“The Pain of Abdominal Pain”
Russell Cameron, M.D.
New Perspectives in Pediatrics Conference
Wednesday, October 21, 2015
Disclosure
I have no relevant financial relationships or
conflicts of interest to disclose.
Objectives
1. Discuss approach to pediatric patients with
functional abdominal pain
2. How to address patient and parental fears
and expectations
3. Discuss when to call a surgeon and when to
call a psychologist
Why is this important?
• About half of patients referred to pediatric GI
clinics have symptoms that do not have a
readily discernible cause
• Knowing how to relieve the physical and
emotional suffering in patients without
“disease” is a necessity for every clinician
Abdominal Pain
• Usually stimulated by one of three pathways:
– Visceral
– Somatic
– Referred
• Variability in the experience of pain
– Neuroanatomic, neurophysiologic,
pathophysiologic, environmental, and
psychosocial
Visceral Pain
• Caused by distended viscus which activates a
local nerve, sending an impulse that travels
through autonomic afferent fibers to the
spinal tract and central nervous system
• Localization of pain is difficult because there
are few afferent nerves traveling from the
viscera, and nerve fibers overlap
• Epigastric, periumbilical, or suprapubic
Somatic Pain
• Carried by somatic nerves in the parietal
peritoneum, muscle, or skin
• Usually well localized and sharp
Referred Pain
• Perceived at a site remote from the actual
affected viscera
• Sharp, localized, or diffuse
Biomedical Model
• Two assumptions:
1. Any symptom can be traced back to a single cause
2. Every symptom is either “organic,” meaning there is an
identifiable, objectively defined pathophysiology, or
“functional,” meaning without identifiable, objectively
defined pathophysiology
– This dualistic approach implicitly places “organic disease”
in high esteem
– Functional disorders are considered less serious,
psychological, or often without etiology or treatment
– The biomedical model works for a broken bone or a kidney
stone, but not so well when there are chronic problems
such as headaches, abdominal pain, or chronic fatigue
Parent’s
Fears
Patient’s
Suffering
Wrong Model
Bad
Experience
Expectations
and
Frustration
Imperfect
Tools
Imperfect
Treatments
SEP 16, 2009 “Misdiagnosis and Regret”
• A reader who was recently found to have a rare, serious condition sent
Doctor D a question about visiting one of several doctors who missed the
diagnosis:
– “It could be terribly awkward to have an appointment with one of them—me
with all my new scars and a scary prognosis and them perhaps with their
former, incorrect diagnoses of various benign conditions hanging in the air”
– “I'd welcome a chance to let them know that I understand that it's impossible
to get these things right instantly every time, and I have no resentment”
– “But would it be better to just see a brand new doctor? Or would my former
doctors want to see me? Or would they rather I melt into the ether and just let
them forget it all?”
• Every doctor has had that “Oh crap! It was X? I thought it was
Y!” panic after finding out about a misdiagnosis. The unspoken
truth is that doctors guess—a lot. Usually we make informed,
educated guesses, but even good guesses can be incorrect. Unusual
conditions can be hard to discover, and we often make several
wrong diagnoses on the way to the right one
• “Retrospectascope” - only medical instrument that produces the
right answer every time
• “We feel all patients demand perfection, and we work with
imperfect tools and imperfect knowledge. Even the best care won't
always produce the right answer—especially at the beginning.
Example
• Ashley is a 17-year-old was referred from the
ER
– Acute onset crampy abdominal pain and loose
stools without blood during her first semester of
college far away from home
– She was upset by a separation from her high
school boyfriend
– Skipping breakfast and lunch to avoid having to
interrupt her classes to use the rest room
– Loosing weight
Work Up
– Screening laboratory tests
– Inflammatory bowel disease (IBD) and Celiac
serology and screening labs were normal
– GI performs an EGD and colonoscopy and 24 hour
pH-Impedance
– All were normal
Pain cont…
– Sharp pains under the ribcage after meals, and the
frequency and severity of the abdominal pain
worsened
– Unable to return to class because of worsening
pain intensity
– PCP sent her to the surgeon who ordered a HIDA
scan
– Ejection fraction was 33% (adult normal 35 to
90%)
The “cure”
– The surgeon removed the gallbladder
– The patient had prolonged pain after surgery and
was discharged on NJ tube feedings, narcotics for
abdominal pain, and polyethylene glycol for
constipation
– She remained out of school for many months,
disabled by pain and unable to eat
The aftermath…
• Psychiatric consult found no eating or thought
disorder and criticized the gastroenterologists for
requesting the consultation, stating that the
request might have been motivated by the
physicians’ failure to find what was wrong
• The patient, family, and clinicians inadvertently
co-created disability by considering only organic
etiologies and avoiding the reality of the patient’s
stressful experiences and functional, physiologic
responses to stress, namely, IBS and functional
nausea and vomiting
Analysis
• They approached the problem from a biomedical
model and the presumption that illness must have an
organic etiology
• Extensive testing for diseases to explain symptoms
• Each negative test result reinforced the worries and
fears that something important was being missed
• Focus on the mystery disease and miss recognizing the
emotional impacts of separations from her family, her
ex-boyfriend, and her failure to adjust to college
• The patient, parent, and provider were upset and
frustrated by the failure to find organic pathology
Biopsychosocial Model
• Engel in 1977
• Goal is to understand and treat illness, the patient’s
subjective sense of suffering, rather than confining the
diagnostic effort to no more than finding disease
• Symptoms may develop from several different
influences, not just disease, and may stem from:
–
–
–
–
Normal development (infant regurgitation)
Psychiatric disease (pain, conversion, factitious disorders)
Impact of culture and society (uninsured)
Functional disorders (symptoms are real, but there is no
easily discerned disease)
D.R. Fleisher, E.J. Feldman: The biopsychosocial model of clinical practice in functional
gastrointestinal disorders. P.E. Hyman p. 2-6 Pediatric Functional Gastrointestinal
Disorders. 1999 Academy Professional Information Services New York 21-22
“Being human is messy and we are not
that good at it”
• Rather than reducing a cluster of symptoms to
a single pathophysiology (reductionism), the
biopsychosocial model expands the potential
for understanding a problem from
simultaneously interacting systems at
subcellular, cellular, tissue, organ,
interpersonal, and environmental levels
Biomedical versus Biopsychosocial
• Not versus but and…
– Most clinicians include elements of both
– All illnesses, organic and functional, can be managed within the framework of
the biopsychosocial rather than the biomedical model
• Goal - improving patients’ well-being
• Difference in what is considered to be impairment and the extent to which
the clinician considers the origin and remedies to that impairment
• Biomedical model limits the role of the clinician to the diagnosis and
treatment of disease and assumes that doing so restores well-being
• Biopsychosocial model expands the meaning of the goal and the clinical
process by which it is achieved
– Illness is defined as the patient’s subjective sense of suffering
– The goal of management is to identify the patient’s disease as well as other
factors contributing to suffering
– Includes an analysis of the relationship and contributions of each factor in the
patient’s illness
Illness
Approach
• Frame the conversation with the following categories:
– Things we needed to know about yesterday because they are
emergent and need an intervention (ASAP)
– Things we want to find out about because it will significantly
change our approach
– Things that we will have to continue to learn about in order to
make the symptoms better
• This will be a process and that the process is frustrating for:
– Patient because they are the one having the pain
– Parent because they are watching their child have pain and feel
helpless to fix it
– Provider because we are having to make educated and
uneducated guesses as to what could be causing the symptoms
“5 symptoms of GI tract”
• Abdominal pain
• Nausea
• Vomiting
• Diarrhea
• Constipation
But…
“2000 + potential causes”
Approach
• Quality, timing, location, associations, and story
are important and should be used as your guide
in working it up and also your guide to stopping
the investigation
– Build trust, show you are listening
– Be nosy
– Be interested
• Acknowledge that this is frustrating and ask what
is your greatest concern, what is your biggest
fear?
Approach
• I use a dry erase board to document the facts of
their story and then use those symptoms to help
come up with a game plan that we all agree on
• There are some baseline labs, stool studies, and
imaging studies that we often order
• Value of the physical exam – lets them know you
are taking this seriously (Abraham Verghese, MD)
https://www.ted.com/talks/abraham_verghese_a
_doctor_s_touch?language=en#t-125798
Testing
• Laboratory, radiologic, endoscopic, and ancillary evaluation
– Should be individualized according to the information obtained during the
history and physical examination
– Most clinicians recommend the following studies as an initial screen for all
patients with recurrent abdominal pain:
• CBC, UA with culture, Liver enzymes, ESR, Celiac and Stool O&P
• If normal, in combination with a normal physical examination, effectively rule out an
organic cause in 95% of cases.
– Other: Noninvasive studies and Invasive studies
– Ex:
• Ultrasound has gained a prominent role over the past decade because it is painless and
does not involve radiation
• 3 studies to investigate the diagnostic value of routine abdominal ultrasound in children
with recurrent abdominal pain failed to demonstrate its utility in this clinical setting
• 217 patients were evaluated and a total of 16 patients were found to have abnormalities
identified by abdominal ultrasound, but in no case could the pain be attributed to the
abnormality
FGID:
Functional Gastrointestinal Disease
•
•
•
•
RAP
FAP
CRAP
IBS
• Functional
Dyspepsia
• Abdominal
Migraines
Apley
• At least 1 episode per month for 3 consecutive
months and severe enough to interfere with
routine functioning
• Affects 10-15% of school age
• Up to 46% of children experience during
childhood
ROME III -> IV (spring 2016)
• a diagnosis of a FGID is
made
• opposed to FGID only
considered as a
diagnosis of exclusion
“When in Rome…”
A. Esophageal Disorders
C. Bowel Disorders
A1. Heartburn
C1. Irritable Bowel Syndrome
A2. Chest Pain Presumed Esophageal
C2. Functional Bloating
A3. Functional Dysphagia
C3. Functional Constipation
A4. Globus
C4. Functional Diarrhea
C5. Unspecified Functional Bowel Disorder
B. Gastroduodenal Disorders
B1. DYSPEPSIA
D. Abdominal Pain Syndrome
B1a. Postprandial Distress Syndrome
B1b. Epigastric Pain Syndrome
E. Gallbladder and Sphincter of Oddi Disorders
B2. BELCHING DISORDERS
B2a. Aerophagia
E1. Gallbladder Disorder
B2b. Unspecified Excessive Belching
E2. Biliary Sphincter of Oddi Disorder
B3. NAUSEA/VOMITING DISORDERS
E3. Pancreatic Sphincter of Oddi Disorder
B3a. Chronic Idiopathic Nausea
B3b. Functional Vomiting
B3c. Cyclic Vomiting Syndrome
B4. Rumination Syndrome in Adults
“When in Rome…”
F. Anorectal Disorders
F1. Fecal Incontinence
F2. ANORECTAL PAIN
F2a. Chronic Proctalgia
F2a.1. Levator Ani Syndrome
F2a.2. Unspecified Functional Anorectal Pain
F2b. Proctalgia Fugax
F3. Defecation Disorders
F3a. Dyssynergic Defecation
F3b. Inadequate Defecatory Propulsion
G. Childhood Functional GI Disorders:
Infant/Toddler
G1. Infant Regurgitation
G2. Infant Rumination Syndrome
G3. Cyclic Vomiting Syndrome
G4. Infant Colic
G5. Functional Diarrhea
G6. Infant Dyschezia
G7. Functional Constipation
H. Childhood Functional GI Disorders:
Child/Adolescent
H1. VOMITING AND AEROPHAGIA
H1a. Adolescent Rumination Syndrome
H1b. Cyclic Vomiting Syndrome
H1c. Aerophagia
H2. ABDOMINAL PAIN-RELATED FUNCTIONAL GI
DISORDERS
H2a. Functional Dyspepsia
H2b. Irritable Bowel Syndrome
H2c. Abdominal Migraine
H2d. Childhood Functional Abdominal Pain
H2d1. Childhood Functional Abdominal Pain
Syndrome
H3. CONSTIPATION AND INCONTINENCE
H3a. Functional Constipation
H3b. Nonretentive Fecal Incontinence
ABDOMINAL PAIN-RELATED
FUNCTIONAL GI DISORDERS
•
•
•
•
•
Functional Dyspepsia
Irritable Bowel Syndrome
Abdominal Migraine
Childhood Functional Abdominal Pain
Childhood Functional Abdominal Pain
Syndrome
Functional Dyspepsia
IBS
Abdominal Migraine
Functional Abdominal Pain
FAP Syndrome
• Bidirectional brain-gut interaction
• Brain receives a stream of interoceptive input from the GI tract, integrates
the information with other interoceptive information from the body and
with contextual information from the environment, and sends an
integrated response back to various target cells
• Homeostasis of the GI tract during physiological perturbations and to
adapt GI function to the overall state of the organism
• Majority of information reaching the brain is not consciously perceived but
serves primarily as input to autonomic reflex pathways
• FAP syndromes, conscious perception of interoceptive information from
the GI tract, or recall of interoceptive memories of such input, can occur in
the form of constant or recurrent discomfort or pain
Treatment of FGID
•
•
•
•
Acknowledgement and Reassurance
Medication
Diet
Therapies
Simulation:
• Parent: “Doctor, what is causing my child’s
pain?”
• Me: “I am not sure yet, but will try and help
your child and you as we navigate through this
process. It is possible we will be wrong before
we find out what is causing it, and it may be
that the symptom is the disease. Like a
headache in the stomach.”
PPIs
• PPIs, however, have only a small benefit over
placebo in the treatment of functional
dyspepsia [Moayyedi et al. 2006]
Histamine
• Predominant dyspepsia, a short course of
empiric therapy with an H2-histamine
receptor antagonist is acceptable
• Failure to respond or a recurrence of
symptoms following discontinuation prompts
further evaluation
• Study showed only subjective improved in
symptoms, and placebo was equally effective
when looking at objective scores
M.C. See, A.H. Birnbaum, C.B. Schecter, et al.: Double-blind, placebo-controlled trial of
famotidine in children with abdominal pain and dyspepsia. Dig Dis Sci. 46:985-992
2001
Periactin
• Cyproheptadine, a central and peripheral H1
nonselective histamine receptor antagonist
with antiserotonergic properties
• A double-blind, randomized, placebocontrolled trial was performed in 29 children
ages 4 to 12 years with FAP
– Randomized to placebo or cyproheptadine
– 86% in the cyproheptadine group and 36% in the
placebo group had improvement or resolution
M. Sadeghian, F. Farahmand, G.H. Fallahi, et al.: Cyproheptadine for the
treatment of functional abdominal pain in childhood: a double-blinded
randomized placebo-controlled trial. Minerva Pediatr. 60:1367-1374 2008
Peppermint Oil
• Soothe the GI tract for hundreds of years
• Relaxes intestinal smooth muscle by decreasing
calcium influx into the smooth muscle cells
• Meta-analysis of five randomized, double-blinded,
placebo-controlled trials performed in adult patients
supported the efficacy of peppermint oil in the
treatment of irritable bowel syndrome
• Randomized, double-blind, controlled trial in pediatric
patients with IBS demonstrated the efficacy of entericcoated peppermint oil capsules in the reduction of pain
during the acute phase of IBS
R.M. Kline, J.J. Kline, J. Di Palma, et al.: Enteric-coated, pH-dependent
peppermint oil capsules for the treatment of irritable bowel syndrome in children.
J Pediatr. 138:125-128 2001
Anticholinergics
• Dicyclomine (Bentyl) and hyoscyamine (Levsin)
• Smooth muscle relaxants, block the muscarinic effects
of acetylcholine on the GI tract, relaxing smooth
muscle and reducing spasm and abdominal pain,
slowing intestinal motility, and decreasing diarrhea
• Efficacy not clearly established in adult trials, no
randomized, double-blind, placebo-controlled trials in
pediatrics
• Potential side effects: drowsiness, blurred vision, dry
mouth, tachycardia, constipation, and urinary retention
• PRN or episodic, up to four times daily
Tricyclic Antidepressants
• Shown to provide relief to patients with FGIDs
• Neuromodulatory and analgesic effects, from a
combined anticholinergic effect on the gastrointestinal
tract, mood elevation and central analgesia
• Two clinical trials to evaluate the efficacy of TCA
therapy in the treatment of FAP in children
– A single-center study of 33 adolescents with IBS found a
beneficial effect of amitriptyline in comparison to placebo
in terms of quality of life and pain relief
– A multicenter randomized double-blinded trial on 90
children showed improvement in 59% of the children
receiving amitriptyline*
M. Saps, N. Youssef, A. Miranda, et al.: Multicenter, randomized, placebocontrolled trial of amitriptyline in children with functional gastrointestinal
disorders. Gastroenterology. 137:1261-1269 2009
Serotonin
• Serotonin is found in high concentrations in
the enterochromaffin
• 14 serotonin receptor subtypes with varying
actions in the peripheral and central nervous
systems exist
• 5-HT3 and 5-HT4 receptors appear to play a
role in the pathophysiology of IBS
SSRIs
• Selective serotonin reuptake inhibitors are helpful
for some patients with unremitting pain and
impaired daily functioning, even if no depressive
symptoms are present
• Citalopram has been studied in children with
FGIDs
– 12-week open-label flexible-dose trial
– By week 12, 50% rated their symptoms as very much
improved
– Also showed improvement in comorbid depression
and anxiety
J.V. Campo, J. Perel, A. Lucas, et al.: Citalopram treatment of pediatric recurrent
abdominal pain and comorbid internalizing disorders: an exploratory study. J Am
Acad Child Adolesc Psychiatry. 43:1234-1242 2004
5-HT3 antagonist
• Ondansetron (Zofran) and Granisetron (Kytril)
• Some chemotherapeutic and radiotherapeutic agents
cause the release of 5-HT from enterochromaffin cells
• Serotonin activates vagal afferents via 5-HT3 receptors,
triggering emesis by stimulation of the area postrema
and chemoreceptor trigger zone
• Ondansetron and granisetron are very effective in
reducing postchemotherapy nausea, but do not
consistently alleviate the pain associated with FGIDs
• Not routinely recommended for FGIDs unless nausea is
a predominant symptom
Probiotics
• Double-blind randomized controlled trial, 50 children
with IBS were treated with either Lactobacillus GG or
placebo for 6 weeks
– No significant differences between treatment and placebo
groups with the exception of abdominal distention
• Larger, 4-week placebo-controlled study, 104 patients
who fulfilled the Rome II criteria for functional
dyspepsia, IBS, or FAP
– 25% in the treatment group and 9.6% in the placebo group
responded to therapy
– IBS more likely to respond to probiotic, compared to
placebo or FAP
M. Bausserman, S. Michail: The use of Lactobacillus GG in irritable bowel syndrome in children: a doubleblind randomized control trial. J Pediatr. 147:197-201 2005
A. Gawronska, Horbath A. Dziechciarz, et al.: A randomized double-blind placebo-controlled trial of
Lactobacillus GG for abdominal pain disorders in children. Aliment Pharmacol Ther. 25:177-184 2007
• Microbiota +
Carbohydrate
(fuel) = Gas +
Byproducts
• Gas = Distension
• Distension = Pain
(nociceptor)
• Byproducts =
Absorption +
Attraction H2O
What Are Prebiotics?
• Different kinds of fiber that encourage beneficial
species of gut flora to grow
• You can’t digest them, but your gut flora can –
and more food for the gut flora means more
flora!
– PREbiotics provide food for the bacteria already living
in your gut
– PRObiotics provide a direct infusion of bacteria that
weren’t there before
– “Synbiotics” refers to supplements that combine
probiotics and prebiotics
Lactose, Fructose, FODMAPs…Oh my…
• Breath tests
• Elimination diets
• Supplemental enzymes
Prebiotic, Probiotic, Symbiotic …
Oh my…
• Prebiotics +/• Probiotics – which one, who do you trust
• Symbiotic – does it even matter, and how
would you even know
What about evil gluten and Paleo?
Cognitive Behavioral Therapy
• 6 studies in a Cochrane review
• Relatively small and had some weaknesses in
design and reporting
• Each reported a statistically significant benefit
to participants in the intervention group
• Cochrane reviewers thought CBT is worth
considering
A.A. Huertas-Ceballos, S. Logan, C. Bennett, C. Macarthur: Psychosocial
interventions for recurrent abdominal pain (RAP) and irritable bowel
syndrome (IBS) in childhood (Review). Cochrane Library. (Issue 4)2009
Relaxation/Arousal Reduction
• A variety of techniques to teach patients to counteract the
physiological sequelae of stress or anxiety
• The most commonly used techniques include progressive muscle
relaxation training; biofeedback for striated muscle tension, skin
temperature, or electrodermal activity; and transcendental or yoga
meditation
• Most techniques incorporate a quiet environment, a relaxed and
comfortable body position, and a mental image to focus attention
away from distracting thoughts or body perceptions
• Audiotapes may be used to guide practice at home
• Relaxation training has been shown in adults to significantly reduce
gastrointestinal symptoms as compared with controls
R.D. Anbar: Self-hypnosis for the treatment of functional abdominal
pain in childhood. Clin Pediatr. 40:447-451 2001
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