The teenager with chronic abdominal pain; the teenager

with chronic symptomsOscar Taube, MD

Coordinator, Adolescent MedicineThe Children’s Hospital at Sinai

September 22, 2009

Case:17 y.o. female seen multiple times over past year at GPA:

Abdominal Pain: Bilateral lower abd. pain; intermittent; 4/5 pain; constipation alternating with diarrhea; BM’s do not relieve pain; Never sexually active.

Headaches: Mainly frontal; several times/week; not interfering with activity; no vision changes, no vomiting; doesn’t waken her from sleep; no URI complaints; no family hx. of migraine. Rx’d in past for sinusitis with amoxicillin- no relief of pain.

Case History, continued

• Backache: Chronic lower back pain, not increased with movement.

• Joint pains: Multiple complaints in past 6 months; mostly hip pains; no morning stiffness.

• Social Hx. Patient’s mother recently became pregnant; pregnancy with complications; mother on bed rest.

• Physical Exam: Abdominal Exam: Mild bilateral lower abd. tenderness; no HSM, masses, guarding, rigidity.Otherwise, PE wnl.

• Labs: CBC, CMP, amylase, lipase, urine culture, STD testing, connective tissue disease testing all negative.

Case History #2Adolescent Consultation Service

Patient• KJ, 19 year old white female w. several

months sharp stabbing upper abdominal pain; sometimes awakens her at night. Decreased appetite. No T, V, D, blood in stools.

• Previous work up: Endoscopy: small gastric/duodenal ulcers; some improvement with PPI’s. CBC/CMP/Amylase-Lipase all normal.

Case #2, continued

• 10 years complaint of joint pains

• Complaint of significant fatigue, even with adequate sleep.

• Several years of frequent headaches; difficulty with concentration, short term memory.

Case #2, continued

• Psychosocial: Raped at age 17, never reported. Admits to depressed, self deprecatory, suicidal ideation. Beck Depression Inventory score 48 (severe range= 29-63).

• Physical exam WNL except for + tenderness on 11 of 18 Fibromyalgia tender-point sites.

Why this combination of topics? (Chronic abd. pain/chronic

symptoms)• The two key symptoms in children and

adolescents with potential somatization disorders are:

• Abdominal pain

• Headaches.

• And chronic fatigue/muscle pain, too.

Epidemiology-Chronic Abdominal Pain

Hyams et. al. J. Pediatrics, 1996. Community based study of abd. pain complaints of suburban 7th, 10th graders:

Middle School (mean age 12.6 years)

13% pain at least weekly

32% pain > 5x. per year

24% pain severe enough to affect activities

Epidemiology, continued.

• Hyams study, continued.

• High school (Mean age 15.6 years)

• 17% at least weekly pain

• 37% pain > 5 x/year

• 17% pain severe enough to affect activities.

• Chronic abdominal pain accounts for 2-4% of all pediatric office visits.

All roads lead to….

Rome!

• Rome III Criteria for Functional Bowel Disorders Associated with Abdominal Pain or Discomfort in Children and Adolescents– Functional Dyspepsia– Irritable Bowel Syndrome– Childhood Functional Abdominal Pain and

Syndrome

Functional Dyspepsia

– A. Persistent/recurrent pain centered in upper abdomen, above umbilicus

– B. Pain not relieved by defecation, or assoc. w. onset of change in stool frequency or stool form (i.e., NOT IBS).

– C. No evidence of inflammatory, anatomic, neoplastic process to explain symptoms

– D. Above must be present at least 1x/week, for at least 2 months.

Irritable Bowel Syndrome

• Recurrent abdominal pain or discomfort at least 3 days per month for the past 3 months, associated with two or more of the following:

• Improvement with defecation

• Onset assoc. w. change in stool frequency

• Onset assoc. w. change in stool form (appearance).

Childhood Functional Abdominal Pain

• All of the following must be present at least once a week for at least 2 months before diagnosis

• A. Episodic or continuous abdominal pain• B. Insufficient criteria for other functional

GI disorders.• C. No evidence of an inflammatory,

anatomic, metabolic, or neoplastic process that explains the symptoms.

Childhood Functional Abdominal Pain Syndrome

• Must include Dx. of Childhood Functional Abdominal Pain at least 25% of the time and one or more of the following:

• A. Some loss of daily activity

• B.Additional Somatic symptoms such as headache, limb pain, or difficulty sleeping.

Differential Dx. Functional Bowel Disorders

• Functional Dyspepsia: GER; Peptic ulcer disease; Biliary tract obstruction/biliary colic; chronic pancreatitis; gastroparesis.

• IBS: Lactose intolerance; IBD; Celiac disease; Infection (e.g. giardiasis); constipation

.

Differential Dx. Functional Bowel Disorders, continued

• Gynecologic Differential Diagnosis:• Pelvic adhesions- Pelvic inflammatory

disease.• Mittelschmerz• Dysmenorrhea• Endometriosis• Ovarian mass.• UTI

Differential Dx. of Abdominal Pain by location

• RUQ:Hepatitis/cholecystitis/pneumonia

• RLQ: Appendicitis/IBD/Salpingitis

• Epigastric: Peptic ulcer disease/pancreatitis/pericarditis

• Periumbillical: Early appy/gastroenteritis

• LUQ: Splenic abcess/pancreatitis

• A very partial list!

Pathogenesis of Functional Bowel Disorders

1.Visceral hypersensitivity or hyperalgesia, with a decreased threshold for pain

2. Altered GI motility3. Psychological stress as a trigger/Genetic

factors/environmental factors4. Other “Medical” factors: Infectious

gastroenteritis as IBS trigger; abnormal serotonergic mechanisms; small intestinal bacterial overgrowth.

Approach to Functional GI Disturbances

• CAREFUL, COMPREHENSIVE HISTORY• (Timing, location, radiation, quality, severity, precipitants, relievers

of pain; associated complaints; diet; family hx., etc.)• CAREFUL, COMPREHENSIVE PHYSICAL EXAM. • (Oral exam; Pubertal stage; abd. Exam including location, rebound,

mass, psoas sign, mass, HSM, kidney size, perianal findings, rectal/pelvic exam, stool for occult blood).

• Plot weight, height on a serial growth chart• Pay attention to the “Red flags”- these point to signs of GI diseases

that may need more aggressive testing, more aggressive pharmacologic, surgical Rx, and most likely will need GI referral.

• Pay attention to the “Red flags” that point to somatiform diagnoses• Limited “General” lab work up: CBC/CRP/Urinalysis

Red Flag signs, sx’s suggestive of organic diseases

• Weight loss• Unexplained fevers• Pain radiating to the back/pain distant from

umbillicus• Bilious emesis• Hematemesis• Chronic diarrhea (>2 weeks)• GI Blood loss• Oral ulcers• Dysphagia

Red flags, continued

• Unexplained rashes• Nocturnal symptoms• Arthritis• Anemia/pallor• Delayed puberty• Deceleration of linear growth velocity• Family hx. of IBD, celiac, peptic ulcer disease• Hepatosplenomegaly• Perianal abnormalities

A brief approach to treatment of Functional Bowel disorders

• Functional Dyspepsia:

• Reassurance

• D/C dyspeptic meds (e.g. ibuprofen)

• D/C dyspeptic foods

• H2 receptor antagonists/PPI’s

• Trial of low dose tricyclic antide-

• pressants qHS.

Rx of Functional Bowel Disorders, continued

• IBS:• Reassurance; explanation• Dietary modifications- If diarrhea,

reduce sorbital, fructose, gas forming vegetables. If constipation: Increase water.

• PharmRx-if constipation: Osmotic laxatives, stool softener. Trial of antidepressants? Probiotics?Peppermint oil?

Biopsychosocial model: A continuum of hierachical systems

that are always interacting:• Biosphere• Society-Nation• Culture-subculture• Community• Family• Person• Nervous system• Organ-organ systems• Tissue• Cell• Organelle• Molecule

Biopsychosocial Model-How NOT to do it

• “First we’ll rule out organic problems, then we’ll explore psych issues.”

• “We’ll do some tests to see what is wrong.”• The clinician focuses her/his efforts-in dealing

with the adolescent who has chronic abdominal pain/chronic somatic symptoms-to determine if the teen is trying to: a. avoid something (primary gain); b. seek attention (secondary gain); c. feign symptoms for internal or external gain.

• “I believe that your pain is real.” (If you’re really sending the message “I don’t believe the pain is real.” )

Somatization

• “The central feature of somatiform disorders is that they present with features of an underlying medical condition, yet such a condition either is not found or does not fully account for the level of functional impairment.”

• -Silber T, Pao, M. Peds.in Review 8/03.

Pathogenesis: Genetic/Family Factors

• Genetics?: Somatoform disorders concordant in twins; cluster in families w. ADD/alcoholism.

• Learned Behavior: In many household, children’s somatic complaints more acceptable than expression of strong feelings.

• Family psychosocial factors: 1. If a family member has a chronic physical illness, +++somatic sx’s among children. (A model). 2.Somatisizing kids often live with somatisizing parents. 3. These sx’s=a reaction to stress.

Somatization: Differential Diagnosis

• Unrecognized physical disease (OH NO!)

• Unrecognized psychiatric disorder (e.g. depression, anxiety)

• Factitious disorder (e.g. malingering)

• Psychological factors affecting medical condition

Campo, et. al. Pediatrics 2004

Psychiatric Disorder

RAP patients (%)

Control patients (%)

P value

Any anxiety disorder

78.6 10.5 <.001

Any depressive disorder

42.9 7.9 <.001

The approach: Somatization “Red Flags”

• Hx. of multiple somatic complaints

• Multiple primary care physician visits

• Multiple specialty consultations

• Family members with chronic and recurrent sx’s.

• “Non-nuclear” family

• Dysfunction in primary areas of life: family, peers, school, sports, leisure activities.

The approach, continued

• VERY CAREFUL, VERY COMPREHENSIVE HISTORY AND PHYSICAL EXAM

• Bring up, EARLY in the evaluation, that there may be stress related factors.

• Ask patient/family their theories re: etiology• Limited lab work up, impose limits on workup.

Suggest limitations on specialty referrals.• Screen for depression/anxiety, etc. YSC,

BDI,etc. • Avoid “mind-body split”/”Functional vs.

organic”/etc. Use an example (e.g. red face”)

Ask the patient/parent-Mothers who endorsed psych-social causes for

their kid’s abd. pain• Cause % endorsing

• Child worried, nervous, tense 50%

• Stress 32%

• Puts too much pressure on self 30%

• XS sensitivity/overreaction to pain 29%

• Abd. pain gets family attention 12%

The approach, continued

• Urge consolidation of care

• Teach self-monitoring techniques (e.g., relaxation, PMR, pain diary )

• Offer reassurance when appropriate

• Aggressively Dx. and Rx. Comorbid psychiatric disease. Insist upon close contact with mental health provider

• Schedule frequent follow-up appt’s.

• Finally, recognize that these patients can be very frustrating and difficult to treat.

• Consultation-physician to physician-for formal consultation, for ideas, and for emotional support- can be vital!

References-1• 1. Braverman P: “Chronic Abdominal Pain”, in Neinstein LS et.al. Editors, Adolescent

Health Care: A Practical Guide. Fifth Edition. 2008. Philadelphia, Lippincott Williams and Wilkins. pp. 508-516.

• 2.Campo JV, BridgeJ, Ehmann M et. al.: “Recurrent Abdominal Pain, Anxiety and Depression in Primary Care. Pediatrics Vol 113 No. 4 April, 2004 pp. 817-824

• 3. Claar RL, Walker LS: “Matenal attributions for the causes and remedies of the children’s abdominal pain.” J. of Pediatric Psychology 1999 Vol. 24 No. 4 pp. 345-354.

• 4.Collins BS, Thomas D: “Chronic Abdominal Pain.” Pediatrics in Review Vol.28 No.9 Sept. 2007 pp.323-331

• 5. Hyams JS, Burke G, Davis PM et.al. “Abdominal Pain and Irritable Bowel Syndrome in Adolescence; a Community- based Study.” J. of Pediatrics Vol. 129 No. 2. 220-226

• 6. Kriepe RE “The Biopsychosocial Approach to Adolescents with Somatoform Disorders.” Adolescent Medicine Clinics Vol. 17 No. 1 Feb. 2006 pp.1-24

References-2• 7. Lake AM: “Chronic Abdominal Pain in Childhood: Diagnosis and

Management.” Am. Family Physician Vol. 59 No.7 April 1, 1999.• 8. Miranda AM: “Early Life Stress and Pain: An Important Link to

Functional Bowel Disorders.” Pediatric Annals Vol. 39 No. 5 May, 2009.

• 9. Servan Schreiber D, Randall K, Tabas G: “Somatizing Patients: Part 1 Practical Diagnosis; Part 2 Practical Management.” Am. Family Physician Vol. 61 No. 4, 5. 2/15 and 3/1/00.

• 10. Silber TJ, Pao M: “Somatization Disorders in Children and Adolescents.” Pediatrics in Review Vol. 24 No. 8 Aug. 2003

• 11. Up to Date articles (May, 2009) on Evaluation/Management of Child with Chronic Abdominal Pain; Somatization; Primary Care Management of Medically Unexplained Symptoms.