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Functional and organic diseases of digestive tract. Etiology, pathogenesis, clinical features, diagnostics, treatment and prevention. Lecturer: Sakharova I.Ye., MD, PhD. Chronic abdominal pain. Frog position in severe crampy abdominal pain. Is it a problem? Prevalence 0.5%-19% in community - PowerPoint PPT Presentation
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Functional and organic diseases of Functional and organic diseases of digestive tract. Etiology, digestive tract. Etiology, pathogenesis, clinical features, pathogenesis, clinical features, diagnostics, treatment and diagnostics, treatment and prevention.prevention.
Lecturer: Sakharova I.Ye., MD, PhD
Chronic abdominal pain
Frog position in severe crampyabdominal pain
Is it a problem?• Prevalence 0.5%-19% in community• 13-17% middle/high school students
weekly pain• 2-4% of paediatric office visits• Considerable morbidity, missed school
days• Difficult, time-consuming and expensive
to manage because of diagnostic uncertainty, chronicity and increasing parental anxiety
What I’ll talk about• Definitions of functional abdominal
pain• Cause of functional abdominal pain• Differentiating organic vs functional
pain• Management of functional abdominal
pain
Rome III criteria, 2006
• Functional dyspepsia• Irritable bowel syndrome• Functional abdominal pain• Functional abdominal pain syndrome• Abdominal migraine
- No evidence of an inflammatory, anatomical, metabolic or neoplastic process
- Criteria fulfilled at least once a week for at least two months before diagnosis
Functional dyspepsia• Persistent or recurrent pain or
discomfort centred in the upper abdomen (above the umbilicus)
• Not relieved by defecation or associated with the onset of a change in stool frequency or stool form
Recurrent abdominal pain (Apley and Naish, 1958)
• Waxes and wanes• 3 episodes in 3 months• Severe enough to affect activities
Irritable bowel syndrome
Abdominal discomfort (uncomfortable sensation not described as pain) or pain associated with two or more of the following at least 25% of the time:
• Improved with defecation• Onset associated with a change in
frequency of stool• Onset associated with a change in form
(appearance) of stool
Functional abdominal pain• Episodic or continuous abdominal
pain• Insufficient criteria for other
functional gastrointestinal disorders
Functional abdominal pain syndrome
Must include functional abdominal pain at least 25% of the time and one or more of the following:
• Some loss of daily functioning• Additional somatic symptoms such as
headache, limb pain, or difficulty in sleeping
Abdominal migraine
• Paroxysmal episodes of intense, acute periumbilical pain that lasts for one or more hours
• Intervening periods of usual health lasting weeks to months
• The pain interferes with normal activities• The pain is associated with two or more of the
following:- Anorexia- Nausea- Vomiting- Headache- Photophobia- Pallor
Criteria fulfilled two or more times in the preceding 12 months
What causes it?• Biopsychosocial model• Visceral sensation, disturbances in GI
motility, hormonal changes, inflammation• Psychological factors• Family dynamics• Brain-gut axis• Sexual abuse – longer duration of symptoms• Parental anxiety in first year of life associated
with chronic abdo pain before age 6• GI problems in parents
Chronic abdo pain in OPDChronic abdo pain in OPD
• Organic vs functional pain
• Organic pain 5% in general population, 40% in paediatric gastroenterology OPD.
Organic vs functional pain
• No diagnostic tools to differentiate• Presence of alarm symptoms or
signs increases the probability of an organic disorder and justifies further tests
History and examinationHistory and examination
• Analysis of the pain• GI symptoms including bowel habit• Genitourinary symptoms• Effect on daily living• Family history – GI problems,
migraine
Alarm symptomsAlarm symptoms• Involuntary weight loss• Deceleration of linear growth• Gastrointestinal blood loss• Significant vomiting• Chronic severe diarrhoea• Unexplained fever• Persistent right upper or right lower
quadrant pain• Family history of inflammatory bowel
disease
Organic pain - differentialGI tract• Chronic constipation• Lactose intolerance• Parasite infection (Giardia)• Excess fructose/sorbitol ingestion• Crohns• Peptic ulcer• Reflux esophagitis• Meckels diverticulum• Recurrent intussusception• Hernia – internal, inguinal, abdominal wall• Chronic appendicitis
Organic pain - differential
Gallbladder and pancreas• Cholelithiasis• Choledochal cyst• Recurrent pancreatitisGenitourinary tract• UTI• Hydronephrosis• Urolithiasis
Miscellaneous causes• Abdominal epilepsy• Gilberts syndrome• Familial Mediterranean fever• Sickle cell crisis• Lead poisoning• HSP• Angioneurotic edema• Acute intermittent porphyria
Diagnostic ToolsDiagnostic Tools• Rome III Criteria• Essential Investigations : according to symptoms
e.g.- CBC- U A , Stool exam- LDG, Amylase ,lipase- Ultrasound- Barium study- Gastric emptying time test ,Intestinal transit
time ,Colonic transit time test- Hydrogen breath test: lactose ,lactulose,glucose- Endoscopy- Skin Prick test- Urea Breath test
Recommendation of North American Society for Pediatric
Gastroenterology, Hepatology and Nutrition
• Additional diagnostic evaluation is not required in children without alarm symptoms
• Testing may be carried out to reassure children and their parents
What are the predictive values of diagnostic tests?
• There is no evidence to suggest that the use of ultrasonographic examination of the abdomen and pelvis in the absence of alarm symptoms has a significant yield of organic disease (evidence quality C).
• There is little evidence to suggest that the use of endoscopy and biopsy in the absence of alarm symptoms has a significant yield of organic disease (evidence quality C).
• There is insufficient evidence to suggest that the use of esophageal pH monitoring in the absence of alarm symptoms has a significant yield of organic disease (evidence quality C).
TreatmentTreatment
• Deal with psychological factors• Educate the family (an important part of
treatment)• Focus on return to normal functioning
rather than on the complete disappearance of pain
• Best prescribe drugs judiciously as part of a multifaceted, individualised approach, to relieve symptoms and disability
TreatmentTreatment
• Medicines:• Acid lowering agents• Mucoprotective drugs• Motility regulators• Laxatives • Analgesics• Probiotics • Gas adsorbants• Dietary and life style change• Psychotherapy
• Pharmacologic treatment approach
A. AntacidsB. H2- receptor antagonistC. Proton pump inhibitorsD. SucralfateE. Prokinetics
Treatment of Acid-related disorders• H2-receptor Antagonists:Ranitidine (2-4 mg/kg/d up to 150 mg bid),Famotidine (1-1.2 mg/kg/d up to 20 mg bid)• PPI:Omeprazole (0.8 mg/kg/d;effective dose
range of 0.3-3.3 mg/kg/d),Lansoprazole (0.8 mg/kg/d)• Cytoprotective Agents:Sucralfate(40-80 mg/kg/d up to 1 g qid)Rabemipride ( 1 x 3 )
PrognosisPrognosis• Majority of children mild symptoms and managed
in primary care• Studies of prognosis are mainly in referred
patients• Systematic review• 29.1% of children had on-going abdo pain
(follow-up ranged 1-29 yrs)• May develop irritable bowel synd as adults• Risk of later emotional symptoms and psychiatric
disorders, particularly anxiety disorders
Success is not final, failure is not fatal. It is the courage tocontinue that counts.
Winston Churchill