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Functional Gastrointestinal Disorders
- 1. FUNCTIONAL PAIN ABDOMEN Pain-Predominant Functional Gastrointestinal Disorders (FGIDs) Dr Pallav Singhal Moderator: Dr Archana Ma’am
- 2. WHAT IS..? RAP: Recurrent Abdominal Pain CAP: Chronic Abdominal Pain FAP: FunctionalAbdominal Pain
- 3. RECURRENTABDOMINAL PAIN 3 main features: Three or more episodes of pain over at least three months Interfere with normal activities Represents a description and not a diagnosis
- 4. CHRONIC ABDOMINAL PAIN Intermittent or constant abdominal pain for a minimum duration of 2 months. Causes: Organic 15 % Functional 70-80% Psychogenic <5 %
- 5. FUNCTIONAL GIT DISORDERS INTRODUCTION Prevalence remains between 10 and 30 % [1, 2] Functional gastrointestinal disorders (FGIDs) common all age groups Are Conditions related to GIT, cannot be attributed to structural or biochemical abnormalities(lacking objective evidence for organic pathology.) Diagnosed according to the symptom-based Rome criteria.
- 7. FGIDS IN N CHILD/ADOLESCENT
- 8. TIMELINE DEPICTINGTHE AGE AT WHICH FGIDS OCCUR
- 9. INFANT COLIC OldWessel et al.’s ‘rule of threes’ crying more than 3 h a day, for more than 3 days a week, for more than 3 weeks in a row New criteria includes prolonged, hard-to-soothe, and unexplained nature of the crying behavior. No evidence of infant failure to thrive, fever or illness
- 10. MANAGEMENT OF IC No consensus on the definition, diagnostic methods and management algorithms. Adequate breastfeeding Soothers and relaxing and distracting massages Pharmacotherapy If human milk cannot be supplied, it is recommended to replace it with casein hydrolysates Role of Semethicone..? Dicyclomine is C/I
- 12. Chronic (≥2 months) Abdominal pain No alarm findings Normal physical examination Stool sample negative for occult blood [7].
- 13. PATHOPHYSIOLOGY
- 14. VISCERAL HYPERSENSITIVITY INTHE CONTEXT OF PHYSIOLOGICAL PERISTALSIS..
- 16. FUNCTIONAL OR NON-ULCER DYSPEPSIA Abdominal Pain Associated with Symptoms of Dyspepsia 1 or more symptoms at least 4 days per month (atleast 2 months): 1. Postprandial fullness 2. Early satiation 3. Epigastric pain or burning not associated with defecation 4. Cannot be fully explained by another medical condition.
- 17. WITHIN FD,THE FOLLOWING SUBTYPES Postprandial distress syndrome Epigastric pain syndrome Pathophysiology : Hypotheses include abnormalities of gastric motor function
- 18. INDICATION OF UPPER GI ENDOSCOPY IN FD Family history of peptic ulcer or H pylori infection Older than 10 years of age Symptoms persist for >6 months Symptoms affect daily activities, including sleep Red flag symptoms Night Pain Pain radiating to back
- 19. DIFFERENTIAL Gastro-esophageal reflux disease Peptic ulcer disease (night-time waking) Helicobacter pylori infection Constipation Viral illness (dyspeptic symptoms may follow a viral illness)
- 20. TREATMENT Avoid NSAIDs, Foods aggravating symptoms. Acid blockade Prokinetics Antidepressant
- 21. IRRITABLE BOWEL SYNDROME Abdominal pain at least once a week for the past 2 months Has two out of three associated features: Onset associated with a change in form of stool Onset associated with a change in stool frequency Relieved with defecation Supportive symptoms- abnormal stool frequency or type, passage of mucus and bloating/distension. Exacerbation of symptoms with stressors No structural or metabolic abnormalities Pain interferes with normal activities
- 22. Subtypes reflecting the predominant stool pattern IBS with constipation IBS with diarrhea IBS with constipation and diarrhea Unspecified IBS
- 23. TREATMENT Probiotics Peppermint oil Elimination diet Behavioral treatment (optimizing symptom coping skills)
- 24. ABDOMINAL MIGRAINE Include all of the following occurring at least twice (for at least 6 months): 1. Paroxysmal abdominal pain lasting 1 hour or more (should be the most severe and distressing symptom) 2. Episodes separated by weeks to months. 3. Pain is incapacitating 4. Stereotypical pattern 5. Pain is associated with 2 or more of Anorexia/ Nausea/Vomiting/ Headache/ Photophobia/ Pallor
- 25. PATHOPHYSIOLOGY Common in Abdominal migraine, CVS, and migraine headache (episodic, self-limited, and stereotypical, and with symptom- free intervals) Similar triggers, Associated symptoms, Relieving factors Abdominal migraine and CVS can evolve into migraine headaches in adulthood.
- 26. TREATMENT oral Pizotifen Amitriptyline/ propranolol/ cyproheptadine.
- 27. FUNCTIONAL ABDOMINAL PAIN-NOS At least 4 times per month (2months) Episodic or continuous abdominal pain. About 35% to 38% of elementary school children report abdominal pain weekly, Only 1/3rd meet Rome criteria of any FAPD
- 28. APPROACH HISTORY Pain (site, intensity, character, timing, relationship to food intake, aggravating or relieving factors Headaches frequently associated. Nausea Hallmark of FAP is School absenteeism Rarely remain in bed instead lying on the couch watching television Pain may delay the onset of sleep but seldom awakens them
- 29. SITE OF PAIN 2,4,8,9 are common sites of FAP Hepatobiliary Renal Appendicular
- 30. PREDOMINANT SYMPTOMWITH PAIN Site Epigastric Periumbilical Lower Abdomen(LLQ) Associated Symptoms Dyspepsia Isolated Paroxysmal periumbilical pain Altered bowel habits
- 31. DIFFERENTIALS OF EPIGASTRIC PAIN Functional 75% Functional dyspepsia. Aerophagia Organic 25% GERD PUD/ H pylori disease Pancreatitis. Biliary disease. Parasitic infestation
- 32. DIFFERENTIALS OF PAIN PERIUMBILICAL Functional >85% Isolated paroxysmal periumbilical pain(Functional abdominal pain) Abdominal Migraine Organic 5-10% Koch’s abdomen. IBD Malrotation. Adhesions Lymphoma Renal colic
- 33. DIFFERENTIALS OF LOWER ABDOMINAL PAIN Functional(75%) IBS Habitual(Functional) constipation Organic(25%) IBD Koch’s abdomen. Food Allergies. Short Bowel syndrome. Malabsorption. Lactose intolerance
- 34. ALARM FEATURES Family history of inflammatory bowel disease, celiac disease, or peptic ulcer disease Persistent right upper or right lower quadrant pain Dysphagia Odynophagia Persistent vomiting Gastrointestinal blood loss Oral aphthous ulcers Skin changes
- 35. …ALARM FEATURES Chronic Diarrhoea, Nocturnal diarrhoea Arthritis Perirectal disease Weight loss Deceleration of linear growth Delayed puberty Unexplained fever Urinary Symptoms Back pain
- 36. …ALARM FEATURES Signs Significant pallor Icterus Abdominal tenderness, Mass abdomen Organomegaly Stool Occult Blood positive
- 37. EXAMINATION Prolonged, disabling symptoms who looks well and is thriving. Assessment of growth, anemia, clubbing, oral ulceration, and perianal disease.
- 38. INVESTIGATIONS Level I: CBC/peripheral smear Urine /Stool routine including OB. Xray Chest/Abdomen.(may not be necessary in all children with CAP US of abdomen CRP/ Fecal Calprotectin
- 39. INVESTIGATIONS Level II (If Red flag signs +): CRP/Blood sugar/amylase/lipase/SGPT,SGOT Screening for Celiac Disease Epigastric pain: UGI Endoscopy, Inv. H.pylori LLQ pain/altered bowel habits, bleeding PR: Colonoscopy Small bowel pathology: Barium studies/CECT abdomen. Hepatobiliary/pancreatic disease: CECT abdomen, MRCP.
- 40. • Majority of children were girls (n=62, 56.4%, n=110) • Most of them belonged to age group 6-12yrs (52.7%). • 28 (42.3%) children with FD had some abnormality • Rapid UreaseTest for H Pylori was positive in 30(51.7%) of children with FD, while only 1 in FAP NOS (p<0.001).
- 41. MANAGEMENT Goal- return to normal function (ie, rehabilitation) rather than complete elimination of pain Individualized Interventions Therapeutic relationship Patient education Behavior modification Improve pain tolerance and coping Avoidance of triggers Symptomatic management
- 42. PATIENT EDUCATION FAPDs are common Pain is real Could be triggered or exacerbated external factors Pain not life-threatening. Treatment focuses on return to normal activity despite discomfort Realistic Goals Return to school
- 43. BEHAVIOUR MODIFICATION Reinforcement Skills outside of the sick role (eg, athletic or artistic abilities) Improved coping
- 44. HOW A CHILD AND HIS/HER FAMILY COPES WITH PAIN INFLUENCES OUTCOMES OF FAPDS
- 45. MANAGEMENT OF SYMPTOMS Abdominal pain Probiotics (eg, Lactobacillus rhamnosus, Lactobacillus reuteri Water-soluble fiber (eg, psyllium/ispaghula husk), dose of 1.5 to 12.5 grams per day Peppermint oil Dyspepsia (Avoid NSAIDs, Foods aggravating symptoms, Acid blockada, Prokinetics, Antidepressant)
- 46. FOLLOW-UP Regular follow-up to Maintain the therapeutic relationship continued education and reassurance Monitor the response to intervention Monitor the development of alarm findings
- 47. PROGNOSIS 30 % – persist as adult 30-50 % - cured, mostly within in 2-6 weeks after diagnosis Remaining – some other form of pain Poor prognosis : Age < 5 years, male sex, pain prone family ( maternal anxiety) symptoms > 6 months, parents resistant to ‘non organic’ diagnosis Long term FU ( 5-7 years)- only 2 % develop organic disease
- 48. SUMMARY
- 50. ..AT LAST LETS ALSO DISCUSS FUNCTIONAL CONSTIPATION No included In ROME IV of FAP Common cause chronic Abd pain. Include 2 or more at least once per week for a minimum of 1 month (insufficient criteria for a diagnosis of irritable bowel syndrome): 2 or fewer defecations in the toilet per week. At least 1 episode of fecal incontinence per week History of retentive posturing or excessive volitional stool retention History of painful or hard bowel movements Presence of a large fecal mass in the rectum History of large diameter stools
- 51. ALARM FEATURES IN CONSTIPATION Passage of meconium >48 h in a term newborn Constipation starting in the first month of life Family history of Hirschsprung’s disease Blood in the stools in the absence of anal fissures Failure to thrive Severe abdominal distension Abnormal thyroid gland Abnormal position of the anus Absent anal or cremasteric reflex Decreased lower extremity strength/tone/reflex Tuft of hair on spine Bilious vomiting
- 52. MANAGEMENT Disimpaction: Polyethylene glycol (PEG) in a dose of 1.5 g/kg/ day for 3-4 days Maintenance (promote regular stooling and prevent reimpaction): lactulose (1-3 ml/kg/day) and PEG (0.8-1.0 g/kg/day) ex Movicol Pediatric 6.9 gm sachet
- 53. MCQ’S 1. Prevelance of FAP A. 2-5% B. 5-10% C. 10-30% D. <2%
- 54. 2. Organic causes account for ………% of FAPD A. 10% B. 15% C. 30% D. <2%
- 55. 3. Latest Rome Criteria is: A. ROME IV (2016) B. ROMEV (2018) C. ROME III (2010) D. ROMEVI (2019)
- 56. 4. Correctly match the following according to ROME IV A. H2a I. IBS B. H2b II. Abdominal Migraine C. H3c III. FD D. H3d IV. FAD-NOS
- 57. 5.Wessel et al’s rule of threes was used for diagnosis of A. IBS B. FD C. IC D. Rumination
- 58. 6. Which is false regarding FAP A. Chronic Pain abdomen ≥2months B. No anatomic defect C. Stool positive for occult blood D. Prevelance 10-30%
- 59. 7.Precentage of children diagnosed as FAP which are cured, mostly within in 2-6 weeks after diagnosis..? A. 2-5% B. 5-10% C. 10-30% D. 30-50%
Editor's Notes
- Biopsychosocial model proposes that the pain is the child’s response to biological factors, governed by an interaction between the child’s temperament and the family and school environments. The Rome criteria for FGIDs were first established in 1990, and these were only applicable in adults. In 1999, with the launch of the Rome II criteria, criteria were established for FGIDs in children. Need of rome: t there are no biochemical markers or structural abnormalities that can be used to objectively diagnose or monitor progression of these disorders. Diagnoses are based on medical history and physical examination. It is essential that these symptom-based diagnostic criteria are accurate, clear, and unambiguous. Uniform diagnostic criteria are also necessary to conduct reliable, reproducible research on the epidemiology, pathophysiology and management of FGIDs in children.
- divided into three main groups: functional nausea and vomiting disorders, functional abdominal pain disorders and functional defecation disorders. diagnosis can only be made if ‘after appropriate medical evaluation, the symptoms cannot be attributed to another medical condition.’ This wording substitutes the previous statement that there had to be ‘absence of inflammatory, anatomic, metabolic, or neoplastic process that explains the subject’s symptoms.’
- New criteria, now focused on symptoms shown to cause distress in parents, i.e. the
- training to parents on behaviors to respond to crying and feeding patterns for nursing mothers; this proved to be more effective for handling IC than hydrolyzed formulas. Breastfeeding provided on demand and completely emptying the mammary gland adequately balances the milk content and the percentage distribution of the macronutrients, Lactobacillus reuteri, because of their adequate safety spectrum and therapeutic properties. immunomodulatory effect on the intestines regulating the fermentation of carbohydrates, positively impacting the symptomatology.. dicyclomine hydrochloride is the only drug that improves the frequency and severity of IC compared to placebos in more than 53% of cases due to its anticholinergic activity. However, it has side effects such as apnea, syncope and dissociative seizures, pharmacological surfactants such as simethicone —whose function is to reduce the surface tension of gases— have not shown greater therapeutic effect than other drugs. There is insufficient evidence to opt for surfactants to treat IC A study(267infants) partially hydrolyzed with oligosacc(carbohydrates) > standard formula with simethicone…reduced colic episodes.. Lactase supplementation…. No adverse effects in any study.. Soy based milk….reduced crying time..but not recommended..thry can impact hormones in baby… Cohrane..acc to availavle evidence no current dietary modification.
- Functional Nausea include all of the following fulfilled for the last 2 months: nausea early in the morning, and observe that when they “sleep late,” that is, past the usual time when they would experience nausea
- One or more episodes of vomiting per week for minimum 2 months. patients with chronic nausea commonly report mild vomiting with varying frequency. The presence of severe vomiting in addition to nausea presents a different situation in which central nervous system disease, GI anatomic abnormalities (eg, malrotation), gastroparesis, and intestinal pseudo-obstruction should be excluded. . Biochemical testing may include measurement of serum electrolytes, calcium, cortisol, and thyroid hormone levels. Intestinal obstruction and motility disorders (eg, gastroparesis, intestinal pseudoobstruction) should be considered and excluded in the presence of recurrent vomiting.
- Cyclic vomiting syndrome 2 or more periods of intense, unremitting nausea and paroxysmal vomiting, lasting hours to days within a 6-month period. Episodes are separated by weeks to months with return to baseline health between episodes . If the predominant feature is abdominal pain, then abdominal migraine should be considered.
- Effortless repetitive regurgitation, reswallowing, and/or spitting within minutes of starting a meal define rumination. Rumination caused by increase in intragastric pressure- opening of the lower esophageal sphincter, leading to the return of gastric content into the esophagus Earlier called ‘adolescent’ rumination syndrome. Now…not…because children who are younger may also suffer from this condition. The elimination of “painless” from the description of the regurgitation is justified by the fact that often patients have another FAPD and by the fact that the act of regurgitation is often triggered by a sensation of discomfort (pressure, pain, burning) in the abdomen that is relieved by regurgitation eliminated the requirement that symptoms do not respond to gastroesophageal reflux disease treatment, as it is not compulsory to treat for gastroesophageal reflux disease before diagnosis of rumination. Func nausea and vomiting….s also experience autonomic symptoms, such as sweating, dizziness, pallor, and tachycardia
- Abdominal distention due to intraluminal air which increases during the day air swallowing is excessive, gas fills the GI lumen, resulting in excessive belching, abdominal distention, flatus, and pain, presumably as a consequence of luminal distention
- Is considered a disorder of the brain-gut axis Visceral hypersensitivity may relate to the child’s psychological distress (anxiety, depression, impulsiveness, anger). Increased mucosal proinflammatory cytokines have been demonstrated and may be induced as a consequence of an acute infectious gastroenteritis (postinfectious IBS).. Impaired gastric accommodation, as determined by a decreased ability of the stomach to relax in response to a meal, has been demonstrated.23 Using electrogastrogram and gastric emptying studies Noxious early life events (eg, surgery) have been associated with a higher risk for developing FAPDs in childhood, Visceral Hypersensitivity in the Context of Physiological Peristalsis.. the contraction of the GI tract follows two patterns: rhythmic phasic contractions (continuously) and giant migrating contractions (several times a day). These peristaltic mechanisms should not generally cause pain. In patients with FAP, increased levels of substance P and other nociceptive transmitters lower the threshold for the child’s perception of pain .. causing visceral hypersensitivity and intestinal dysmotility [28]. The presence of physical and psychological stressors exacerbate this ‘visceral’ hypersensitivity
- (A) neither RPC rhythmic phasic contractions or GMC giant migrating contractions pierce the nociceptive threshold to cause pain. However, in a child with gastroenteritis (child B) the GMCs are of greater amplitude, breaking the nociceptive threshold, and causing pain. Infection can be a stressor for RAP, for example 1/3 of patients after a bout of gastroenteritis develop IBS, with evidence of mucosal lymphocytic infiltration on biopsies. In a child with FAP (child C): the visceral hypersensitivity has lowered the nociceptive threshold, causing a perception of pain. The aim iswill return to normal (D). RPC retrograde peristaltic contractions GMC giant migrating contractions.
- No relief from defecation or associated with change in bowel pattern (i.e. not IBS). Persistent or recurrent epigastric pain (ulcer like) Once a week for the past 2 months No relief from defecation in the new diagnostic criteria rome IV, the previous sentence ‘‘no evidence for organic disease’’ is replaced with the new ‘‘after appropriate medical evaluation the symptoms cannot be attributed to another medical condition’’ Pain interferes with normal activities
- Postprandial distress syndrome includes bothersome postprandial fullness or early satiation that prevents finishing a regular meal. Supportive features include upper abdominal bloating, postprandial nausea, or excessive belching pain or burning localized to the epigastrium. The pain is not generalized or localized to other abdominal or chest regions and is not relieved by defecation or passage of flatus. Supportive criteria can include (a) burning quality of the pain but without a retrosternal component and Hypotheses include abnormalities of gastric motor function, genetic predisposition. Impaired gastric accommodation, as determined by a decreased ability of the stomach to relax in response to a meal, has been demonstrated.23 Using electrogastrogram and gastric emptying studies
- (eg, caffeine containing, spicy, fatty) Acid blockade with histamine receptor antagonists and proton pump inhibitors can be offered for pain predominant symptoms omeprazole is superior to ranitidine, famotidine, and cimetidine. Nausea, bloating, and early satiety are more difficult to treat, and prokinetics such as cisapride and domperidone low-dose tricyclic antidepressant therapy with agents such as amitriptyline and imipramine is often considered in difficult cases
- description of exacerbation of symptoms with stressors (physical/psychological), for example with exams/performances family history of IBS is common In children with constipation, the pain does not resolve with resolution of the constipation (children in whom the pain resolves have functional constipation, not irritable bowel syndrome
- Greater the number of alarm symptoms present, the greater the likelihood of an organic disease Determination of fecal calprotectin is increasingly being utilized as a noninvasive screen for intestinal mucosal inflammation and appears to be superior to standard testing such as C-reactive protein
- elimination diet reducing intake of fermentable oligosaccharides, disaccharides, monosaccharides, and polyols.5
- Paroxysmal episodes of intense, acute periumbilical, midline or diffuse abdominal pain lasting 1 hour or more (should be the most severe and distressing symptom) 6. cannot be fully explained by another medical condition.
- t similar triggers (eg, stress, fatigue, and travel), associated symptoms (eg, anorexia, nausea, and vomiting), and relieving factors (eg, rest and sleep)
- A double-blind, placebo-controlled, crossover trial in 14 children found a prophylactic benefit of oral pizotifen, a drug with antiserotonin and antihistamine effects Prophylaxis with drugs such as amitriptyline,61 propranolol, and cyproheptadine62 has been successful.
- substitutes for the Rome III terms functional abdominal pain and FAPS continuous abdominal pain that does not occur solely during physiologic events (eg, eating, menses)
- best diagnostic tool is a detailed history both from the patient and the family Pain…mostly periumbilical, On morning wakening, improves in the afternoon and becomes severe again prior to bedtime suggests FAP) Night---GERD, Vomiting, gastrointestinal bleeding, weight loss, or diarrhoea suggest an organic cause. Parents may emphasise the severity of pain and associated pallor and lethargy in response to any suggestion of non-organic aetiology. conscientious, obsessional, sensitive, insecure, anxious, and prone to peer relationship problems.3.. Garralda ME J Child Psychol Psychiatry. 1996 Jan; 37(1):13-33. Inquire about parental illness, bereavement in close family members .. worry about their parents mortality, financial problems, unemployment, and marital disharmony. Parents often fail to appreciate that children as young as 6–8 years are aware of and worry about such issues.
- With predominant symptom of dyspepsia
- presence of ‘red flag signs’ such as vomiting, weight loss, poor height gain, fever, hematemesis bleeding per rectum, rash, and arthralgia may indicate an organic pain Persistent right upper ..hepatobiliary dis Rt lower quad..appendicitis. Dysphagia, Odynophagia –esophagitis, achalasia Persistent vomiting –CVS, PEPTIC ACID DIS, BOWEL OBSTRUCTION, HEPATOBILIARY DISEASE, Oral aphthous ulcers..ibd Skin changes (rash eczema)…ibd, celiac disease, food allergy
- Chronic Diarrhoea, Nocturnal diarrhoea (enteric infection, celiac disease, IBD, IMMUNE DEFICINCY Bloody diarrhoea..ibd Perirectal disease (skin tag, rash)..IBD Deceleration of linear growth…ibd, celiac disease Unexplained fever INFECTION, INFLAMM Urinary Symptoms recurrent uti Back pain…referred, chr pancreatitis
- Organomegaly: hepatomegaly..chr hepatitis, splenomegaly:splenic abscess/ infact, hemolytic dis, Abdominal tenderness…costovertebral tenderness…pyelonephritis
- Level I investigations sufficient if pain has the characteristics of functional pain described earlier, and no Red Flag signs or symptoms are present Complete blood counts including peripheral smear is a simple screening method to identify anemia, leukemia, lead poisoning and sickle cell disease. Urine and stool microscopy should always be included in the evaluation of CAP. Albuminuria, pyuria or hematuria will be a quick test to check problems of the urinary tract. The presence of ova and trophozoites in stool is diagnostic of parasitic infestation such as giardiasis and the presence of occult blood denotes mucosal lesions such as IBD or tuberculosis. When alarm or warning signs are present few more investigations are included. CRP an acute phase reactant is valuable in checking inflammatory disease. Blood sugar should be included in the protocol as diabetic ketoacidosis may present with abdominal pain. X-ray chest and Mantoux test are done for those children with a contact history or symptoms suggestive of Tuberculosis. X-ray abdomen is useful when there is a suspicion of renal or pancreatic disease. The presence of pancreatic calculi or calculi in the kidney, ureters or in the urinary bladder may clinch the cause of pain. Ultrasound (US) of abdomen is probably one of the most widely used non-invasive investigation in the work up for CAP and rates over other radiological investigations because of the absence of radiation. screening for celiac is recommended in places where the prevalence is high. Determination of fecal calprotectin is increasingly being utilized as a noninvasive screen for intestinal mucosal inflammation and appears to be superior to standard testing such as C-reactive protein
- Presence of alarm symptoms and the clinical suspicion of organic pain necessitate further workup. Persistent dyspepsia, vomiting and epigastric pain would merit an Upper GI Endoscopy (UGIE).C olonoscopy is done if there is bleeding PR
- management is individualized according to child and family behaviors, triggers, and symptoms. Therapeutic relationship : reassured by the clinician's acknowledging that the pain is real and has affected important activities in the child's or adolescent's life. The patient and family should be assured that the clinician will initiate a treatment plan and continue to follow up with the patient on a regular basis alliance may be strengthened by focusing on the shared goal of return to normal function – for both the child and family. The child's or adolescent's pain may have become a focal point of the family's life, creating stress for other members.
- FAPDs are common, occurring in approximately 10 to 20 percent of children. Pain is real, thought to be caused by a heightened sensitivity to the normal function of the stomach and bowel. Could be triggered or exacerbated external factors environmental (eg, gastrointestinal infection, medications) and psychosocial factors, including stress, anxiety, and social reinforcement (eg, attention, staying home from school.. responses to stress or anxiety include headaches, churning of the stomach before a test, and nausea when given bad news. Goals for management should be realistic (eg, maintenance of normal activities, increased tolerance of symptoms Return to school — A plan for return to school is crucial. School absenteeism adds to family stress and can interfere with the child or adolescent's school performance and social functioning
- Reinforcement of non pain (healthy or adaptive) behaviors and avoiding/stopping reinforcement of pain behaviors ..by :Providing attention to the pain (eg, asking about symptoms, by allowing the child to stay home from school or leave school, excusing the child from completing his or her homework, Allowing the child who stays home from school to watch television Praising/rewarding the child for attending school or extracurricular activities Coping is defined as voluntary efforts to regulate emotion, thought, behavior, physiology, and the environment in response to stressful events or circumstances .. Psychosocial therapies that may improve the ability to cope include relaxation( deep breathing exercises to be performed at least twice a da), distraction (Distraction techniques include conversation, games)
- The judgemnet of any pain episode experienced by a child may have significant impact on the child’s ability to cope effectively and accommodate to the pain, and consequently his or her normal function and development. In the presence of risk factors or when protective factors are less effective, the child may develop a maladaptive response leading to a state of chronic pain. From Walker et al
- Alterations to commensal bacterial populations have been implicated in dysmotility, visceral hypersensitivity, abnormal colonic fermentation, and immunologic activation. Probiotics may improve gastrointestinal symptoms by restoring the microbial balance in the gut through metabolic competition with pathogens, by enhancing the intestine's mucosal barrier, or by altering the intestinal inflammatory response probiotic be tried for four to six weeks before reassessment of symptoms of abdominal pain and/or abnormal bowel movements.. 2017 systematic review and meta-analysis of seven randomized trials that compared probiotics with placebo in 722 children with recurrent abdominal pain/functional gastrointestinal disorders (FGIDs) found moderate quality evidence that probiotics improve pain at zero to three months.. Rome iv The committee recommends that patients with constipation and abdominal pain initially be treated for constipation only. If abdominal pain resolves with constipation treatment, patient has functional constipation. If pain does not resolve with appropriate constipation treatment alone, the patient likely has IBS with constipation. I Fibre.. altered composition of stool and gas, and/or accelerated gastrointestinal transit … . A reasonable target for total dietary fiber intake is the child's age in years plus 5 to 10 grams per day. 2017 systematic review concluded that there was no evidence to support the use of fiber supplementation for treatment of recurrent abdominal pain/FGIDs in children peppermint oil is thought to decrease smooth muscle spasms in the gastrointestinal tract . A 2011 meta-analysis of randomized trials in patients >12 years of age concluded that peppermint oil was effective in the treatment of IBS
- whose diarrhea consists of ≥3 loose or watery stools per day for more than two weeks (which is an alarm symptom) require evaluation for organic disease