Chronic Abdominal Pain in the Adolescent: Is it Irritable Bowel Syndrome?
Brock J. Doubledee, D.O Pediatric Gastroenterology
Recurrent Abdominal Pain (RAP)
Is responsible for 2-4% of pediatric office visits. Affects 7-25% of school-aged children and adolescents.
Prevalence of RAP increases with increasing age into adolescence. Gender ratio is equal in early childhood but becomes female predominant in late childhood and adolescence.
Pace et al. World J Gastroenterol 2006; 12(24): 3874-3877
Red Flags in Pediatric Abdominal Pain
Persistent right upper or right lower quadrant pain Pain that wakes the child from sleep Dysphagia Arthritis Persistent vomiting Perirectal disease Gastrointestinal blood loss
Involuntary weight loss Nocturnal diarrhea Deceleration of linear growth Family history of inflammatory bowel disease, celiac disease, or peptic ulcer disease Delayed puberty Unexplained fever
Drossman D, Corazziari E, Spiller R, Talley N, Thompson W, Whitehead W, eds. Rome III. The Functional Gastrointestinal Disorders. 3rd ed. McLean, VA 2006
Testing
History Physical Lab
Stool Serum
Radiology Nuclear Medicine
Functional gastrointestinal disorders (FGIDs)
Functional dyspepsia Irritable bowel syndrome Abdominal migraine Childhood functional abdominal pain Childhood functional abdominal pain syndrome
Drossman D, Corazziari E, Spiller R, Talley N, Thompson W, Whitehead W, eds. Rome III. The Functional Gastrointestinal Disorders. 3rd ed. McLean, VA 2006
Functional Dyspepsia
Must include all of the following:
1.Persistent or recurrent pain or discomfort centered in the upper abdomen (above the umbilicus) 2.Not relieved by defecation or associated with the onset of a change in stool frequency or stool form (ie, not IBS) 3.No evidence of an inflammatory, anatomic, metabolic, or neoplastic process that explains the subject’s symptoms
Drossman D, Corazziari E, Spiller R, Talley N, Thompson W, Whitehead W, eds. Rome III. The Functional Gastrointestinal Disorders. 3rd ed. McLean, VA 2006
Abdominal Migraine
Must include all of the following:
1.Paroxysmal episodes of intense, acute periumbilical pain that lasts for 1 hour or more 2.Intervening periods of usual health lasting weeks to months 3.The pain interferes with normal activities 4.The pain is associated with 2 or more of the following:
5.No evidence of an inflammatory, anatomic, metabolic, or neoplastic process considered that explains the subject’s symptoms
a.Anorexia b.Nausea c.Vomiting d.Headache e.Photophobia f.Pallor
Drossman D, Corazziari E, Spiller R, Talley N, Thompson W, Whitehead W, eds. Rome III. The Functional Gastrointestinal Disorders. 3rd ed. McLean, VA 2006
Childhood Functional Abdominal Pain
Must include all of the following:
1. Episodic or continuous abdominal pain 2. Insufficient criteria for other FGIDs 3. No evidence of an inflammatory, anatomic, metabolic, or neoplastic process that explains the subject’s symptoms
Drossman D, Corazziari E, Spiller R, Talley N, Thompson W, Whitehead W, eds. Rome III. The Functional Gastrointestinal Disorders. 3rd ed. McLean, VA 2006
Childhood Functional Abdominal Pain Syndrome
Must include childhood functional abdominal pain at least 25% of the time and 1 or more of the following:
1. Some loss of daily functioning 2. Additional somatic symptoms such as headache, limb pain, or difficulty sleeping
Drossman D, Corazziari E, Spiller R, Talley N, Thompson W, Whitehead W, eds. Rome III. The Functional Gastrointestinal Disorders. 3rd ed. McLean, VA 2006
Irritable Bowel Syndrome
Must include all of the following:
1. Abdominal discomfort (an uncomfortable sensation not described as pain) or pain associated with 2 or more of the following at least 25% of the time:
a. Improved with defecation b. Onset associated with a change in frequency of stool c. Onset associated with a change in form (appearance) of stool
2. No evidence of an inflammatory, anatomic, metabolic, or neoplastic process that explains the subject’s symptoms
Drossman D, Corazziari E, Spiller R, Talley N, Thompson W, Whitehead W, eds. Rome III. The Functional Gastrointestinal Disorders. 3rd ed. McLean, VA 2006
The Bristol Stool Form
Seven categories defined Form depends upon colon transit time
Type 1 Type 2
Lumpier stools correlate with longer colon transit
Type 3
Type 4 Type 5 Type 6 Type 7
Often used in studies
Subjective
Categorical variable
Should not average results
Davies G et al. Gut 1986;27:164–9
Prevalence of IBS Across the World
Scandinavia IBS: 13%
UK IBS: 22% USA IBS: 9–20%
Australia IBS: 12% New Zealand IBS: 17%
Overlapping Upper GI Symptoms in Patients with IBS
Symptoms Number of symptoms Lower abdominal pain (%) Upper abdominal pain (%) Bloating (%) Indigestion (%) Nausea (%) Early satiety (%) Heartburn (%) IBS with constipation (n =76) 6.67 40.8 36.8 75.0 48.7 46.1 42.7 32.9 IBS with diarrhea (n =64) 4.62 24.4 24.4 40.9 36.4 47.7 25.0 40.9
Talley et al. Am J Gastroenterol 2003;98:2454–9
IBS Subtypes
Drossman D, Corazziari E, Spiller R, Talley N, Thompson W, Whitehead W, eds. Rome III. The Functional Gastrointestinal Disorders. 3rd ed. McLean, VA 2006
Conceptual mechanisms interacting in the development of FGIDs and IBS
Genes/ Environment
Disordered motility
Abnormal sensation
Camilleri et al. Aliment Pharmacol Ther 1997; 11: 3
Heritability of IBS and FGIDs: the evidence
IBS and FGID runs in families. Genetic?
2
1
Similar psychosocial factors may contribute to clustering in families?
3
1 Morris-Yates et al. Am J Gastroenterol 1998;93:1311–7 2 Levy et al. Gastroenterology 2001;121:799–804 3 Locke et al. Mayo Clin Proc 2000;75:907–12
Familial association in FGIDs
2.5 2.0
2.3 1.8 1.4 1.4 1.5
Odds ratio 1.5
1.0 0.5 0
GERD
Diarrhea
Constipation Dyspepsia
IBS
Locke et al. Mayo Clin Proc 2000;75:907-912
Evidence for Visceral Hypersensitivity in IBS
Decreased pain and discomfort thresholds to rectal balloon distension compared to controls1,2 Altered viscerosomatic referral areas. Increased intensity of sensations.
2 1,2
Increased responses in terms of arousal, emotion and perceived stress. 3
1 Munakata et al, Gastroenterology 1997; 122: 55 2 Mertz et al, Gastroenterology 1995; 109: 40 3 Mayer et al, Am J Med 1999; 107: 12S
Regional GI Tract Visceral Hypersensitivity in IBS
80 IBS Healthy controls 60
Patients (%)
40
20
0
Rectum
Colon
Ileum
Jejunum
Duodenum Esophagus
Trimble et al. Dig Dis Sci 1995;40:1607–13
Development of IBS After Infectious Diarrhea
109 3 months post discharge Acute gastroenteritis (hospitalized): No prior history of any bowel disorder Rectal biopsies 30 declined
94 completed
10 IBS
105.7* 15 withdrew
19 no IBS
83.2
(mean chronic inflammatory cells/hpf)
22 IBS (23%) Alternating 2 Diarrhea 18 Constipation 2
Gwee et al. Gut 1999;44:400–406
Common Pathophysiologic Mechanisms
Level of evidence IBS Visceral hypersensitivity Upper GI Motility Lower GI Motility Genetics Psychiatric co-morbidity Post infection Serotonin signaling abnormalities +++ + +++ ? + + + FGIDs +++ +++ + ? + + ?
Treatments
Unfortunately there are few treatments with any overwhelming success Based on symptoms some pharmacologic treatments may be effective in selected patients Psychological and behavioral interventions have shown varied success
IBS Drugs for Dominant Symptom
Symptom
Diarrhea
Drug
Loperamide
Dose
2–4 mg when necessary Maximum 12 g/d
Cholestyramine resin Alosetron
4 g with meal 0.5–1 mg bid (for severe IBS, women)
Constipation
Psyllium Methylcellulose Lactulose syrup 70% sorbitol Polyethylene glycol 3350 Tegaserod Magnesium hydroxide
3.4 g bid with meals, then adjust 2 g bid with meals, then adjust 10–20 g bid 15 mL bid 17 g in 8 oz water daily 6 mg bid 2–4 tbsp daily Start 25–50 mg hs, then adjust Begin small, increase as needed
Abdominal pain
Tricyclic antidepressants Selective serotonin reuptake inhibitors
Drossman D, Corazziari E, Spiller R, Talley N, Thompson W, Whitehead W, eds. Rome III. The Functional Gastrointestinal Disorders. 3rd ed. McLean, VA 2006