Recurrent abdominal pain Quak Seng Hock Department of Paediatrics - - PowerPoint PPT Presentation

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Recurrent abdominal pain Quak Seng Hock Department of Paediatrics - - PowerPoint PPT Presentation

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Recurrent abdominal pain Quak Seng Hock Department of Paediatrics KTP- University Childrens Medical Institute National University Hospital NUHS June 2015; GI teaching Case history LJR 12 old boy seen at CE repeatedly for severe

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June 2015; GI teaching

Recurrent abdominal pain

Quak Seng Hock Department of Paediatrics KTP-University Children’s Medical Institute National University Hospital NUHS

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June 2015; GI teaching

Case history

  • LJR
  • 12 old boy seen at CE repeatedly for severe

abdominal colic at right upper quadrant

  • Physical examination: mild tenderness RHC and

epigastrium

  • Symptomatic treatment and referred to specialist

clinic for further management

  • Noted weight loss
  • Seen by various doctors: gastritis
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June 2015; GI teaching

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June 2015; GI teaching

  • utline
  • The pain
  • Epidemiology
  • Long term outcome
  • Some interesting cases
  • management
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June 2015; GI teaching

Definition

  • At least 3 bouts of abdominal pain, severe

enough to interfere with daily activities, over a period of at least 3 months

– J Apley 1958

  • In practice, RAP includes children

and adolescents in which parents seek advice though the duration may not be 3 months

  • Exclude acute abdominal pain
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June 2015; GI teaching

Pain characteristics

  • Location
  • Severity
  • Frequency
  • Personality
  • Timing of pain
  • Associated features
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June 2015; GI teaching

  • utline
  • The pain
  • Epidemiology
  • Long term outcome
  • Some interesting cases
  • management
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June 2015; GI teaching

Age distribution

Quak &Wong; IMJ 1997

5 10 15 20 25 30 <1 1+ 2+ 3+ 4+ 5+ 6+ 7+ 8+ 9+ 10+ 11+ 12+

Age

Age

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June 2015; GI teaching

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June 2015; GI teaching

Helicobacter pylori, gastroduodenal disease and recurrent abdominal pain in children

– Macarthur C, et al. JAMA 1995;273:729-34

  • 45 studies from Jan 1983-July 1994
  • Prevalence of HP infection in children with DU

was high

  • Prevalence rate of infection in children with

RAP inconsistent

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June 2015; GI teaching

Red Flag symptoms

  • Localization of pain away from the umbilicus
  • Pain associated with changes in bowel habits,

particularly diarrhea, constipation, or nocturnal bowel movements

  • Pain associated with night wakening
  • Repetitive emesis, especially if bilious
  • Constitutional symptoms, such as recurrent fever,

loss of appetite or energy

  • RAP in children < 4 years of age
  • Weight loss
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June 2015; GI teaching

Red Flag signs

  • Loss of weight or decline in height velocity
  • Organomegaly
  • Localized abdominal tenderness, particularly

away from umbilicus

  • Peri-anal abnormalities (fissures, ulceration of

skin tags)

  • Joint swelling, redness or warm
  • Ventral hernias of abdominal wall
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June 2015; GI teaching

  • utline
  • The pain
  • Epidemiology
  • Long term outcome
  • Some interesting cases
  • management
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June 2015; GI teaching

RAP in children: a long term follow-up

Maqni et al. Eur J Pediatr 1987;146:72-4

  • Long term follow up, minimum of 10 years
  • Total of 16 children

– Completely disappeared: 50% – Persisted: 25% – Other painful symptoms : 25%

  • Poor outcome

– Painful family – Many surgical procedures – Low educational level and social class

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June 2015; GI teaching

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June 2015; GI teaching

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June 2015; GI teaching

  • utline
  • The pain
  • Epidemiology
  • Long term outcome
  • Some interesting cases
  • management
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June 2015; GI teaching

ML

  • 3+ year old boy
  • Previously well
  • Seen various doctors for RAP
  • Treated for constipation
  • Referred to NUH because pain persistent and

progressively more frequent and severe

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June 2015; GI teaching

ML

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June 2015; GI teaching

XC

  • 5 year old boy
  • Recurrent bouts of severe

abdominal pain

  • Usually improved after

vomiting

  • In between episodes of pain,

he is well

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June 2015; GI teaching

XC

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June 2015; GI teaching

NKL

  • 10 year old Chinese boy with RAP
  • Associated with vomiting which may last for

days (up to 7-10 days)

  • Weight loss
  • Missed school for > 6 months
  • Thin boy with no abnormality found in

abdomen

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June 2015; GI teaching

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June 2015; GI teaching

PF

  • 12 year old Chinese girl
  • Seen by various doctors for RAP
  • Noted to have iron deficiency anaemia
  • Treated for gastritis, anaemia without

improvement

  • Later seen be endocrinologist for delayed

puberty

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June 2015; GI teaching

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June 2015; GI teaching

  • utline
  • The pain
  • Epidemiology
  • Long term outcome
  • Some interesting cases
  • management
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June 2015; GI teaching

Clinical approach

  • What are the three important investigations:
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June 2015; GI teaching

Clinical approach

  • Three important investigations:

– 1) good history and physical examination

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June 2015; GI teaching

Clinical approach

  • Three important investigations:

– 1) good history and physical examination – 2) good history

and physical examination

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June 2015; GI teaching

Clinical approach

  • Three important investigations:

– 1) good history and physical examination – 2) good history and

physical examination

– 3) good history

and physical examination

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June 2015; GI teaching

Understanding the scenario

Pain patient parents environment

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June 2015; GI teaching

Initial screening tests

  • Anthropometrics
  • Urinalysis
  • ESR
  • Stool occult blood
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June 2015; GI teaching

Initial screening tests

  • Anthropometrics
  • Urinalysis
  • ESR
  • Stool occult blood
  • Next steps

– Ultrasound – Food diary – Only when indicated:

  • Invasive procedures
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June 2015; GI teaching

Food as cause of RAP

  • Lactose intolerance

– Some 40% of patients with RAP has lactose intolerance

  • Quak & Wong IMJ 1997
  • Other food

– Mainly as food additives: sorbitol, artificial sweeteners

  • Eosinophilic gastroenteritis

– Tien FM, et al. Pediatrics & Neonatology 2011

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June 2015; GI teaching

Ann Nutr Metab 2012;61-95-101

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June 2015; GI teaching

Cochrane review 2009, issue 1

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June 2015; GI teaching

Clinical Psychology review 2011;31:1192-7

  • Meta-analysis of 10 interventional studies
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June 2015; GI teaching

Clinical Psychology review 2011;31:1192-7

  • Psychological therapies, mainly cognitive-behavioral therapy,

have a moderate effect on the reduction of pain in children with RAP

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June 2015; GI teaching

  • 63 patients (11-18 years) randomly assigned

to receive standard medical care (SMC) or written self-disclosure (WSD) + SMC

  • WSD + SMC associated with significantly fewer

pain experiences and reduced health care utilization

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June 2015; GI teaching

summary

  • RAP is common
  • Significant effect on HRQoL
  • Red flags
  • Good history and careful physical examination

remain the key step toward successful management

  • For functional RAP, CBT is successful in

reducing the frequency and severity of pain

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June 2015; GI teaching

Thank you Terima Kaseh