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
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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 diffuseSlide9Slide10
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 fatigueSlide11Slide12Slide13
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
.Slide15Slide16
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”Slide28Slide29
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
abnormalitySlide32Slide33Slide34Slide35Slide36Slide37Slide38Slide39Slide40
RAP
FAP
CRAPIBSFGID:Functional Gastrointestinal Disease
Functional Dyspepsia
Abdominal MigrainesSlide41Slide42
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 childhoodSlide43Slide44Slide45Slide46Slide47
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 painSlide57Slide58Slide59Slide60Slide61
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 H2OSlide74Slide75Slide76Slide77Slide78Slide79
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?Slide83Slide84Slide85
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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