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“The Pain of Abdominal Pain” “The Pain of Abdominal Pain”

“The Pain of Abdominal Pain” - PowerPoint Presentation

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“The Pain of Abdominal Pain” - PPT Presentation

Russell Cameron MD New Perspectives in Pediatrics Conference Wednesday October 21 2015 Disclosure I have no relevant financial relationships or conflicts of interest to disclose Objectives ID: 742722

functional pain disorders abdominal pain functional abdominal disorders syndrome placebo patients symptoms treatment children bowel double ibs controlled disease

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Slide1

“The Pain of Abdominal Pain”

Russell Cameron, M.D.New Perspectives in Pediatrics ConferenceWednesday, October 21, 2015Slide2

Disclosure

I have no relevant financial relationships or conflicts of interest to disclose.Slide3

Objectives

Discuss approach to pediatric patients with functional abdominal painHow to address patient and parental fears and expectationsDiscuss when to call a surgeon and when to call a psychologistSlide4

Why is this important?

About half of patients referred to pediatric GI clinics have symptoms that do not have a readily discernible causeKnowing how to relieve the physical and emotional suffering in patients without

“disease” is a necessity for every clinicianSlide5

Abdominal Pain

Usually stimulated by one of three pathways:VisceralSomaticReferredVariability in the experience of painNeuroanatomic, neurophysiologic, pathophysiologic, environmental, and psychosocial Slide6

Visceral Pain

Caused by distended viscus which activates a local nerve, sending an impulse that travels through autonomic afferent fibers to the spinal tract and central nervous system Localization of pain is difficult because there are few afferent nerves traveling from the viscera, and nerve fibers overlapEpigastric, periumbilical, or suprapubicSlide7

Somatic Pain

Carried by somatic nerves in the parietal peritoneum, muscle, or skinUsually well localized and sharpSlide8

Referred Pain

Perceived at a site remote from the actual affected visceraSharp, localized, or diffuseSlide9
Slide10

Biomedical Model

Two assumptions: Any symptom can be traced back to a single causeE

very symptom is either “organic,” meaning there is an identifiable, objectively defined pathophysiology, or “functional,” meaning without identifiable, objectively defined pathophysiologyThis dualistic approach implicitly places “organic disease” in high esteemFunctional disorders are considered less serious, psychological, or often without etiology or

treatment

The

biomedical model works for a broken bone or a kidney stone, but not so well when there are chronic problems such as headaches, abdominal pain, or chronic fatigueSlide11
Slide12
Slide13

SEP 16,

2009 “Misdiagnosis

and Regret”A reader who was recently found to have a rare, serious condition sent Doctor D a question about visiting one of several doctors who missed the

diagnosis:

“It

could be terribly awkward to have an appointment with one of them—me with all my new scars and a scary prognosis and them perhaps with their former, incorrect diagnoses of various benign conditions hanging in the

air”

“I'd

welcome a chance to let them know that I understand that it's impossible to get these things right instantly every time, and I have no

resentment”

“But

would it be better to just see a brand new doctor? Or would my former doctors want to see me? Or would they rather I melt into the ether and just let them forget it all

?”Slide14

Every doctor has had that 

“Oh crap! It was X? I thought it was Y!” panic after finding out about a misdiagnosis. The unspoken truth is that doctors guess—a lot. Usually we make informed, educated guesses, but even good guesses can be incorrect. Unusual conditions can be hard to discover, and we often make several wrong diagnoses on the way to the right one“

Retrospectascope” - only medical instrument that produces the right answer every time“We feel all patients demand perfection, and we work with imperfect tools and imperfect knowledge. Even the best care won't always produce the right answer—especially at the beginning

.Slide15
Slide16

Example

Ashley is a 17-year-old was referred from the ERAcute onset crampy abdominal pain and loose stools without blood during her first semester of college far away from homeShe was upset by a separation

from her high school boyfriendSkipping breakfast and lunch to avoid having to interrupt her classes to use the rest roomLoosing weightSlide17

Work Up

Screening laboratory tests Inflammatory bowel disease (IBD) and Celiac serology and screening labs were normalGI performs an EGD and

colonoscopy and 24 hour pH-ImpedanceAll were normalSlide18

Pain cont…

Sharp pains under the ribcage after meals, and the frequency and severity of the abdominal pain worsenedUnable to return to class because of worsening pain intensityPCP sent her to the

surgeon who ordered a HIDA scanEjection fraction was 33% (adult normal 35 to 90%)Slide19

The “cure”

The surgeon removed the gallbladderThe patient had prolonged pain after surgery and was discharged on NJ tube feedings, narcotics for abdominal pain, and polyethylene glycol for constipationShe remained out of school for many months, disabled by pain and unable to

eatSlide20

The aftermath…

Psychiatric consult found no eating or thought disorder and criticized the gastroenterologists for requesting the consultation, stating that the request might have been motivated by the physicians’ failure to find what was wrongThe patient, family, and clinicians inadvertently co-created disability by considering only organic etiologies and avoiding the reality of the patient’s stressful experiences and functional, physiologic responses to stress, namely, IBS and functional nausea and

vomitingSlide21

Analysis

They approached the problem from a biomedical model and the presumption that illness must have an organic etiologyExtensive

testing for diseases to explain symptomsEach negative test result reinforced the worries and fears that something important was being missedFocus on the mystery disease and miss recognizing the

emotional impacts of separations from her family, her ex-boyfriend, and her failure to adjust to

college

The patient, parent, and provider were

upset and frustrated by the failure to find organic

pathologySlide22

Biopsychosocial Model

Engel in 1977Goal is to understand and treat illness, the patient’s subjective sense of suffering, rather than confining the diagnostic effort to no more than finding disease

Symptoms may develop from several different influences, not just disease, and may stem from: Normal development (infant regurgitation)P

sychiatric

disease

(pain, conversion, factitious disorders)

I

mpact

of culture and society

(uninsured)

Functional disorders (symptoms

are real, but there is no easily discerned

disease)

D.R. Fleisher, E.J. Feldman: The

biopsychosocial

model of clinical practice in functional gastrointestinal disorders. P.E. Hyman p. 2-6 Pediatric Functional Gastrointestinal Disorders. 1999 Academy Professional Information Services New York 21-22Slide23

“Being human is messy and we are not that good at it”

Rather than reducing a cluster of symptoms to a single pathophysiology (reductionism), the biopsychosocial model expands the potential for understanding a problem from simultaneously interacting systems at subcellular, cellular, tissue, organ, interpersonal, and environmental levelsSlide24

Biomedical versus Biopsychosocial

Not versus but and… Most clinicians include elements of bothAll illnesses, organic and functional,

can be managed within the framework of the biopsychosocial rather than the biomedical modelGoal - improving patients’ well-beingDifference in what is considered to be impairment and the extent to which the clinician considers the origin and remedies to that

impairment

B

iomedical

model limits the role of the

clinician

to the diagnosis and treatment of disease and assumes that doing so restores

well-being

Biopsychosocial

model expands the meaning of the goal and the clinical process by which it is

achieved

Illness

is defined as the patient’s subjective sense of

suffering

The

goal of management is to identify the patient’s disease as well as other factors contributing to

suffering

I

ncludes

an analysis of the relationship and contributions of each factor in the patient’s

illnessSlide25

Illness

Slide26

Approach

Frame the conversation with the following categories:Things we needed to know about yesterday because they are emergent and need an intervention (ASAP)Things we want to find out about because it will significantly change our approach

Things that we will have to continue to learn about in order to make the symptoms betterThis will be a process and that the process is frustrating for:Patient because they are the one having the pain

P

arent

because they are watching their child have pain and feel helpless to fix it

P

rovider

because we are having to make educated and uneducated guesses as to what could be causing the

symptomsSlide27

“5 symptoms of GI tract”

Abdominal pain

NauseaVomitingDiarrheaConstipation

But…

“2000 + potential causes”Slide28
Slide29

Approach

Quality, timing, location, associations, and story are important and should be used as your guide in working it up and also your guide to stopping the investigationBuild trust, show you are listening Be nosy Be interested Acknowledge that this is frustrating and ask what is your greatest concern, what is your biggest

fear?Slide30

Approach

I use a dry erase board to document the facts of their story and then use those symptoms to help come up with a game plan that we all agree onThere are some baseline labs, stool studies, and imaging studies that we often order Value of the physical exam – lets them know you are taking this seriously (Abraham Verghese,

MD) https://www.ted.com/talks/abraham_verghese_a_doctor_s_touch?language=en#t-125798Slide31

Testing

Laboratory, radiologic, endoscopic, and ancillary evaluationShould be individualized according to the information obtained during the history and physical examinationMost clinicians recommend the following studies as an initial screen for all patients with recurrent abdominal pain:

CBC, UA with culture, Liver enzymes, ESR, Celiac and Stool O&PIf normal, in combination with a normal physical examination, effectively rule out an organic cause in 95% of cases.Other: Noninvasive studies and Invasive studies

Ex:

Ultrasound

has gained a prominent role over the past decade because it is painless and does not involve

radiation

3 studies

to investigate the diagnostic value of routine abdominal ultrasound in children with recurrent abdominal

pain failed

to demonstrate its utility in this clinical

setting

217

patients were

evaluated and a

total of 16 patients were found to have abnormalities identified by abdominal ultrasound, but in no case could the pain be attributed to the

abnormalitySlide32
Slide33
Slide34
Slide35
Slide36
Slide37
Slide38
Slide39
Slide40

RAP

FAP

CRAPIBSFGID:Functional Gastrointestinal Disease

Functional Dyspepsia

Abdominal MigrainesSlide41
Slide42

Apley

At least 1 episode per month for 3 consecutive months and severe enough to interfere with routine functioningAffects 10-15% of school age Up to 46% of children experience during childhoodSlide43
Slide44
Slide45
Slide46
Slide47

ROME III -> IV (spring 2016)

a diagnosis of a FGID is madeopposed to FGID only considered as a diagnosis of exclusionSlide48

“When in Rome…”

A. Esophageal Disorders A1. Heartburn A2

. Chest Pain Presumed Esophageal A3. Functional Dysphagia A4. Globus

B

.

Gastroduodenal

Disorders

B1

.

DYSPEPSIA

B1a

. Postprandial Distress Syndrome

B1b

. Epigastric Pain Syndrome

B2

. BELCHING DISORDERS

B2a

.

Aerophagia

B2b

. Unspecified Excessive Belching

B3

.

NAUSEA/VOMITING DISORDERS

B3a

. Chronic Idiopathic

Nausea

B3b

. Functional Vomiting

B3c

. Cyclic Vomiting Syndrome

B4

. Rumination Syndrome in Adults

C.

Bowel

Disorders

C1

. Irritable Bowel Syndrome

C2

. Functional Bloating

C3

. Functional Constipation

C4

. Functional Diarrhea

C5

. Unspecified Functional Bowel

Disorder

D

.

Abdominal

Pain

Syndrome

E

.

Gallbladder

and Sphincter of

Oddi

Disorders

E1

.

Gallbladder

Disorder

E2

.

Biliary

Sphincter of

Oddi

Disorder

E3

.

Pancreatic

Sphincter of

Oddi

DisorderSlide49

“When in Rome…”

F. Anorectal DisordersF1. Fecal IncontinenceF2. ANORECTAL

PAINF2a. Chronic ProctalgiaF2a.1. Levator Ani Syndrome

F2a.2. Unspecified Functional

Anorectal

Pain

F2b.

Proctalgia

Fugax

F3.

Defecation

Disorders

F3a

.

Dyssynergic

Defecation

F3b

. Inadequate

Defecatory

Propulsion

G

. Childhood Functional GI Disorders: Infant/Toddler

G1. Infant Regurgitation

G2

. Infant Rumination Syndrome

G3

. Cyclic Vomiting Syndrome

G4

. Infant Colic

G5

. Functional Diarrhea

G6

. Infant

Dyschezia

G7

. Functional

Constipation

H. Childhood Functional GI Disorders: Child/Adolescent

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

.

Nonretentive

Fecal IncontinenceSlide50

ABDOMINAL PAIN-RELATED FUNCTIONAL GI DISORDERS

Functional DyspepsiaIrritable Bowel SyndromeAbdominal MigraineChildhood Functional Abdominal PainChildhood

Functional Abdominal Pain SyndromeSlide51

Functional DyspepsiaSlide52

IBSSlide53

Abdominal MigraineSlide54

Functional Abdominal PainSlide55

FAP SyndromeSlide56

B

idirectional brain-gut interaction Brain receives a stream of interoceptive input from the GI tract, integrates the information with other interoceptive information from the body and with contextual information from the environment, and sends an integrated response back to various target cells

Homeostasis of the GI tract during physiological perturbations and to adapt GI function to the overall state of the organismMajority of information reaching the brain is not consciously perceived but serves primarily as input to autonomic reflex pathwaysFAP syndromes, conscious perception of interoceptive information from the GI tract, or recall of

interoceptive

memories of such input, can occur in the form of constant or recurrent discomfort or painSlide57
Slide58
Slide59
Slide60
Slide61

Treatment of FGID

Acknowledgement and Reassurance MedicationDietTherapies Slide62

Simulation:

Parent: “Doctor, what is causing my child’s pain?”Me: “I am not sure yet, but will try and help your child and you as we navigate through this process. It is possible we will be wrong before we find out what is causing it, and it may be that the symptom is the disease. Like a headache in the stomach.” Slide63

PPIs

PPIs, however, have only a small benefit over placebo in the treatment of functional dyspepsia [Moayyedi et al. 2006]Slide64

Histamine

Predominant dyspepsia, a short course of empiric therapy with an H2-histamine receptor antagonist is acceptableFailure to respond or a recurrence of symptoms following discontinuation prompts further

evaluationStudy showed only subjective improved in symptoms, and placebo was equally effective when looking at objective scores

M.C. See, A.H. Birnbaum, C.B.

Schecter

, et al.: Double-blind, placebo-controlled trial of famotidine in children with abdominal pain and dyspepsia. Dig Dis Sci. 46:985-992 2001Slide65

Periactin

Cyproheptadine, a central and peripheral H1 nonselective histamine receptor antagonist with antiserotonergic propertiesA double-blind, randomized, placebo-controlled trial was performed in 29 children ages 4 to 12 years with FAPRandomized

to placebo or cyproheptadine86% in the cyproheptadine group and 36% in the placebo group had improvement or resolution

M.

Sadeghian

, F.

Farahmand

, G.H.

Fallahi

, et al.:

Cyproheptadine

for the treatment of functional abdominal pain in childhood: a double-blinded randomized placebo-controlled trial. Minerva

Pediatr

. 60:1367-1374 2008Slide66

Peppermint Oil

Soothe the GI tract for hundreds of yearsRelaxes intestinal smooth muscle by decreasing calcium influx into the smooth muscle cellsM

eta-analysis of five randomized, double-blinded, placebo-controlled trials performed in adult patients supported the efficacy of peppermint oil in the treatment of irritable bowel syndromeRandomized, double-blind, controlled trial in pediatric patients with IBS demonstrated the efficacy of enteric-coated peppermint oil capsules in the reduction of pain during the acute phase of

IBS

R.M. Kline, J.J. Kline, J. Di Palma, et al.: Enteric-coated,

pH-dependent

peppermint

oil capsules for the treatment of irritable bowel syndrome in children.

J

Pediatr

. 138:125-128 2001Slide67

Anticholinergics

Dicyclomine (Bentyl) and hyoscyamine (Levsin) S

mooth muscle relaxants, block the muscarinic effects of acetylcholine on the GI tract, relaxing smooth muscle and reducing spasm and abdominal pain, slowing intestinal motility, and decreasing diarrhea

Efficacy not

clearly established in adult trials,

no randomized

, double-blind, placebo-controlled

trials in pediatrics

Potential

side

effects: drowsiness

, blurred vision, dry mouth, tachycardia, constipation, and urinary

retention

PRN or episodic, up to four

times

dailySlide68

Tricyclic Antidepressants

Shown to provide relief to patients with FGIDsNeuromodulatory and analgesic effects, from

a combined anticholinergic effect on the gastrointestinal tract, mood elevation and central analgesiaTwo clinical trials to evaluate the efficacy of TCA therapy in the treatment of FAP in childrenA single-center study

of 33

adolescents with IBS found a beneficial effect of amitriptyline in comparison to placebo in terms of quality of life and pain

relief

A multicenter

randomized double-blinded trial

on

90

children showed

improvement in 59% of the children receiving

amitriptyline*

M. Saps, N. Youssef, A. Miranda, et al.: Multicenter, randomized, placebo-controlled trial of amitriptyline in children with functional gastrointestinal disorders. Gastroenterology. 137:1261-1269 2009Slide69

Serotonin

Serotonin is found in high concentrations in the enterochromaffin14 serotonin receptor subtypes with varying actions in the peripheral and central nervous systems exist5-HT3 and 5-HT4 receptors appear to play a role in the pathophysiology of IBSSlide70

SSRIs

Selective serotonin reuptake inhibitors are helpful for some patients with unremitting pain and impaired daily functioning, even if no depressive symptoms are presentCitalopram has been studied in children with FGIDs 12-week

open-label flexible-dose trialBy week 12, 50% rated their symptoms as very much improvedAlso showed improvement in comorbid depression and

anxiety

J.V. Campo, J.

Perel

, A. Lucas, et al.: Citalopram treatment of pediatric recurrent abdominal pain and comorbid internalizing disorders: an exploratory study. J Am

Acad

Child

Adolesc

Psychiatry. 43:1234-1242 2004Slide71

5-HT3 antagonist

Ondansetron (Zofran) and Granisetron (Kytril)

Some chemotherapeutic and radiotherapeutic agents cause the release of 5-HT from enterochromaffin cellsSerotonin activates vagal afferents via 5-HT3 receptors, triggering emesis by stimulation of the area postrema

and chemoreceptor trigger

zone

Ondansetron

and

granisetron

are very effective in reducing

postchemotherapy

nausea, but do not consistently alleviate the pain associated with

FGIDs

N

ot

routinely recommended for

FGIDs

unless nausea is a predominant symptomSlide72

Probiotics

Double-blind randomized controlled trial, 50 children with IBS were treated with either Lactobacillus GG or placebo for 6 weeksNo significant

differences between treatment and placebo groups with the exception of abdominal distentionLarger, 4-week placebo-controlled study, 104 patients who fulfilled the Rome II criteria for functional dyspepsia, IBS, or

FAP

25%

in

the treatment group and

9.6% in the placebo group responded to

therapy

IBS

more likely to respond to

probiotic, compared to placebo

or

FAP

M.

Bausserman

, S.

Michail

: The use of Lactobacillus GG in irritable bowel syndrome in children: a double-blind randomized control trial. J

Pediatr

. 147:197-201 2005

A

.

Gawronska

,

Horbath

A.

Dziechciarz

, et al.: A randomized double-blind placebo-controlled trial of Lactobacillus GG for abdominal pain disorders in children. Aliment

Pharmacol

Ther

. 25:177-184 2007Slide73

Microbiota

+ Carbohydrate (fuel) = Gas + Byproducts

Gas

=

Distension

Distension

= Pain

(

nociceptor)

Byproducts

= Absorption + Attraction H2OSlide74
Slide75
Slide76
Slide77
Slide78
Slide79

What Are Prebiotics?

Different kinds of fiber that encourage beneficial species of gut flora to growYou can’t digest them, but your gut flora can – and more food for the gut flora means more flora!

PREbiotics provide food for the bacteria already living in your gutPRObiotics provide a direct infusion of bacteria that weren’t there before“Synbiotics

” refers to supplements that combine probiotics and

prebioticsSlide80

Lactose, Fructose, FODMAPs…Oh my…

Breath testsElimination dietsSupplemental enzymesSlide81

Prebiotic, Probiotic, Symbiotic … Oh my…

Prebiotics +/-Probiotics – which one, who do you trustSymbiotic – does it even matter, and how would you even knowSlide82

What about evil gluten and Paleo?Slide83
Slide84
Slide85

Cognitive Behavioral Therapy

6 studies in a Cochrane reviewRelatively small and had some weaknesses in design and reportingEach reported a statistically significant benefit to participants in the intervention groupCochrane reviewers thought CBT

is worth consideringA.A. Huertas-Ceballos, S. Logan, C. Bennett, C. Macarthur: Psychosocial interventions for recurrent abdominal pain (RAP) and irritable bowel syndrome (IBS) in childhood (Review). Cochrane Library. (Issue 4)2009Slide86

Relaxation/Arousal Reduction

A variety of techniques to teach patients to counteract the physiological sequelae of stress or anxietyThe most commonly used techniques include progressive muscle relaxation training; biofeedback for striated muscle tension, skin temperature, or electrodermal activity; and transcendental or yoga

meditationMost techniques incorporate a quiet environment, a relaxed and comfortable body position, and a mental image to focus attention away from distracting thoughts or body perceptionsAudiotapes may be used to guide practice at homeRelaxation

training has been shown in adults to significantly reduce gastrointestinal symptoms as compared with

controls

R.D. Anbar: Self-hypnosis for the treatment of functional abdominal pain in childhood.

Clin

Pediatr

. 40:447-451 2001Slide87

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