The teenager with chronic abdominal pain; the teenager with chronic symptoms Oscar Taube, MD Coordinator, Adolescent Medicine The 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 #2 Adolescent 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 motility 3. Psychological stress as a trigger/Genetic factors/environmental factors 4. 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 RAP Disorder patients (%) Control patients (%) P value Any anxiety 78.6 disorder 10.5 <.001 Any 42.9 depressive disorder 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. 345354. • 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.