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Morning ReportJune 11, 2012
Holly Shillington, MD, PGY-2
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The Case12 year old female in GI clinic with her father
presents with abdominal pain for one year.
Started May 2011 with a stomach flu (vomitingand diarrhea x 1 week)
Afterwards, she still had occasional abdominalpain, especially prior to dance competitions.
No pain over the summer.
Pain started again in August with school.
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Location: periumbilical, but often diffuse.7-10/10 pain, squeezing. Missed 30days of school this year.Lasts for hours.2 x weekly dailyTylenol, defecation doesnt help. Dancecompetitions make it worse.No association with menses, specific
foods, or eating itself.Often associated with nausea.
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Stooling: Has soft stools once daily. Nostraining. No bloody stools. No change inconsistency or frequency of stool.
Diet: Eats a balanced diet, including fruitsand veggies.
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ROS
Denies weight loss, fever, mouth sores,perianal sores, rectal bleeding, rash,diarrhea, dysuria, vomiting, or any otherconcerns. No trauma.
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PMH: Broke left arm in 2008
Meds: noneNKDAIMMS: UTD
Family Hx: Adopted, bio-parents arehispanic.
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Pre-Teen Only Interview
Never been sexually active. LMP one
week ago.Denies verbal, physical, sexualabuse.
No other concerns from patient.
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Dads Concerns
Describes daughter as dramatic andfears that stress may have a role in her
pain.Patient was too anxious to sleep by herselfuntil one year ago, and now she needs to
listen to soothing music to fall asleep.
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Objective
VS: T 37, HR 85, RR 16, BP 110/70, wt 43kg
PE: sitting upright, pleasant. No acutedistress. Exam is normal.
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DDX of Chronic Abdominal Pain
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DDX of Chronic Abdominal PainGI
Malabsorption/Lactose IntoleranceCeliac diseaseConstipationInflammatory Bowel DiseaseRefluxEsophagitis or Gastritis (peptic,eosinophilic, infectious)Peptic ulcerBezoarFunctional dyspepsia
AerophagiaIrritable bowel syndromeFunctional abdominal pain
GYNPelvic Inflammatory DiseaseEctopic PregnancyOvarian Cyst
NeurologicAbdominal Migraine
InfectiousGiardiasisUTI
Parasitic infection
Thyroid Disease
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Labs
Normal TSH, T4, CMP, ESR, CBC, UA,Celiac panel
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Functional Abdominal Pain
Defined by the Rome III criteria:Functional Abdominal Pain: episodic or continuous pain at leastonce a week for at least 2 months without evidence of an
inflammatory, anatomic, metabolic, or neoplastic process andwith some loss of daily functioning. Insufficient criteria for otherdisoders:
Functional Dyspepsia: epigastric painIrritable Bowel Syndrome: Onset associated with change in stoolfrequency or consistency, improvement with defecation.
Abdominal Migraine: 2 or more episodes of intense periumbilicalpain associated with 2 or more symptoms (anorexia, nausea,vomiting, headache, photophobia, pallor) in the past 12 months,separated by a symptom free period.
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Functional Abdominal Pain
Proposed MechanismAn earlier event (infectious, allergic,
inflammatory, tramatic, emotional) results insensitization of the GI tract leading toabnormal sensation and motor reactivity inresponse to normal stimuli (a meal, gutdistension) or psychologically stressful stimuli.Visceral Hyperalgesia
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Functional Abdominal Pain
Red Flags that may indicate an organic cause for chronicabdominal pain:
Dysphagia
VomitingWeight loss, fever, rash, mouth sores, joint painFMHx of IBD, celiac dz, or peptic ulcers.Impaired growthDelayed pubertyRebound, guarding, abd distension, abd mass, HSMPerianal dz (tags, fissures, fistulas)Blood in stool
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Functional Abdominal Pain
Work Up:If no red flags on a complete history and
physical, stool testing for occult blood isusually sufficient to exclude organicpathology.Additional testing should be guided by historyand exam.
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Functional Abdominal Pain
Treatment:Reassurance: Explain visceral hyperalgesia.
Can compare abd pain to headache as anailment that is commonly experienced and notusually 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 bevery effective in reducing chronic abd pain
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Functional Abdominal Pain
Treatment, cont:Peppermint Oil: Helpful! gut analgesic
Pills, tea, Altoids, Peppermint Patties.Cyproheptadine: Appetitie stimulant. Shown to beeffective in a double-blinded randomized placebo-controlled trial (Sadeghian, et al.)
Probiotics: Lactobacillus has found to be helpful.Psychological treatments: cognitive-behavioralstrategies, hypnotherapy, guided imagery, etc.
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Functional Abdominal Pain
Treatment goal is to decrease pain andreturn child to normal level of functioning.
Completely abolishing pain is not theexpected outcome, or even the goal. Thisshould be explained to parents andpatient.
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Case Wrap Up
Levsin 0.125 mg SL q 6 prn crampingIf needing Levsin more than a few times a week,may consider starting amitryptiline.Melatonin 3 mg qHS for sleep and to decreasevisceral hyperalgesia.Must go to school, despite pain.Counseling for coping strategies and relaxationtechniquesFollow up in 4 months
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References
Almadhoun, O. (2012). Managing Chronic AbdominalPain in Children. Contemporary Pediatrics . Vol. 29, No.3, 18-23.
Evaluation of the child and adolescent with chronicabdominal pain Up To Date . 7 June 2012Management of the child and adolescent with chronicabdominal pain Up To Date . 7 June 2012.Sadeghian, et al. Cyproheptadine for the treatment of
functional abdominal pain in childhood: a double-blindedrandomized placebo-controlled trial. Minerva Pediatr .2008;60(6):1367-1374.