Children and Adolescents Dr Subhajit Bhakta MBBS MD Paediatrics Senior Resident amp Clinical Tutor Department of Paediatric Medicine MEDICAL COLLEGE AND HOSPITAL KOLKATA ID: 912027
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Slide1
Childhood Functional Gastrointestinal Disorder(Children and Adolescents)
Dr
Subhajit
Bhakta
MBBS, MD (Paediatrics)
Senior Resident & Clinical Tutor
Department of Paediatric Medicine
MEDICAL COLLEGE AND HOSPITAL, KOLKATA
Slide2OVERVIEWFunctional gastrointestinal disorders (FGIDs) are conditions that include a combination of symptoms that are: Chronic or recurrent
That are not explained entirely with current structural or biochemical investigations.
‘Functional
’ emphasizes that many of the symptoms accompany normal development and may be response to otherwise normal internal and external cues.
Slide3HISTORY In 1987, Professor Aldo Torsoli
described various gastrointestinal disturbances that appeared to cluster together with significant prevalence, constituting disorders.
From there on a consensus approach was felt necessary for defining such disorders for research and clinical management guidelines. >> ROME FOUNDATION AND ROME CRITERIA:
1990: ROME I ( focused mainly on adults)
1996: ROME II ( included
Paediatrics
patients also)
2006: ROME III
2016: ROME IV
Slide4ROME IV : What has changed?‘Symptoms Based Diagnosis’ has taken precedence:Less reliance of extensive investigations.Emphasis on ‘ selective or no testing’.
2.
“no evidence for organic disease”
in all definitions replaced by
“after appropriate medical evaluation the symptoms cannot be attributed to another medical condition.”
( understanding the fact the FGIDs can co-exist with other medical condition having GI symptoms i.e. IBD
Slide5ROME IV : What has changed contd…….3. “abdominal pain related functional gastrointestinal disorders”
has been changed to
“functional abdominal pain disorders”:
4.
The fact that the different FGIDs can occur together and overlap significantly.
5.
The classification and diagnostic criteria is tweaked and modified : help both clinician and researchers.
Slide6Functional Gastrointestinal Disorders: Children and AdolescentsH1. Functional nausea and vomiting disorders (changed term)
H1a. Cyclic vomiting syndrome
H1b. Functional nausea and functional vomiting
H1c. Rumination syndrome
H1d.
Aerophagia
H2. Functional abdominal pain disorders (changed term)
H2a. Functional dyspepsia
H2b. Irritable bowel syndrome
H2c. Abdominal migraine
H2d. Functional abdominal pain not otherwise specified (new term)
H3. Functional defecation disorders
H3a. Functional constipation
H3b. Non-retentive
fecal
incontinence
Slide7H1b: Functional Nausea and functional VomitingThese are new definitions in ROME IV:H1b1. Functional Nausea
Must include all of the following fulfilled for the last
2
months:
Bothersome nausea as the predominant symptom,
occurring
at least twice per week
, and generally
not related to meals.
Not consistently associated with vomiting.
3)
After appropriate evaluation, the nausea cannot be
fully explained by another medical condition
Slide8H1b: Functional Nausea and functional Vomiting cont…
H1b2. Functional Vomiting
Must include all of the following
for at least 2 months
before diagnosis:
On average,
1 or more episodes of vomiting per
Week
.
Absence of
self-induced vomiting or criteria for an
eating disorder or rumination.
After appropriate evaluation, the vomiting cannot
be fully explained by another medical condition.
Slide9H1b: Functional Nausea and functional Vomiting cont…
Insufficient pediatric data on the prevalence of isolated nausea, isolated vomiting, or a combination of both in the literature.
They can occur in isolation or in combination.
The absence of ‘ concomitant pain’
differentiate this clinical entity from ‘ functional dyspepsia’.
This usually presents with
chronic but mild symptoms.
Recurrent and severe pattern of vomiting should raise more severe organic/ metabolic causes. ( CNS, GI obstruction, Gastroparesis, Endocrinal disorders).
Slide10H1b: Functional Nausea and functional Vomiting cont…
Predominantly seen in children
with Psychological issues
i.e. Anxiety, Depression.
Important observation being ‘ Experiencing nausea only in early morning’ with history of ‘ sleeping late’ at night.
TREATMENT OF ‘Functional Nausea and functional vomiting’:
With Psychological
Comoribidity
: Mental Health Intervention: CBT, Hypnotherapy.
Intractable Symptoms :
Cyproheptadine
, may be helpful.
Gastric Electrical Stimulus, may be helpful.
Slide11H1a: Cyclical Vomiting SyndromeCommunity Prevalence: 0.2 – 1.0 %.Median age of onset:
3.5-7
yrs
( can occur in infants to adults). 46% by 3
rd
year of life.
If abdominal pain and vomiting both are present, the predominant or more consistent symptom should be considered for the primary diagnosis.
i.e.
If the predominant feature is abdominal pain, then abdominal migraine should be considered rather than CVS.
Higher likelihood of underlying neuro-metabolic diseases in children with early onset of symptoms.
Metabolic testing should be carried out during vomiting episodes and before starting of IV fluids.
Slide12H1a: Cyclical Vomiting Syndromecont…
H1a. Diagnostic Criteria for Cyclic Vomiting Syndrome
Must include all of the following:
1. The occurrence of
2 or more periods
of intense,
unremitting nausea and paroxysmal vomiting,
lasting hours to
days within a 6-month period.
2. Episodes are
stereotypica
l
in each patient.
3. Episodes are separated by weeks to months
with
return to baseline health
between episodes.
4. After appropriate medical evaluation, the symptoms cannot be attributed to another condition
Slide13H1a: Cyclical Vomiting Syndromecont…Importance on ‘Stereotypic Presentation’ in each individuals. …… ----------------‘Pattern’.
In ROME III “usual state of health” was there instead of “return to baseline health”.
“usual state of health”
could have been misinterpreted as being asymptomatic between episodes.
but the new phrase allowed the coexistence of mild GI symptoms at baseline, which is often seen in clinical settings.
Slide14H1a: Cyclical Vomiting Syndromecont…TREATMENT OF CVS;
1
ST
Line: < 5 years:
Cyproheptadine
.
> 5 years: Amitriptyline.
2
nd
Line:
Propanolol
prophylaxis (all ages)
Adjunctive : Acupuncture, CBT,
Co-enzyme Q10, L-Carnitine.
Abortive therapy: Hospitalisation, Liberal IV fluids, Anti-emetics
Slide15H1c : Rumination SyndromeOccurs in all ages: Adolescent Girls are particularly vulnerableSeen as a ‘ Habit disorder’.
Almost always there is a trigger event: An
intercurrent
infectious process / Traumatic Psychosocial events.
Association with Psychiatric morbidity : Depression, Anxiety, OCD,PTSD
May be associated with other FGIDs.
Effortless repetitive regurgitation, re-swallowing, and/or spitting within minutes of starting a meal define rumination.
Slide16H1c : Rumination SyndromeH1c. Diagnostic Criteria for Rumination Syndrome
Must include all of the following:
Repeated regurgitation and
rechewing
or expulsion of food that:
a.Begins
soon after ingestion of a meal
b. Does not occur during sleep
2. Not preceded by retching
3. After appropriate evaluation, the symptoms
cannot be fully explained by another medical
condition.
An eating disorder must be ruled out
Criteria fulfilled for at least 2 months before diagnosis.
Slide17H1c : Rumination Syndrome‘Adolescent Ruminition Syndrome’ term obsolete.
Its not necessarily ‘Painless’ as some discomfort/ bloating may be present.
Not compulsory to rule out ‘Gastro
esophageal
reflux’ before diagnosis.
PATHOPHYSIOLOGY:
Anatomical displacement of LES into thoracic cavity after increased intra gastric pressure/ intra abdominal pressure.
Gastro-
jejunal
manometry
suggest :
simultaneous increase in pressure (“r” waves) across multiple areas of the upper gut. These pressure waves are thought to be the result of the contraction of the skeletal abdominal muscles.
Slide18H1c : Rumination SyndromeDIFFERENTIALS:Eating disorder ( Bulimia) must be excluded.Gastroesophageal reflux, gastroparesis, achalasia etc.
TREATMENT:
Management as habit disorder.
Novel inpatient inter-disciplinary approach (psychiatrist,
ped
gastro
, nutritionist)
Slide19H1d : AerophagiaFairly common in Paediatric Population ( Prevalence 4.5-7.5%).
Particularly common in patients of ‘Neuro Cognitive Disability’
Younger children – Stress related/ Anxiety related,
Older children – Chewing gum, rapid drinking habit.
Common symptoms : Belching, fullness, early satiety, flatus.
Slide20H1d : Aerophagia
H1d. Diagnostic Criteria for
Aerophagia
.
Must include all of the following:
Excessive
air swallowing
Abdominal distention due to intraluminal air
which increases during the day
Repetitive belching and/or increased flatus
After appropriate evaluation, the symptoms cannot be fully explained by another medical condition.
Criteria must be fulfilled
for at least 2 months
before diagnosis
Slide21H1d : AerophagiaClinical Evaluation:D/D to rule out : Gastroparesis, Pseudo Obstruction, Malabsorption (celiac ,
Disaccharidase
def
), bacterial overgrowth.
Treatment:
There are no controlled studies in children to guide therapy,
largely supportive and may
include behavioral therapy, psychotherapy, and benzodiazepines.
Slide22H2. Functional abdominal pain disorders
Slide23H2a: Functional DyspepsiaH2a. Diagnostic Criteria for Functional Dyspepsia;
Must include
1 or more
of the following bothersome
symptoms
at least 4 days per month:
1. Postprandial fullness
2. Early satiation
3. Epigastric pain or burning not associated with
defecation.
After appropriate evaluation, the symptoms
cannot be fully explained by another medical
condition.
Criteria fulfilled for at least 2 months before diagnosis.
PAIN is not an
essential criteria for Diagnosis.
Slide24H2a: Functional Dyspepsia2 subtypes of FD identified:Postp
ara
ndial
distress syndrome:
Meal induced
dyspeptic symptoms.
Supportive features include upper abdominal bloating, postprandial nausea, or excessive belching.
Suggestive of
Motility disturbance.
2. Epigastric pain syndrome:
which includes all of the following: bothersome (severe enough to interfere with normal activities)
pain or burning
localized to the epigastrium.
Not relieved by defecation or passage of flatus.
Supportive criteria can include:
burning quality of the pain but without a retrosternal component
the pain commonly
induced or relieved by ingestion of a meal but may occur while fasting.
D/D- Peptic ulcer ds, GERD
Slide25H2a: Functional DyspepsiaFD is a multifactorial heterogeneous disorder.
Environmental factor
1.Food allergy.
2. Bacterial Gastritis( not viral).
H PYLORI not a
pediatric
scenario unlike adult(in absence of duodenal ulcer)
Host Factor:
Stress/
psycogenic
factors.
Genetic Predisposition.
Organ Factor:
1.Gastric motor dysfunction.
2.Visceral hypersensitivity.
3.Low grade inflammation.(Eosinophil and mast cells invading lamina
propia
.
Slide26H2a: Functional DyspepsiaClinical Evaluation:FD symptoms overlaps with many organic GI disorders ( peptic ulcer ds, GERD, Eosinophilic esophagitis, IBD etc.
ROME IV committee advised necessary further investigation for following
“POTENTIAL ALARM FEATURES”
1.Family history of inflammatory bowel disease, celiac disease, or peptic ulcer disease.
2. Persistent right upper or right lower quadrant pain.
3. Dysphagia/Odynophagia / Persistent vomiting/Gastrointestinal blood loss.
4. Arthritis / Perirectal disease/ Nocturnal
diarrhea
/ Involuntary weight loss/ Deceleration of linear growth/Delayed puberty.
5. Unexplained fever
Slide27H2a: Functional DyspepsiaRole of Upper GI Endoscopy:No need to do routinely.Indication:
A family history of Peptic Ulcer ds / H pylori infection.
> 10 yrs.
Symptoms persisting more than 6 months.
Symptoms severe enough to affect activities of daily living, including sleep.
ROME IV recognizes that local practice patterns and social considerations may influence the decision.
Slide28H2a: Functional DyspepsiaTREATMENT: Avoidance of Food allergens, Caffiene
, Spicy foods, NSAIDS.
PAIN Management: PPI > H2 Blocker ( 4 weeks management)
BLOATING/ EARLY SATIETY Symptoms(most difficult to manage)-
Prokinetics
.
Low dose TCA ( Imipramine, amitriptyline) : data lacking.
Psychological factors to be addressed.
A Retrospective Open-labelled study:
Cyproheptadine
is safe and may be given.(
Rodriguez L, Diaz J,
Nurko
S. Safety and efficacy of
cyproheptadine
for treating dyspeptic symptoms in children. J
Pediatr
2013;163:261–267
)
Refractory to Medical treatment: Gastric Electrical stimulation,
Slide29H2b: Irritable Bowel SyndromePrevalence of IBS- 2-5%
H2b. Diagnostic Criteria for Irritable Bowel Syndrome
Must include all of the following:
1. Abdominal pain
at least 4 days per month
associated with one or more of the following:
a. Related to defecation
b. A change in frequency of stool
c. A change in form (appearance) of stool
2. In children with constipation, the pain does not
resolve with resolution of the constipation (
children in whom the pain resolves have functional
constipation, not irritable bowel syndrome
)
3. After appropriate evaluation, the symptoms
cannot be fully explained by another medical
condition.
Criteria fulfilled for at least 2 months before diagnosi
s
Slide30H2b: Irritable Bowel SyndromeIBS Subtypes : depending on the predominant stool types. IBS with
Diarrhea
,
IBS with Constipation,
IBS with constipation and
diarrhea
and
Unspecified IBS
As many as 75% of children with constipation report pain
Studies have shown IBS patients often receive a diagnosis of functional constipation.
Patients with constipation and abdominal pain initially be treated for constipation only.
If abdominal pain resolves with constipation treatment, the patient has functional constipation.
If pain does not resolve with appropriate constipation treatment alone, the patient likely has IBS with constipation
.
Slide31H2b: Irritable Bowel SyndromePathophysiology : Brain – Gut Axis: Perception of pain and discomfort.Alteration in GUT microbiome: ? Cause/ ? Effect…..not known
Slide32H2b: Irritable Bowel SyndromeCLINICAL EVALUATION:Need to differentiate from Functional Constipation.
More the number of ‘Alarm Features’ more the chance of alternate diagnosis (celiac/ carbohydrate
malabs
., IBD
etc
)
Fecal
Calprotectin is being increasingly used to evaluate
Gi
mucosal inflammation.
TREATMENT:
Role of Probiotics (
Multistrain
> mono strain ; studies at least 8
wks
therapy, mostly used Lactobacilli
acidophilum
and
bifidobacterium
sp.)
Pepperment
oil for pain relief. ( small prospective double blind trial)
Elimination Diet (
oligosachharide
,
disachharide
,
monosachharides
and polyols)
Behavioral
therapy (Symptoms Coping Skills)
Slide33H2c: Abdominal MigraineAbdominal Migraine, Cyclical Vomiting Syndrome and Migraine are disorders of same spectrum. Same dynamics of symptomatology.( recurrent crippling episodes with near normal intervals, individual stereotypic presentations)Similar trigger and relieving factors.
Similar prodromal symptoms.
Similar Pathophysiology.
Similar treatment approaches.
Prevalence of Abdominal Migraine vary from 1% to 23%.
Slide34H2c: Abdominal MigraineH2c. Diagnostic Criteria for Abdominal Migraine
Must include all of the following occurring
at least twice
in 6 months.
Paroxysmal episodes of intense, acute periumbilical, midline or diffuse abdominal pain lasting
1 hour or more (should be the most severe and
distressing symptom).
2. Episodes are separated by weeks to months.
3. The pain is incapacitating and interferes with
normal activities.
4. Stereotypical pattern and symptoms in the individual patient.
5. The pain is associated with 2 or more of the
following:
a. Anorexia
b. Nausea
c. Vomiting
d. Headache
e. Photophobia
f. Pallor
6. After appropriate evaluation, the symptoms
cannot be fully explained by another medical
condition.
Slide35H2c: Abdominal MigraineCLINICAL EVALUATION:Counselling the parents that Abdominal Migraine may evolve to Migraine in adulthood.
For very worrisome cases the D/Ds must be excluded (
Recurerent
GI and Urological
obs
, Recurrent Pancreatitis,
Biliarty
tract ds, FMF, Metabolic ds like porphyria).
TREATMENT:
Acute Symptomatic management.
Prophylaxis: Oral
Pizotifen
( Anti Serotonin and
AntiHistaminic
effect)
Amitryptyline
,
Propanolol
,
Cyproheptadine
.
Slide36H2d: Functional Abdominal Pain-Not Otherwise Specified.The term functional abdominal pain not otherwise specified in Rome IV substitutes for the Rome III terms functional abdominal pain and FAPS.A mean of 35% to 38% of elementary school children report abdominal pain weekly. But only One third of these patients meet the ROME IV criteria for FAPD.
H2d. Diagnostic
Criteriaa
for Functional
AbdominalPain
-
NOS
Must be fulfilled at least 4 times per month and include
all of the following:
Episodic or continuous abdominal pain that does
not occur solely during physiologic events (
eg
.
eating, menses)
Insufficient criteria for irritable bowel syndrome,
functional dyspepsia, or abdominal migraine
After appropriate evaluation, the abdominal pain
cannot be fully explained by another medical
condition
Criteria fulfilled for at least 2 months before diagnosis
Slide37H2d: Functional Abdominal Pain-Not Otherwise Specified.TREATMENT:Antispasmodic ( not superior to placebo in trials)Short course of
Amytriptyline
, Citalopram.
Behavioral
therapy: Pain Coping Management.
Slide38H3a: Functional ConstipationMean Prevalence is around 12%.Prevalent across all Socio economic, racio
-cultural, dietary practice and equally in both sex.
Most problematic during ‘Toilet training’ age groups.
PATHOPHYSIOLOGY:
Holding Up:
Pain, Social(
school,travel
)
Increased Retention in Colon> Water absorption> more hard stool
Retention> Colonic distention
Loss of rectal sensation
Colonic decreased motility
Fecal
incontinence
Decreased urge to
defaecate
Slide39H3a: Functional ConstipationH3a. Diagnostic Criteria for Functional Constipation
Must include 2 or more of the following occurring at
least once per week for a minimum of 1 month with
insufficient criteria for a diagnosis of irritable bowel
syndrome:
2 or fewer defecations in the toilet per week in a
child of a developmental age of at least 4 years
At least 1 episode of fecal incontinence per week
History of retentive posturing or excessive volitional stool retention
History of painful or hard bowel movements
Presence of a large fecal mass in the rectum
History of large diameter stools that can obstruct
the toilet
After appropriate evaluation, the symptoms cannot be
fully explained by another medical condition.
Slide40H3a: Functional ConstipationNo Need for further Investigation if there is no ‘Alarm Signs’A plain abdominal radiograph may be used in a child if fecal impaction is suspected but in whom physical examination is unreliable/not possible.
No need for Routine allergy test for
cowmilk
, tests for hypothyroidism, celiac ds, hypercalcemia
unless there is a Alarm Sign.
Anorectal
manometry
in the evaluation of intractable constipation is to assess the presence of the
rectoanal
inhibitory reflex
Slide41H3a: Functional ConstipationTREATMENT:Education: Toilet training, Reward(Positive reinforcement), Dietary and Fluid intake.
Pharmacological:
Disimpaction
: Oral/ rectal
preperations
.
Maintenance:
Polyethelene
Glycol> Lactulose
Addition of prebiotics and probiotics to the regimen currently does not seem to be supported by adequate evidences.
However L.
reuteri
is emerging as the probiotic of interest in treatment of FC
Slide42H3b. Nonretentive Fecal Incontinence
H3b. Diagnostic Criteria for
Nonretentive
Fecal
Incontinence
At least a 1-month history of the following symptoms in
a child with a developmental age older than 4 years:
Defecation into places inappropriate to the sociocultural context
2. No evidence of fecal retention
3. After appropriate medical evaluation, the fecal
incontinence cannot be explained by another
medical condition
Slide43H3b. Nonretentive Fecal Incontinence
NFI
FC
related
FI
Normal Defaecation frequency and stool
consistency
Abnormal defaecation
frequency and/or stool consistency.
Complete evacuation of colonic contents
Only staining of undergarments.
No Palpable mass in Abdomen
or rectum( P/R exam)
Often
Palpable mass in abdomen or rectum.
Normal Anorectal Motility Parameters
Abnormal Anorectal motility
paramteres
Total or segmental colonic transit time
not increased
Colonic transit
time significantly increased.
Slide44H3b. Nonretentive Fecal Incontinence
Pronounced Psychological factor:
Impulsive action against unconscious
anger,Sexual
abuse, mostly in school going age group.
Treatment:
Difficult to treat
Parent counselling.
Trigger( family conflict, sexual abuse) to be addressed.
Behavioral
therapy: most helpful ( confidence and self respect building, reward, removal of social phobia), toilet training,
At 18 years of age, 15% of adolescents with NFI still had the disorder
Slide45TAKE HOME MESSAGEFGID is still an entity where more researches are needed to fully understand different disorders.The definitions and guidelines are ever changing.Understanding the different classifications needed for Clinical and research purpose.Psychological aspect of the disorder is to be given primary importance.Least role of extensive investigation> investigate only on ‘Alarm Signs’Parent counselling probably more important than pharmacology.
Slide46THANK You