Functional and organic diseases of Functional and organic diseases of digestive tract. Etiology, digestive tract. Etiology, pathogenesis, clinical features, pathogenesis, clinical features, diagnostics, treatment and diagnostics, treatment and prevention.prevention.

Lecturer: Sakharova I.Ye., MD, PhD

Chronic abdominal pain

Frog position in severe crampyabdominal pain

Is it a problem?• Prevalence 0.5%-19% in community• 13-17% middle/high school students

weekly pain• 2-4% of paediatric office visits• Considerable morbidity, missed school

days• Difficult, time-consuming and expensive

to manage because of diagnostic uncertainty, chronicity and increasing parental anxiety

What I’ll talk about• Definitions of functional abdominal

pain• Cause of functional abdominal pain• Differentiating organic vs functional

pain• Management of functional abdominal

pain

Rome III criteria, 2006

• Functional dyspepsia• Irritable bowel syndrome• Functional abdominal pain• Functional abdominal pain syndrome• Abdominal 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 dyspepsia• Persistent 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 wanes• 3 episodes in 3 months• Severe 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 defecation• Onset associated with a change in

frequency of stool• Onset associated with a change in form

(appearance) of stool

Functional abdominal pain• Episodic or continuous abdominal

pain• Insufficient 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 functioning• Additional somatic symptoms such as

headache, limb pain, or difficulty in sleeping

Abdominal migraine

• Paroxysmal episodes of intense, acute periumbilical pain that lasts for one or more hours

• Intervening periods of usual health lasting weeks to months

• The pain interferes with normal activities• The pain is associated with two or more of the

following:- Anorexia- Nausea- Vomiting- Headache- Photophobia- Pallor

Criteria fulfilled two or more times in the preceding 12 months

What causes it?• Biopsychosocial model• Visceral sensation, disturbances in GI

motility, hormonal changes, inflammation• Psychological factors• Family dynamics• Brain-gut axis• Sexual abuse – longer duration of symptoms• Parental anxiety in first year of life associated

with chronic abdo pain before age 6• GI problems in parents

Chronic abdo pain in OPDChronic 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 differentiate• Presence of alarm symptoms or

signs increases the probability of an organic disorder and justifies further tests

History and examinationHistory and examination

• Analysis of the pain• GI symptoms including bowel habit• Genitourinary symptoms• Effect on daily living• Family history – GI problems,

migraine

Alarm symptomsAlarm symptoms• Involuntary weight loss• Deceleration of linear growth• Gastrointestinal blood loss• Significant vomiting• Chronic severe diarrhoea• Unexplained fever• Persistent right upper or right lower

quadrant pain• Family history of inflammatory bowel

disease

Organic pain - differentialGI tract• Chronic constipation• Lactose intolerance• Parasite infection (Giardia)• Excess fructose/sorbitol ingestion• Crohns• Peptic ulcer• Reflux esophagitis• Meckels diverticulum• Recurrent intussusception• Hernia – internal, inguinal, abdominal wall• Chronic appendicitis

Organic pain - differential

Gallbladder and pancreas• Cholelithiasis• Choledochal cyst• Recurrent pancreatitisGenitourinary tract• UTI• Hydronephrosis• Urolithiasis

Miscellaneous causes• Abdominal epilepsy• Gilberts syndrome• Familial Mediterranean fever• Sickle cell crisis• Lead poisoning• HSP• Angioneurotic edema• Acute intermittent porphyria

Diagnostic ToolsDiagnostic Tools• Rome III Criteria• Essential 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 Nutrition

• Additional diagnostic evaluation is not required in children without alarm symptoms

• Testing 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).

TreatmentTreatment

• Deal with psychological factors• Educate the family (an important part of

treatment)• Focus on return to normal functioning

rather than on the complete disappearance of pain

• Best prescribe drugs judiciously as part of a multifaceted, individualised approach, to relieve symptoms and disability

TreatmentTreatment

• Medicines:• Acid lowering agents• Mucoprotective drugs• Motility regulators• Laxatives • Analgesics• Probiotics • Gas adsorbants• Dietary and life style change• Psychotherapy

• Pharmacologic treatment approach

A. AntacidsB. H2- receptor antagonistC. Proton pump inhibitorsD. SucralfateE. Prokinetics

Treatment of Acid-related disorders• H2-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 )

PrognosisPrognosis• Majority of children mild symptoms and managed

in primary care• Studies of prognosis are mainly in referred

patients• Systematic review• 29.1% of children had on-going abdo pain

(follow-up ranged 1-29 yrs)• May develop irritable bowel synd as adults• Risk 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