam including location, rebound,
mass, psoas sign, mass, HSM, kidney size, perianal findings, rectal/pelvic exam, stool for occult blood).
• Plot weight, height on a serial growth chart• Pay attention to the “Red flags”- these point to signs of GI diseases
that may need more aggressive testing, more aggressive pharmacologic, surgical Rx, and most likely will need GI referral.
• Pay attention to the “Red flags” that point to somatiform diagnoses• Limited “General” lab work up: CBC/CRP/Urinalysis
![Page 22: The teenager with chronic abdominal pain; the teenager with chronic symptoms Oscar Taube, MD Coordinator, Adolescent Medicine The Children’s Hospital at](https://reader036.vdocuments.us/reader036/viewer/2022062421/56649dea5503460f94ae5d59/html5/thumbnails/22.jpg)
Red Flag signs, sx’s suggestive of organic diseases
• Weight loss• Unexplained fevers• Pain radiating to the back/pain distant from
umbillicus• Bilious emesis• Hematemesis• Chronic diarrhea (>2 weeks)• GI Blood loss• Oral ulcers• Dysphagia
![Page 23: The teenager with chronic abdominal pain; the teenager with chronic symptoms Oscar Taube, MD Coordinator, Adolescent Medicine The Children’s Hospital at](https://reader036.vdocuments.us/reader036/viewer/2022062421/56649dea5503460f94ae5d59/html5/thumbnails/23.jpg)
Red flags, continued
• Unexplained rashes• Nocturnal symptoms• Arthritis• Anemia/pallor• Delayed puberty• Deceleration of linear growth velocity• Family hx. of IBD, celiac, peptic ulcer disease• Hepatosplenomegaly• Perianal abnormalities
![Page 24: The teenager with chronic abdominal pain; the teenager with chronic symptoms Oscar Taube, MD Coordinator, Adolescent Medicine The Children’s Hospital at](https://reader036.vdocuments.us/reader036/viewer/2022062421/56649dea5503460f94ae5d59/html5/thumbnails/24.jpg)
A brief approach to treatment of Functional Bowel disorders
• Functional Dyspepsia:
• Reassurance
• D/C dyspeptic meds (e.g. ibuprofen)
• D/C dyspeptic foods
• H2 receptor antagonists/PPI’s
• Trial of low dose tricyclic antide-
• pressants qHS.
![Page 25: The teenager with chronic abdominal pain; the teenager with chronic symptoms Oscar Taube, MD Coordinator, Adolescent Medicine The Children’s Hospital at](https://reader036.vdocuments.us/reader036/viewer/2022062421/56649dea5503460f94ae5d59/html5/thumbnails/25.jpg)
Rx of Functional Bowel Disorders, continued
• IBS:• Reassurance; explanation• Dietary modifications- If diarrhea,
reduce sorbital, fructose, gas forming vegetables. If constipation: Increase water.
• PharmRx-if constipation: Osmotic laxatives, stool softener. Trial of antidepressants? Probiotics?Peppermint oil?
![Page 26: The teenager with chronic abdominal pain; the teenager with chronic symptoms Oscar Taube, MD Coordinator, Adolescent Medicine The Children’s Hospital at](https://reader036.vdocuments.us/reader036/viewer/2022062421/56649dea5503460f94ae5d59/html5/thumbnails/26.jpg)
Biopsychosocial model: A continuum of hierachical systems
that are always interacting:• Biosphere• Society-Nation• Culture-subculture• Community• Family• Person• Nervous system• Organ-organ systems• Tissue• Cell• Organelle• Molecule
![Page 27: The teenager with chronic abdominal pain; the teenager with chronic symptoms Oscar Taube, MD Coordinator, Adolescent Medicine The Children’s Hospital at](https://reader036.vdocuments.us/reader036/viewer/2022062421/56649dea5503460f94ae5d59/html5/thumbnails/27.jpg)
Biopsychosocial Model-How NOT to do it
• “First we’ll rule out organic problems, then we’ll explore psych issues.”
• “We’ll do some tests to see what is wrong.”• The clinician focuses her/his efforts-in dealing
with the adolescent who has chronic abdominal pain/chronic somatic symptoms-to determine if the teen is trying to: a. avoid something (primary gain); b. seek attention (secondary gain); c. feign symptoms for internal or external gain.
• “I believe that your pain is real.” (If you’re really sending the message “I don’t believe the pain is real.” )
![Page 28: The teenager with chronic abdominal pain; the teenager with chronic symptoms Oscar Taube, MD Coordinator, Adolescent Medicine The Children’s Hospital at](https://reader036.vdocuments.us/reader036/viewer/2022062421/56649dea5503460f94ae5d59/html5/thumbnails/28.jpg)
Somatization
• “The central feature of somatiform disorders is that they present with features of an underlying medical condition, yet such a condition either is not found or does not fully account for the level of functional impairment.”
• -Silber T, Pao, M. Peds.in Review 8/03.
![Page 29: The teenager with chronic abdominal pain; the teenager with chronic symptoms Oscar Taube, MD Coordinator, Adolescent Medicine The Children’s Hospital at](https://reader036.vdocuments.us/reader036/viewer/2022062421/56649dea5503460f94ae5d59/html5/thumbnails/29.jpg)
Pathogenesis: Genetic/Family Factors
• Genetics?: Somatoform disorders concordant in twins; cluster in families w. ADD/alcoholism.
• Learned Behavior: In many household, children’s somatic complaints more acceptable than expression of strong feelings.
• Family psychosocial factors: 1. If a family member has a chronic physical illness, +++somatic sx’s among children. (A model). 2.Somatisizing kids often live with somatisizing parents. 3. These sx’s=a reaction to stress.
![Page 30: The teenager with chronic abdominal pain; the teenager with chronic symptoms Oscar Taube, MD Coordinator, Adolescent Medicine The Children’s Hospital at](https://reader036.vdocuments.us/reader036/viewer/2022062421/56649dea5503460f94ae5d59/html5/thumbnails/30.jpg)
Somatization: Differential Diagnosis
• Unrecognized physical disease (OH NO!)
• Unrecognized psychiatric disorder (e.g. depression, anxiety)
• Factitious disorder (e.g. malingering)
• Psychological factors affecting medical condition
![Page 31: The teenager with chronic abdominal pain; the teenager with chronic symptoms Oscar Taube, MD Coordinator, Adolescent Medicine The Children’s Hospital at](https://reader036.vdocuments.us/reader036/viewer/2022062421/56649dea5503460f94ae5d59/html5/thumbnails/31.jpg)
Campo, et. al. Pediatrics 2004
Psychiatric Disorder
RAP patients (%)
Control patients (%)
P value
Any anxiety disorder
78.6 10.5 <.001
Any depressive disorder
42.9 7.9 <.001
![Page 32: The teenager with chronic abdominal pain; the teenager with chronic symptoms Oscar Taube, MD Coordinator, Adolescent Medicine The Children’s Hospital at](https://reader036.vdocuments.us/reader036/viewer/2022062421/56649dea5503460f94ae5d59/html5/thumbnails/32.jpg)
The approach: Somatization “Red Flags”
• Hx. of multiple somatic complaints
• Multiple primary care physician visits
• Multiple specialty consultations
• Family members with chronic and recurrent sx’s.
• “Non-nuclear” family
• Dysfunction in primary areas of life: family, peers, school, sports, leisure activities.
![Page 33: The teenager with chronic abdominal pain; the teenager with chronic symptoms Oscar Taube, MD Coordinator, Adolescent Medicine The Children’s Hospital at](https://reader036.vdocuments.us/reader036/viewer/2022062421/56649dea5503460f94ae5d59/html5/thumbnails/33.jpg)
The approach, continued
• VERY CAREFUL, VERY COMPREHENSIVE HISTORY AND PHYSICAL EXAM
• Bring up, EARLY in the evaluation, that there may be stress related factors.
• Ask patient/family their theories re: etiology• Limited lab work up, impose limits on workup.
Suggest limitations on specialty referrals.• Screen for depression/anxiety, etc. YSC,
BDI,etc. • Avoid “mind-body split”/”Functional vs.
organic”/etc. Use an example (e.g. red face”)
![Page 34: The teenager with chronic abdominal pain; the teenager with chronic symptoms Oscar Taube, MD Coordinator, Adolescent Medicine The Children’s Hospital at](https://reader036.vdocuments.us/reader036/viewer/2022062421/56649dea5503460f94ae5d59/html5/thumbnails/34.jpg)
Ask the patient/parent-Mothers who endorsed psych-social causes for
their kid’s abd. pain• Cause % endorsing
• Child worried, nervous, tense 50%
• Stress 32%
• Puts too much pressure on self 30%
• XS sensitivity/overreaction to pain 29%
• Abd. pain gets family attention 12%
![Page 35: The teenager with chronic abdominal pain; the teenager with chronic symptoms Oscar Taube, MD Coordinator, Adolescent Medicine The Children’s Hospital at](https://reader036.vdocuments.us/reader036/viewer/2022062421/56649dea5503460f94ae5d59/html5/thumbnails/35.jpg)
The approach, continued
• Urge consolidation of care
• Teach self-monitoring techniques (e.g., relaxation, PMR, pain diary )
• Offer reassurance when appropriate
• Aggressively Dx. and Rx. Comorbid psychiatric disease. Insist upon close contact with mental health provider
• Schedule frequent follow-up appt’s.
![Page 36: The teenager with chronic abdominal pain; the teenager with chronic symptoms Oscar Taube, MD Coordinator, Adolescent Medicine The Children’s Hospital at](https://reader036.vdocuments.us/reader036/viewer/2022062421/56649dea5503460f94ae5d59/html5/thumbnails/36.jpg)
• Finally, recognize that these patients can be very frustrating and difficult to treat.
• Consultation-physician to physician-for formal consultation, for ideas, and for emotional support- can be vital!
![Page 37: The teenager with chronic abdominal pain; the teenager with chronic symptoms Oscar Taube, MD Coordinator, Adolescent Medicine The Children’s Hospital at](https://reader036.vdocuments.us/reader036/viewer/2022062421/56649dea5503460f94ae5d59/html5/thumbnails/37.jpg)
References-1• 1. Braverman P: “Chronic Abdominal Pain”, in Neinstein LS et.al. Editors, Adolescent
Health Care: A Practical Guide. Fifth Edition. 2008. Philadelphia, Lippincott Williams and Wilkins. pp. 508-516.
• 2.Campo JV, BridgeJ, Ehmann M et. al.: “Recurrent Abdominal Pain, Anxiety and Depression in Primary Care. Pediatrics Vol 113 No. 4 April, 2004 pp. 817-824
• 3. Claar RL, Walker LS: “Matenal attributions for the causes and remedies of the children’s abdominal pain.” J. of Pediatric Psychology 1999 Vol. 24 No. 4 pp. 345-354.
• 4.Collins BS, Thomas D: “Chronic Abdominal Pain.” Pediatrics in Review Vol.28 No.9 Sept. 2007 pp.323-331
• 5. Hyams JS, Burke G, Davis PM et.al. “Abdominal Pain and Irritable Bowel Syndrome in Adolescence; a Community- based Study.” J. of Pediatrics Vol. 129 No. 2. 220-226
• 6. Kriepe RE “The Biopsychosocial Approach to Adolescents with Somatoform Disorders.” Adolescent Medicine Clinics Vol. 17 No. 1 Feb. 2006 pp.1-24
![Page 38: The teenager with chronic abdominal pain; the teenager with chronic symptoms Oscar Taube, MD Coordinator, Adolescent Medicine The Children’s Hospital at](https://reader036.vdocuments.us/reader036/viewer/2022062421/56649dea5503460f94ae5d59/html5/thumbnails/38.jpg)
References-2• 7. Lake AM: “Chronic Abdominal Pain in Childhood: Diagnosis and
Management.” Am. Family Physician Vol. 59 No.7 April 1, 1999.• 8. Miranda AM: “Early Life Stress and Pain: An Important Link to
Functional Bowel Disorders.” Pediatric Annals Vol. 39 No. 5 May, 2009.
• 9. Servan Schreiber D, Randall K, Tabas G: “Somatizing Patients: Part 1 Practical Diagnosis; Part 2 Practical Management.” Am. Family Physician Vol. 61 No. 4, 5. 2/15 and 3/1/00.
• 10. Silber TJ, Pao M: “Somatization Disorders in Children and Adolescents.” Pediatrics in Review Vol. 24 No. 8 Aug. 2003
• 11. Up to Date articles (May, 2009) on Evaluation/Management of Child with Chronic Abdominal Pain; Somatization; Primary Care Management of Medically Unexplained Symptoms.