If you can't read please download the document
Upload
michon
View
33
Download
3
Embed Size (px)
DESCRIPTION
Functional and organic diseases of gastro-duodenal zone and intestine. 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 13-17% middle/high school students weekly pain - PowerPoint PPT Presentation
Citation preview
Functional and organic diseases of gastro-duodenal zone and intestine.Lecturer: Sakharova I.Ye., MD, PhD
Chronic abdominal pain
Frog position in severe crampyabdominal pain
Is it a problem?Prevalence 0.5%-19% in community13-17% middle/high school students weekly pain2-4% of paediatric office visitsConsiderable morbidity, missed school daysDifficult, time-consuming and expensive to manage because of diagnostic uncertainty, chronicity and increasing parental anxiety
What Ill talk aboutDefinitions of functional abdominal painCause of functional abdominal painDifferentiating organic vs functional painManagement of functional abdominal pain
Rome III criteria, 2006
Functional dyspepsiaIrritable bowel syndromeFunctional abdominal painFunctional abdominal pain syndromeAbdominal 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 dyspepsiaPersistent 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 wanes3 episodes in 3 monthsSevere 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 defecationOnset associated with a change in frequency of stoolOnset associated with a change in form (appearance) of stool
Functional abdominal painEpisodic or continuous abdominal painInsufficient 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 functioningAdditional somatic symptoms such as headache, limb pain, or difficulty in sleeping
Abdominal migraineParoxysmal episodes of intense, acute periumbilical pain that lasts for one or more hoursIntervening periods of usual health lasting weeks to monthsThe pain interferes with normal activitiesThe pain is associated with two or more of the following:- Anorexia- Nausea- Vomiting- Headache- Photophobia- PallorCriteria fulfilled two or more times in the preceding 12 months
What causes it?Biopsychosocial modelVisceral sensation, disturbances in GI motility, hormonal changes, inflammationPsychological factorsFamily dynamicsBrain-gut axisSexual abuse longer duration of symptomsParental anxiety in first year of life associated with chronic abdo pain before age 6GI problems in parents
Chronic 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 differentiatePresence of alarm symptoms or signs increases the probability of an organic disorder and justifies further tests
History and examination
Analysis of the painGI symptoms including bowel habitGenitourinary symptomsEffect on daily livingFamily history GI problems, migraine
Alarm symptoms
Involuntary weight lossDeceleration of linear growthGastrointestinal blood lossSignificant vomitingChronic severe diarrhoeaUnexplained feverPersistent right upper or right lower quadrant painFamily history of inflammatory bowel disease
Organic pain - differentialGI tractChronic constipationLactose intoleranceParasite infection (Giardia)Excess fructose/sorbitol ingestionCrohnsPeptic ulcerReflux esophagitisMeckels diverticulumRecurrent intussusceptionHernia internal, inguinal, abdominal wallChronic appendicitis
Organic pain - differentialGallbladder and pancreas CholelithiasisCholedochal cystRecurrent pancreatitisGenitourinary tract UTI Hydronephrosis Urolithiasis
Miscellaneous causesAbdominal epilepsyGilberts syndromeFamilial Mediterranean feverSickle cell crisisLead poisoningHSPAngioneurotic edemaAcute intermittent porphyria
Diagnostic Tools
Rome III CriteriaEssential 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 NutritionAdditional diagnostic evaluation is not required in children without alarm symptomsTesting 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).
Treatment
Deal with psychological factorsEducate the family (an important part of treatment)Focus on return to normal functioning rather than on the complete disappearance of painBest prescribe drugs judiciously as part of a multifaceted, individualised approach, to relieve symptoms and disability
Treatment
Medicines:Acid lowering agentsMucoprotective drugsMotility regulatorsLaxatives AnalgesicsProbiotics Gas adsorbantsDietary and life style changePsychotherapy
Pharmacologic treatment approachA. AntacidsB. H2- receptor antagonistC. Proton pump inhibitorsD. SucralfateE. Prokinetics
Treatment of Acid-related disordersH2-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 )
Prognosis
Majority of children mild symptoms and managed in primary careStudies of prognosis are mainly in referred patientsSystematic review 29.1% of children had on-going abdo pain (follow-up ranged 1-29 yrs)May develop irritable bowel synd as adultsRisk 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