Consultant Paediatrician with gastroenterology interest East and North Hertfordshire NHS Trust Aims amp Objectives Introduction Causes Associate factors Functional GI disorders Rome criteria ID: 1010712
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1. Chronic Abdominal painDr. K. TamilselvanConsultant Paediatrician with gastroenterology interestEast and North Hertfordshire NHS Trust
2. Aims & ObjectivesIntroductionCauses/ Associate factorsFunctional GI disorders – Rome criteriaPresenting symptoms and signsDifferential diagnosisInvestigationsTreatmentPrimary care pathwayTake home messages
3. IntroductionChronic abdominal pain/ Recurrent abdominal pain/ Functional abdominal pain Very common - 10-15% children in UK5-10% have underlying organic diseaseIt is uncommon < 4 yearsF>M
4. Causative factors Visceral hyperalgesia/ altered brain-gut interaction/ cortical nociceptive abnormal wiring Research – Functional MRI in healthy subjects vs adolescents with IBS - Structural and functional differences in brain - reinforces the theory of psychological aspects of treatmentGut microbiota
5. Associated & Risk factorsAssociated factors – stress - significant event - less coping strategiesRisk factors – parental anxiety Family h/o GI illness genetic predisposition
6. Functional VS organic GI disordersRange of disorders confined to GI tract but can’t be explained by structural or biochemical abnormalitiesSymptom causes - significant impact on families - Patient quality of life - healthcare utilization and costs
7. Functional GI disordersDiagnosis is based on symptoms and examinationRobust symptom based criteria – accurate, clear and unambiguous
8. Rome criteriaDefinition criteria – working committee of Rome foundation through literature review and consensus processRome criteria – 1 was published in 1990 for adults - 3 including children in 2006 and 4 criteria in 2016
9. Why the clear diagnosis is important?Objective diagnosisMonitor progress of the diseaseClear objective criteria mean - Clear to explain the parents - better understanding of the condition - for accepting the diagnosis - for addressing psychological aspects and personnel impact of the disease
10. Functional GI disorders – Rome 4 criteriaFunctional nausea and vomiting disordersFunctional abdominal pain disordersFunctional defecation disorders
11. Functional GI disorders – Rome 4 criteriaFunctional nausea and vomiting (> 2/12 except cyclical vomiting) a, Cyclical vomiting syndrome b, Functional nausea and functional vomiting c, Rumination syndrome d, Aerophagia
12. Rome 4 criteria continuedFunctional defecation disorders (>1 month) a, Functional constipation b, Non- retentive faecal incontinence
13. Functional abdominal pain disordersFunctional dyspepsia Irritable bowel syndromeAbdominal migraineFunctional abdominal pain – not otherwise specified
14. Functional dyspepsia (4 days/month)Postprandial distress syndrome Post prandial fullness/ early satiety Post prandial nausea upper abdomen bloating Excessive belchingEpigastric pain syndrome Burning quality, not relieved by defaecation, no retrosternal compartment, pain increased or reduced by meal Criteria fulfilled at least 2 months before the diagnosis
15. Irritable bowel Syndrome (4 days/month)Related to defecationChange in frequency of the stoolChange in form (appearance) of the stoolChildren with constipation pain does not resolve after defecationCriteria fulfilled at least 2 months before the diagnosis
16. Abdominal migraine (at least twice)Paroxysmal episodes of intense, acute, peri-umbilical or diffuse pain lasting for 1 hour or more Episodes separated by weeks to monthsPain affects the normal activitiesPain associated with 2 or more of the following anorexia/nausea/vomiting/headache/photophobia/pallorCriteria fulfilled for at least 6 months before diagnosis
17. Functional abdominal pain – NOS ( 4 times/month)Random functional or continuous painInsufficient criteria for IBS, functional dyspepsia or abdominal migraineCriteria fulfilled for at least 2 months before diagnosis
18. Presenting symptomsGI symptoms – Abdominal pain, vomiting, diarrhea, abdominal bloating, distension, dysphagia, GI blood lossDiet h/oAppetite/energy level/ weight lossJoint pains/ Other symptoms
19. Examination findingsMouth ulcersPallor, JaundiceAbdominal examination – Tenderness, mass, hepatosplenomegalyPerianal examination
20. InvestigationsAs clinically indicatedBlood testsStool testsUSUrine
21. Differential diagnosisCoeliac diseaseIBDConstipationGORDLactose intolerance
22. TreatmentTreat as clinically indicated Constipation GORD* Lactose intolerance Functional disorders
23. Treatment-Functional disordersEffective Reassurance (Visceral hypersensitivity)Parents respond by attention or distraction/no instructionEducation to parents – Lifestyle modifications (Distraction, exercise, diet, sleep)Going to school important – more distractiveUse common termsExplain overall favorable prognosisChild should be active participant
24. DietFiber supplement/Lactose free - No evidence Fodmap – Some evidence in IBS (hydrogen product – methane production)Probiotics
25. Medications Buscopan (hyoscine)- antimuscarinic – reduce intestinal motility Mebevarine – better for short term –direct action on smooth muscle (No significance if used >8 weeks) Peppermint oil capsule – direct action on smooth muscle –IBS Antidepressants – TCA Improvement in global well being likely from central effect Lack of additional pain improvement argues its use
26. Psychology treatmentHypnotherapyCBTYogaPsychology counselling
27.
28. Take home messagesThink about coeliac disease and IBDDo coeliac screen Think about functional abdominal disorders