Abdominal Pain

1. Abdominal Pain This slide set provides an overview of pediatric gastroesophageal reflux (GER). Information on the epidemiology, pathophysiology, and clinical manifestations of gastroesophageal reflux disease (GERD) are reviewed. Recommendations for the evaluation and management of infants and children with GER are presented, based on the clinical practice guidelines of the North American Society for Pediatric Gastroenterology, Hepatology and Nutrition (NASPGHAN) [1]. The NASPGHAN guidelines, which are evidence based, were published in 2001 in the Journal of Pediatric Gastroenterology and Nutrition and are also available on www.naspghan.org (click on �Medical Professionals� and then �Position Papers�). Reference 1. Rudolph C, Mazur LJ, Liptak GS, Baker R, Boyle JT, Colletti RB, Gerson W, Werlin S. Evaluation and treatment of gastroesophageal reflux in infants and children: recommendations of the North American Society for Pediatric Gastroenterology, Hepatology and Nutrition. J Pediatr Gastroenterol Nutr 2001;32:S1-31.This slide set provides an overview of pediatric gastroesophageal reflux (GER). Information on the epidemiology, pathophysiology, and clinical manifestations of gastroesophageal reflux disease (GERD) are reviewed. Recommendations for the evaluation and management of infants and children with GER are presented, based on the clinical practice guidelines of the North American Society for Pediatric Gastroenterology, Hepatology and Nutrition (NASPGHAN) [1]. The NASPGHAN guidelines, which are evidence based, were published in 2001 in the Journal of Pediatric Gastroenterology and Nutrition and are also available on www.naspghan.org (click on �Medical Professionals� and then �Position Papers�). Reference 1. Rudolph C, Mazur LJ, Liptak GS, Baker R, Boyle JT, Colletti RB, Gerson W, Werlin S. Evaluation and treatment of gastroesophageal reflux in infants and children: recommendations of the North American Society for Pediatric Gastroenterology, Hepatology and Nutrition. J Pediatr Gastroenterol Nutr 2001;32:S1-31.

2. 25-Jul-12 � M.Miqdady, M.D. 2 Abdominal Pain-A Practical Guide to Differential Diagnosis:Outline Causes (GI & non-GI) Acute Vs. Chronic Epigastric pain RUQ pain Mid to lower Abd. Pain RLQ pain Chronic & recurrent abdominal pain. C&RAP

3. 25-Jul-12 � M.Miqdady, M.D. 3 Abdominal Pain Common GI Associations Functional abdominal pain (non-organic) Gastroenteritis Constipation PUD: Gastritis, ulcer, GERD Lactose intolerance IBD Liver biliary diseases Parasitic infections Intussusception Surgical diseases: Appendicitis, Intestinal obstruction, Incarcerated hernia, volvulus (malrotation)

4. 25-Jul-12 � M.Miqdady, M.D. 4 Abdominal Pain Common non-GI Associations Lower respiratory infections Renal diseases (obstruction, infection) Urological diseases Gynecological diseases Sickle cell anemia Endocrine diseases HSP (Henoch Schonlein Purpura)

5. 25-Jul-12 � M.Miqdady, M.D. 5 Abdominal Pain Abdominal pain can be perceived by autonomic sensory pathways from: The abdominal viscera Somatic sensory pathways from the parietal peritoneum, Abdominal wall Retro peritoneal skeletal muscles Referred pain: due to local irritation with referral along the pathway of innervations of the organ.

6. 25-Jul-12 � M.Miqdady, M.D. 6 Abdominal Pain: Visceral pain In response to Stretching (distention) Inflammation Ischemia Dull or aching sensation, poorly localized

7. 25-Jul-12 � M.Miqdady, M.D. 7 Abdominal Pain: Visceral pain Epigastric: Foregut, liver, biliary tree, pancreas Periumbilical: Midgut Suprapubic: Hindgut, urinary tract, genitals Foregut: Distal esophagus till duodenum, Midgut: Jejunum till 2/3 T. colon, Hindgut: distal 1/3 T.colon till rectosigmoidForegut: Distal esophagus till duodenum, Midgut: Jejunum till 2/3 T. colon, Hindgut: distal 1/3 T.colon till rectosigmoid

8. 25-Jul-12 � M.Miqdady, M.D. 8 Abdominal Pain: Somatic pain Somatic pain is well localized and intense (often sharp) in character. An intra-abdominal process will manifest somatic pain if an inflammatory process affecting a viscus touches a somatic organ (ie, the anterior parietal peritoneum or abdominal wall). Associated with voluntary guarding, or involuntary rigidity.

9. 25-Jul-12 � M.Miqdady, M.D. 9 Abdominal Pain: Referred pain The classic example of referred abdominal pain is pneumonia. ( the shared central projections of the parietal pleura of the lung and the abdominal wall)

10. 25-Jul-12 � M.Miqdady, M.D. 10 Abdominal Pain All three types of pain may be modified by a child�s level of tolerance, development , psychogenic and environmental factors which may augment or inhibit the perception of pain.

11. 25-Jul-12 � M.Miqdady, M.D. 11 Abdominal Pain-A Practical Guide to Differential Diagnosis Acute pain (recent) Chronic & Recurrent Abdominal Pain (C&RAP)

12. 25-Jul-12 � M.Miqdady, M.D. 12 Organic: Epigastric Pain GERD Gastritis Ulcer disease H. pylori Pancreatitis

13. 25-Jul-12 � M.Miqdady, M.D. 13 GERD, Gastritis, Ulcer Pain is epigastric Regurgitation, retrosternal pain Pain after meals Awaken at night Vomiting Positive family history Recent viral infection Response to antacids, H2 blockers or PPI

14. 25-Jul-12 � M.Miqdady, M.D. 14 Diagnosis of GERD, Gastritis, Ulcer 24 hour pH probe Upper Endoscopy H. pylori IgG antibodies Urea breath test Trial on H2 blocker or PPI for 2-4 weeks

15. 25-Jul-12 � M.Miqdady, M.D. 15 Pancreatitis Pain is epigastric or mid abdomen Etiology � idiopathic, viral infection, trauma,, drugs, biliary tract disease, hyperlipidemeia Family history Jaundice Diagnosis: lipase/amylase, liver transaminases, U/S, CT, ERCP, MRCP

16. 25-Jul-12 � M.Miqdady, M.D. 16 Right Upper Quadrant Pain Liver Biliary tree

17. 25-Jul-12 � M.Miqdady, M.D. 17 Hepatitis Pain is RUQ Nausea, anorexia, vomiting May be anicteric RUQ tenderness, tender hepatomegaly Diagnosis Elevated liver transaminases Specific hepatitis antibodies (Hep A-E, EBV, CMV)

18. 25-Jul-12 � M.Miqdady, M.D. 18 Biliary Tract Disease Pain is RUQ/epigastric Increases for 10-20 minutes, lasts 1-2 hours Radiates to back or shoulder Risk factors - obesity, family history, short gut, TPN, hemolysis, CF, Crohn�s disease Diagnosis: lipase/amylase, Liver transaminases, U/S, CT, ERCP

19. 25-Jul-12 � M.Miqdady, M.D. 19 Mid to Lower Abdominal Pain Constipation Parasitic infection Lactose intolerance Air swallowing Urinary tract obstruction

20. 25-Jul-12 � M.Miqdady, M.D. 20 Constipation Pain is lower or moves History may be poor You have to ask specifically about bowel movements Abdominal/rectal exam - variable findings Therapeutic trial

21. 25-Jul-12 � M.Miqdady, M.D. 21 Parasitic Infection Pain is mid to lower abdomen Common causes - Giardia, Cryptosporidium. Anorexia, bloating, diarrhea Diagnosis: Stool O&P, Giardia antigen

22. 25-Jul-12 � M.Miqdady, M.D. 22 Lactose Intolerance The second most common cause of abdominal pain in childhood. In affected children lactase activity is genetically programmed to begin to decrease at 4-6 yr of age. If milk drinking continues at a constant rate, the enzyme activity will not be sufficient to hydrolyze the entire amount of lactose ingested.If milk drinking continues at a constant rate, the enzyme activity will not be sufficient to hydrolyze the entire amount of lactose ingested.

23. 25-Jul-12 � M.Miqdady, M.D. 23 Lactose Intolerance As a result, some lactose spills into the distal small bowel and colon, where it is fermented by bacteria Gases such as hydrogen and carbon dioxide are produced. Gas production causes intestinal dilatation & pain.

24. 25-Jul-12 � M.Miqdady, M.D. 24 Lactose Intolerance Diarrhea results from the osmotic effect of the unabsorbed sugar and its fermentative products. Early in the development of lactose intolerance, pain may be the sole symptom.

25. 25-Jul-12 � M.Miqdady, M.D. 25 Lactose Intolerance Pain is lower to mid abdomen Occurs 1-3 hours after ingesting milk or ice cream Diarrhea less common in older children

26. 25-Jul-12 � M.Miqdady, M.D. 26 Lactose Intolerance: Diagnosis Diagnosis Elimination diet for 2 weeks If the abdominal pain disappears, the diagnosis can be suspected. It should be confirmed by giving the child lactose again and observing for exacerbation of symptoms.

27. 25-Jul-12 � M.Miqdady, M.D. 27 Lactose Intolerance: Diagnosis This cycle should be completed twice to ensure that lactose intolerance is present.

28. 25-Jul-12 � M.Miqdady, M.D. 28 Lactose Intolerance: Management Lactose intolerance is a dose-related phenomenon, most children can tolerate some lactose-containing foods. Low-lactose dairy products (e.g., cheese) should be reintroduced as tolerated. Low-lactose dairy products (e.g., cheese) should be reintroduced as tolerated, which would preclude the need for calcium supplementation. Low-lactose dairy products (e.g., cheese) should be reintroduced as tolerated, which would preclude the need for calcium supplementation.

29. 25-Jul-12 � M.Miqdady, M.D. 29 Urinary Tract Disease Pain is periumbilical, flank, lower abdomen Signs of infection Fever Vomiting Urgency, bed wetting UPJ obstruction Diagnosis: urinalysis, urine culture, U/S

30. 25-Jul-12 � M.Miqdady, M.D. 30 Right Lower Quadrant Pain Appendicitis Mesenteric lymphadenitis Crohn�s disease Gynecological problems

31. 25-Jul-12 � M.Miqdady, M.D. 31 Mesenteric Adenitis Pain is RLQ Following viral respiratory illness, Yersinia enterocolitica Fever, vomiting, diarrhea Time course 2-4 weeks Diagnosis by exclusion: CBC, urine, stool studies, U/S, barium contrast studies

32. 25-Jul-12 � M.Miqdady, M.D. 32 Gynecologic Pain Pain is RLQ or LLQ Diagnosis: GYN evaluation and pelvic U/S Dysmenorrhea Endometriosis Benign ovarian cysts do not cause pain Dysmenorrhea Endometriosis Benign ovarian cysts do not cause pain

33. 25-Jul-12 � M.Miqdady, M.D. 33 Crohn�s Disease Pain may be any location, but RLQ common Oral ulcers, arthritis, growth failure, fever, perianal disease Family history Diagnosis: CBC, sed rate, upper GI/small bowel series, Endoscopy

34. 25-Jul-12 � M.Miqdady, M.D. 34 Musculoskeletal Pain Engaged in intensive exercise training programs, history of new exercise, injury These exercises result in strained muscles and chronic myositis of specific muscle bundles. The pain usually is described as sharp or knifelike Triggered by various activities or body positions.

35. 25-Jul-12 � M.Miqdady, M.D. 35 Musculoskeletal Pain It is usually located at the insertion of the rectus or oblique muscles into the costal margin (upper or mid abdomen, lower chest) or iliac crest. Palpating along these insertions with a fair degree of pressure may reproduces the pain and establishes the diagnosis. Rectus abdominus stretch may also reveal pain Rectus abdominus stretch may also reveal pain

36. 25-Jul-12 � M.Miqdady, M.D. 36 Musculoskeletal Pain If the abdominal muscles are tightened during the physical examination and the pain still is reproduced by palpation, the origin undoubtedly is musculoskeletal.

37. 25-Jul-12 � M.Miqdady, M.D. 37 C&RAP J. Apley: Definition of RAP Intermittent abdominal pain in children between the ages of 4 and 16 years that persists more than three months and affects normal activity (The Child With Abdominal Pains. London, 1975, Blackwell Scientific)

38. 25-Jul-12 � M.Miqdady, M.D. 38 Chronic &Recurrent Abdominal Pain (C&RAP) 10-15% of school children. Most common age is 5-14yr (school age) 5 - 6 years of age both sexes affected equally After this age, incidence greater in girls Organic cause in 10%. Often disease of child & family.

39. 25-Jul-12 � M.Miqdady, M.D. 39 Chronic &Recurrent Abdominal Pain (C&RAP) Functional pain is the most common cause of C&RAP

40. 25-Jul-12 � M.Miqdady, M.D. 40 C&RAPClinical manifestations Location: peri-umbilical. Gradual onset, crampy, daily or several times a week, variable severity. Interferes with activity. Normal growth. Rarely awakened at night.

41. 25-Jul-12 � M.Miqdady, M.D. 41 C&RAPClinical manifestations Physical Exam Abdominal tenderness is common, but mild. No guarding or rebound. Rectal exam may reveal pellet like stools.

42. 25-Jul-12 � M.Miqdady, M.D. 42 C&RAP Psychological Factors Primary or adaptive. Children may be overly sensitive / insecure. Often positive family history of IBS. Specific stress factors e.g death, marital discord, divorce, changing school.

43. 25-Jul-12 � M.Miqdady, M.D. 43 C&RAP:Work-Up CBC, ESR Amylase, lipase Guaiac stool O&P, Giardia Ag U/A, U Cx Lactose hydrogen breath test. Imaging Endoscopy

44. 25-Jul-12 � M.Miqdady, M.D. 44 C&RAP: Red flags Under 4 yrs of age. Pain away from peri-umbilical area. Weight loss, growth failure Bilious emesis (contains biliary fluids, green) Fever Awakened at night. Perianal disease Anemia ?sedimentation rate Occult blood in stool

45. 25-Jul-12 � M.Miqdady, M.D. 45 C&RAP Management Primary objective is to return to normal activities. The Dx of functional pain is a positive Dx. Reassure the child and family that pain is real and abdominal in origin. Explain pathophysiology. Introduce the idea at the first visit. F\U visits is necessary.

46. 25-Jul-12 � M.Miqdady, M.D. 46 C&RAP Management The child must attend school or seen by their physician. A visit to the school nurse should be allowed, but not to be send home unless �truly� sick, e.g fever, vomiting. Medications do not help symptoms. If the pain is severe acetaminophen may be used Antimotility agents usually are ineffective. High fiber diet may be helpful Psychological help to cope with pain.

47. 25-Jul-12 � M.Miqdady, M.D. 47 C&RAP Prognosis Many adults with IBS report that their symptoms began in childhood RAP and IBS may be the same syndrome at different developmental stages It has been observed that RAP and IBS often �run in the family� (Rasquin-Weber A. Gut 1999;45 Suppl 2:60) (Hyams JS. J Pediatr 1996;129:220)