Morning Report June 11, 2012

Holly Shillington, MD, PGY-2

The Case
12 year old female in GI clinic with her father presents with abdominal pain for one year.

Started May 2011 with a stomach flu (vomiting and diarrhea x 1 week) Afterwards, she still had occasional abdominal pain, especially prior to dance competitions. No pain over the summer. Pain started again in August with school.

Location: periumbilical, but often diffuse. 7-10/10 pain, squeezing. Missed 30 days of school this year. Lasts for hours. 2 x weekly daily Tylenol, defecation doesnt help. Dance competitions make it worse. No association with menses, specific foods, or eating itself. Often associated with nausea.

Stooling: Has soft stools once daily. No straining. No bloody stools. No change in consistency or frequency of stool.
Diet: Eats a balanced diet, including fruits and veggies.

ROS
Denies weight loss, fever, mouth sores, perianal sores, rectal bleeding, rash, diarrhea, dysuria, vomiting, or any other concerns. No trauma.

PMH: Broke left arm in 2008 Meds: none NKDA IMMS: UTD Family Hx: Adopted, bio-parents are hispanic.

Pre-Teen Only Interview

Never

been sexually active. LMP one week ago. Denies verbal, physical, sexual abuse. No other concerns from patient.

Dads Concerns
Describes daughter as dramatic and fears that stress may have a role in her pain. Patient was too anxious to sleep by herself until one year ago, and now she needs to listen to soothing music to fall asleep.

Objective

VS: T 37, HR 85, RR 16, BP 110/70, wt 43 kg

PE: sitting upright, pleasant. No acute distress. Exam is normal.

DDX of Chronic Abdominal Pain

DDX of Chronic Abdominal Pain

GI

Malabsorption/Lactose Intolerance Celiac disease Constipation Inflammatory Bowel Disease Reflux Esophagitis or Gastritis (peptic, eosinophilic, infectious) Peptic ulcer Bezoar Functional dyspepsia Aerophagia Irritable bowel syndrome Functional abdominal pain

GYN Pelvic Inflammatory Disease Ectopic Pregnancy Ovarian Cyst

Neurologic Abdominal Migraine Infectious Giardiasis UTI Parasitic infection Thyroid Disease

Labs

Normal TSH, T4, CMP, ESR, CBC, UA, Celiac panel

Functional Abdominal Pain

Defined by the Rome III criteria:

Functional Abdominal Pain: episodic or continuous pain at least once a week for at least 2 months without evidence of an inflammatory, anatomic, metabolic, or neoplastic process and with some loss of daily functioning. Insufficient criteria for other disoders:

Functional Dyspepsia: epigastric pain Irritable Bowel Syndrome: Onset associated with change in stool frequency or consistency, improvement with defecation. Abdominal Migraine: 2 or more episodes of intense periumbilical pain associated with 2 or more symptoms (anorexia, nausea, vomiting, headache, photophobia, pallor) in the past 12 months, separated by a symptom free period.

Functional Abdominal Pain

Proposed Mechanism
An

earlier event (infectious, allergic, inflammatory, tramatic, emotional) results in sensitization of the GI tract leading to abnormal sensation and motor reactivity in response to normal stimuli (a meal, gut distension) or psychologically stressful stimuli. Visceral Hyperalgesia

Functional Abdominal Pain

Red Flags that may indicate an organic cause for chronic abdominal pain:

Dysphagia Vomiting Weight loss, fever, rash, mouth sores, joint pain FMHx of IBD, celiac dz, or peptic ulcers. Impaired growth Delayed puberty Rebound, guarding, abd distension, abd mass, HSM Perianal dz (tags, fissures, fistulas) Blood in stool

Functional Abdominal Pain

Work Up:
If

no red flags on a complete history and physical, stool testing for occult blood is usually sufficient to exclude organic pathology. Additional testing should be guided by history and exam.

Functional Abdominal Pain

Treatment:
Reassurance:

Explain visceral hyperalgesia. Can compare abd pain to headache as an ailment that is commonly experienced and not usually associated with serious dz. Diet: Lack of evidence for high-fiber or lactose-free diets for children with FAP. Antispasmodics: (ex. Levsin) Not shown to be very effective in reducing chronic abd pain

Functional Abdominal Pain

Treatment, cont:
Peppermint

Oil: Helpful! gut analgesic

Pills, tea, Altoids, Peppermint Patties.

Cyproheptadine:

Appetitie stimulant. Shown to be effective in a double-blinded randomized placebocontrolled trial (Sadeghian, et al.) Probiotics: Lactobacillus has found to be helpful. Psychological treatments: cognitive-behavioral strategies, hypnotherapy, guided imagery, etc.

Functional Abdominal Pain

Treatment goal is to decrease pain and return child to normal level of functioning.
Completely abolishing pain is not the expected outcome, or even the goal. This should be explained to parents and patient.

Case Wrap Up

Levsin 0.125 mg SL q 6 prn cramping If needing Levsin more than a few times a week, may consider starting amitryptiline. Melatonin 3 mg qHS for sleep and to decrease visceral hyperalgesia. Must go to school, despite pain. Counseling for coping strategies and relaxation techniques Follow up in 4 months

References

Almadhoun, O. (2012). Managing Chronic Abdominal Pain in Children. Contemporary Pediatrics. Vol. 29, No. 3, 18-23. Evaluation of the child and adolescent with chronic abdominal pain Up To Date. 7 June 2012 Management of the child and adolescent with chronic abdominal pain Up To Date. 7 June 2012. Sadeghian, et al. Cyproheptadine for the treatment of functional abdominal pain in childhood: a double-blinded randomized placebo-controlled trial. Minerva Pediatr. 2008;60(6):1367-1374.