Abdominal Complaints in

School Age Children

Michael A. D’Amico, MD
Pediatric Gastroenterology and Nutrition
May 16, 2012
 Objectives
• Become familiar with common causes of
abdominal complaints in school age children
• Understand the therapeutic approach to these
conditions
• Know when to make appropriate referrals
• Explore presentation content further with Q & A’s
 Statements
• No financial disclosures
• I may be discussing off-label use of some
medications
Common Abdominal Complaints
• Developmental level of child
– introspection
• Comfort level
• Social context

Often difficult to express or verbalize

precise sensation
 Common Complaints
(symptoms)
• Pain
– Most common
– Vague
• Don’t feel well, My tummy hurts, Hunger, Nausea
• Upset stomach
• Constipation
– Hard to go, takes a long time going
• Diarrhea
 Common Complaints
• Vomiting
• Dysphagia
– Difficulty swallowing
• “Accidents”
– Stool incontinence
– Encopresis
• Blood in stool
– hematochezia
Classification of Abdominal Pain
• Organic
• Non-organic
– Aka: “Functional” abdominal pain
– Avoid terms like psychogenic, nervous stomach
or “its all in your head”
 Organic Causes of Chronic
Abdominal Pain
• Gastrointestinal
– Esophagitis
– Gastritis/Peptic Ulcer
– Malrotation/adhesions
– Duplications
– Hernias
– IBD
– Constipation
– Parasitic infection/infestation
– Bezoar or foreign body
– Carbohydrate intolerance
– Intussusception
– Tumor
– Ischemic
• Hepatobiliary/pancreatic
– Chronic hepatitis
– Cholelithiaisis/Cholecystitis
– Choledochal cyst
– Chronic pancreatitis/pseudocyst
• Respiratory
– Infection, inflammation or tumor near
diaphram
• Genitourinary
– UPJ obstruction/hydronephrosis
– Nephrolithiasis
– Recurrent pyelo/cystitis
– Hematocolpos
– Mittleshmerz
– Endometriosis
• Metabolic/Hematologic
– Porphria
– Hereditary angioedema
– DM
– Lead poisoning
– Sickle cell disease
– Collagen vascular disease
• Musculoskeletal
– Trauma, tumor, infection
 Suggestive of Organic Cause of
Chronic Abdominal Pain
• < 5 yrs
• Constitutional Sx: fever, wt loss, rash, joint pain
• Emesis (bilious, hematemesis)
• Pain that awakens from sleep
• Pain well localized away from umbilicus
• Referred pain
• Family Hx of IDB, PUD, etc
• Perianal disease
• Occult or gross blood in stool
• Abnormal testing
 Constipation
• Likely the most common cause of
complaints of abdominal pain in school age
children
• Will spend the most time on this today
 Constipation
• Chronic constipation is a very
common pediatric problem
• Accounts for 3 – 5% of visits to
primary provider
• Up to 25% of referrals to pediatric
GI
• Male to female ratio is 6:1
• Parental anxiety/stress
 Constipation in children with
disabilities
• More common
– 75 – 90% with neuromuscular and
developmental disabilities
• Delay in diagnosis and treatment
• Longer therapy
• More medications and interventions
• More tests (x-ray, barium enema,
manometry, colonscopy)
 Constipation: Definition
• Passage of fewer than 3 stools per week or
• Passage of painful, large hard stools
regardless of frequency
– Children may have fecal impaction with
frequent small bowel movements “around” the
impacted mass -- OVERFLOW
• Subjective
 “Normal” stooling patterns
• Frequency varies with age
– Highly variable in early infancy depending on
feeding source (breast-fed vs. formula)
– By 4 months most infants average 2 stools/day
(range 1 – 7/day in 93%)
– Toddlers and school-age children average 1.2
bowel movements/day
• Adults range from 3/day to 3/week
 Defecation
• Fecal filling of the rectum

• Reflex relaxation of the

tonically contracted
internal anal sphincter

• Voluntary contraction of
external anal sphincter

• “Fecal continence”
 Defecation
• Voluntary relaxation of
external anal sphincter and
puborectalis muscle
“opens” and “straightens”
passage
• Straining (Valsalva
maneuver), increasing
intra-abdominal pressure
and rectal contractions
helps propel stool outside
body
• Coordinated by sensory
epithelium of anorectal
mucosa
 The Colon
• Stores and desiccates liquid stool received
from the ileum
• Propulsive contractions stimulated by
– Eating (gastro-colic reflex)
– Distension (bulk)
• Transit time increases with age and varies
with nutritional (dietary) components of
stool – mostly FIBER
 Constipation can be caused by
• Insufficient fiber intake
• Insufficient water intake
• Tumors, fractures or lesions
• Spinal cord/disc disease
• Large bowel nervous disorders
• Neuromuscular disorders/motility disorder
– Paradoxical puborectalis contraction
• Metabolic or endocrine disorders
• Dehydration
• Medications
• Behavioral problems
→ usually multifactorial
 Withholding
• Most common cause of constipation in
children is withholding of stool
– Usually because of a prior painful bowel
movement (?associated anal fissure)
• Subconscious
• Initiates habit cycle of stool retention
– Stretches rectum and later proximal colon
– Reabsorption of fluid and electrolytes
 Withholding
• Self-perpetuating
– Larger and harder stools are more difficult to
pass
– Reinforcement of painful experience and
further withholding
• Leads to fecal impaction
– Further stretching and so on and so on and……
→ overflow incontinence (ENCOPRESIS)
Pediatr Clin North Am 1982;29:315-30
Who’s affected?
 Encopresis
• “Soiling”
• Less common
• Most commonly due to constipation
– “Retention encopresis”
– “Overflow incontinence”
• Reported frequency varies
– 1 – 8% of school-age children
 Encopresis
• Involuntary leakage of liquid or semi-
formed stool around the constipated fecal
mass is the usual trigger to bring patients to
medical attention
• Chronic rectal distension from fecal
retention decreases sensation of stool
volume which formerly caused the “urge”
to defecate
 Medications
• Narcotic or opioid pain medications
• Anesthetics
• Anticholinergics/anti-spasmodics
• Anticonvulsants/ketogenic diets
• Antipsychotics/antidepressants/stimulants
• Barium
• Minerals: calcium, iron, lead, aluminum, bismuth
• Nonsteroidal anti-inflammatory agents
 Clinical Signs and Symptoms
• Frequency of BM’s with chronic constipation may
NOT be a reliable indicator
• Other signs & symptoms such as abdominal pain
and distension develop
• Clogging the toilet
• Frequent soiling or leaking may be confused as
diarrhea or over treatment with stool softeners
• Cyclic appetite blunting with periods of poor
weight gain, followed by remarkable response to
therapy
 Clinical signs and symptoms
• Efforts to withhold may may be
misinterpreted as attempts to strain or
defecate
• Common withholding maneuvers
– Posturing
– Scissoring of the legs
– Dancing back & forth, from leg to leg
– Occasionally resembling seizures
 Clinical signs and symptoms
• Urinary incontinence
– ~30% diurnal enuresis
– 35% nocturnal
• Recurrent urinary tract infection (~10%)
• Physical exam
– Abdominal mass
– Peri-anal fissures, hemorrhoids
So what can we do?
 A few basic tenets
• Soften the stool
• Provide a secure, conducive environment to
sit, sit, sit
 Goals for Stooling
• Soft, but formed stool
• Upright position with knees/hips bent to
maximize Valsalva
• Feet securely planted on firm surface
• Appropriately sized seat
Treatment
 Maintenance
• Keep the colon “clean”
• Osmotic agents
– Lactulose
– Docusate (Colace)
– Miralax
• Mineral oil
– Softener and emollient (lubricates)
 Maintenance
• Bulking agents
– Fiber
• Stimulants
– Senna (Sennakot)
– Bisacodyl (Dulcolax)
– Lose effect with time (tachyphylaxis)
• Motility agents
– Metoclopramide (Reglan)
– Serotoninergic agonists
 Other Therapies
• Biofeedback
– Electromyography
– Manometry
• Reward systems
• Individual or family therapy
• Pyschotherapy
• Pyschopharmacotherapy
 Patience
Time
Support and encouragement
 Prognosis
• Generally good
– The colon can and will return to normal caliber
and function
• Muscular
• Sensory
• Directly correlates with
– ability to adhere to regimen and toileting
– Retraining and resolution of withholding
 GERD
The Antireflux Barrier
 Pathogenic Factors in GERD
Mechanisms of GER
• Transient LES relaxation
• Intra-abdominal pressure
Pharynx • Reduced esophageal capacitance
• Gastric compliance
UES
• Delayed gastric emptying

Esophagus
Mechanisms of Esophageal Complications
• Impaired esophageal clearance
• Defective tissue resistance
• Noxious composition of refluxate
Crural Angle
diaphragm of His
Mechanisms of Airway Complications
Pylorus • Vagal reflexes
LES • Impaired airway protection

Stomach
 Presenting Symptoms and Signs
of GERD
• Recurrent vomiting • Dysphagia or feeding
• Poor weight gain refusal
• Irritability in infant • Apnea or ALTE
• Heartburn • Asthma
• Esophagitis • Recurrent pneumonia
• Upper airway symptoms
 Differential Diagnosis of Vomiting in Infants
and Children
GI Obstruction GI Disorders Neurologic
• Pyloric stenosis • Achalasia • Hydrocephalus
• Malrotation • Gastroparesis • Subdural hematoma
• Intermittent • Gastroenteritis • Intracranial
intussusception hemorrhage
Metabolic/Endocrine
Infections • Galactosemia Renal
• Sepsis • Fructose intolerance • Obstructive uropathy
• Meningitis • Urea cycle defects • Renal insufficiency
• Urinary tract infection
Toxic Cardiac
Allergic • Lead • Congestive heart
• Dietary protein failure
intolerance

Adapted from Rudolph et al, J Pediatr Gastroenterol Nutr 2001;32:S1

 Pharmacotherapy
• Antacids
• Histamine-2 receptor antagonists
• Proton pump inhibitors
• Prokinetic agents
• Surface agents
 Goals of Pharmacotherapy
• Control symptoms
• Promote healing
• Prevent complications
• Improve health-related quality of life
• Avoid adverse effects of treatment
 Principles of Antireflux Surgery

Restore intra- Reduce

abdominal segment hiatal hernia
of esophagus when present
Approximate
Wrap fundus
diaphagmatic
around LES to
crurae
reinforce
antireflux barrier
 Peptic Disease
• PUD – peptic ulcer disease
– Very uncommon in children
• H. pylori gastritis
– Acid-loving bacteria
– Uncommon in young children
 Dietary Intolerance
• Carbohydrate Intolerance
– Most common form is Lactose Intolerance
– Deficiency (primary or secodary) in small
bowel enzyme LACTASE
• Food allergy
– Many possibilities
• Cow/soy protein, nuts, fish, shell fish, wheat
 Dietary Intolerance
• Celiac disease
• Aka – Celiac sprue, Gluten sensitivity
• Autoimmune disease
• Environmental trigger
• Complex genetics
• Treatment: GFD (gluten free diet)
 Inflammatory Bowel Disease
• Crohn’s Disease
– Possibly entire GI tract
• Ulcerative colitis
– Restricted to large intestine (colon)
 Parasitic Infections
• Giardia
– Most common
– Usually associated with diarrhea, weight loss
• Round worms (nematodes)
– Ascaris
– Enterobius vermicularis (pinworms)
 Others (rare)
• Hepatitis
• Choledocholithiasis (gallstones)
• Kidney stones
• Pancreatitis
• Eosinophilic esophagitis
• Foreign bodies
– (ie. bezoar)
Chronic Recurrent Abdominal Pain

• Chronic
• Recurrent
• Abdominal
• Pain
– Aka – Functional
abdominal pain
- Functional GI Disorders -
 Functional Abdominal Pain
• Chronic or recurrent if at least 1 episode of
pain occurs each month of 3 consecutive
months AND is severe enough to interfere
with functioning
• ~10 to 15% of school age kids
• More recently – up to 20% of middle & high
school students report pain daily or weekly
 Functional Abdominal Pain
• What is it? →→ Dysfunctional
• What is it NOT?
– Psychogenic
– Imaginary
– Malingering
 Functional Abdominal Pain
• Genuine pain
• Cannot be explained on the basis of
structural or biochemical abnormalities
• Generally localizable
– Commonly periumbilical
– Can be diffuse
 Epigastric FAP
• Associated with nausea, vomiting, bloating,
belching, early satiety
• Confused with GERD, gastritis
• Commonly “Non-ulcer dyspepsia”
 Periumbilical FAP
• Usually no associated symptomatology
• No change in bowel patterns
• No patterns or discernible triggers to pain
• Most common
 Infraumbilical FAP
• Associated with cramps, distension,
bloating
• Altered bowel movements
– Constipation
– Diarrhea
• Irritable Bowel Syndrome (IBS)
 Clinical Characteristics of FAP
• > 5 yrs
• Paroxysms of abd pain
• Location: periumbilical (epigastric, infraumbilical)
• Pain characterization: vague, non-localizing or
radiating
• Poor temporal correlation with activity, meal,
bowel pattern
• Interferes with normal activity
– Direct relationship with time missed in school/work
• Normal PE, laboratory/other studies
 Cyclic Vomiting Syndrome
• Not rare –estimated ~1.9% incidence in
children
– Less common in adults
• Diagnosis – average 9.6 years
• Onset of Sx 5.3 years
– Delay in diagnosis
• F:M 1.2:1
• Cycles 4 -12/year
CVS
 CVS
• Likely a heterogeneous group of disorders
• Most commonly linked to migraines
– ? share a common pathophysiologic process
• Also linked to food allergy, mitochondrial,
metabolic, and endocrine disorders
 CVS and migraines
• Linked to both migraine headaches and abdominal
migraines
– Abdominal migraines similar with core symptom pain
– Both with high incidence of headache
• Discreteness of episodes – normal health in
between
• Progression of cyclic vomiting to migraine
headaches
• Strong family history (~80%)
• Response to antimigraine therapy
 CVS
• Triggers – stress, illness, caffeine/foods,
menstruation (catamenial)
• Autonomic imbalance
– Severe tachycardia, hypertension, and/or
orthostasis during episodes
– Autonomic imbalance with enhanced
sympathetic and diminished parasympathetic
vagal modulation (71%)
To J, et al. J Pediatr 1999 Sep;135(3):363-6
The Brain-Gut Axis
 Brain-Gut Connection:
Corticotropin Releasing Factor
• Paraventricular nucleus (hypothalamus)
• Dorsal vagal complex
– Endogenous brain CRF mediates psychological,
physical, somatovisceral, and immunological stress-
induced delayed gastric emptying in rats.
• Postoperative gastric ileus is prevented by
peripheral injection of CRF antagonists.
• CVS is precipitated by stimulation of CRF release
– resulting endocrine, autonomic, and visceral changes
are indicative of central CRF activation.
Tache Y. Dig Dis Sci 1999 Aug;44(8 Suppl):79S-86S.
 Emotional Motor System
• Overlap of brain regions concerned with
processing visceral afferent innervation
(mainly colon) with central autonomic
regulation of GI motility and secretion
• Rostral portion of the anterior cingulate
cortex (ACC) is the visceromotor cortex
– Projects to hypothalamic nuclei, amygdala,
periaqueductal grey and brainstem nuclei
Summary of FGIDs
What can be done?
 Pharmacotherapy
• Anti-spasmodics
– (anti-cholinergics, anti-histamines)
– Dicyclomine (Levsin, Bentyl)
– Hycosamine
• Serotoninergics
– Agonist: Tegaserod (Zelnorm)
– Antagonist: Alosetron (Lotronex)
 Antidepressants
Tricyclics
– 3° - Amitriptyline, Imipramine
– 2° - Nortriptyline, Desipramine
Lower doses than anti-depressant use provide:
• anxiolytic effects
• anti-nociceptive properties and facilitate central pain
tolerance
• peripheral analgesic effects at the level of visceral
mechanoreceptors and afferent nerve fibers
 Antidepressants
• SSRIs
– Equivocal beneficial effects
– Many due to anti-anxiety effects
• SNRIs
– No randomized trials in FGIDs (adults or kids)
– Many open label studies and anecdotal data to
suggest promise with less side effects than
TCAs
 Non-pharmacologic Therapy
• Cognitive Behavioral Therapy
• Interpersonal dynamic psychotherapy
• Deep muscle relaxation
• Stress reduction techniques
• Biofeedback
CBT more effective in IBS than TCA and anti-
spasmodics (~80%)
Drossman DA, et al. Gastroenterology 2003
 Psychosocial
• Psychosocial aspects can not be underscored
enough
• “Continued symptoms coupled with negative
work-ups (lack of definitive tests or marker), lack
of understanding of parents and patients, and
incomplete or ambivalent explanations from
providers can lead to constant worry, fear and
anxiety, thus perpetuating symptoms and
influencing healthcare-seeking behavior
adversely”.
Syed IM, et al. Gastroenterology and Hepatology, 2006
 Factors Influencing Long-Term
Prognosis
Factor Better Prognosis Worse Prognosis
Sex Female Male
Age of Onset > 6 yrs < 6 yrs
Family Normal “Painful”
Duration of Sx < 6 months > 6 months
Education level > High school < High school
completed
Socioeconomic class Middle-upper Lower
Surgery Infrequent Frequent
 Summary of FGID
• FGIDs are a spectrum of biopsychosocial
disorders that lack a diagnostic marker
• Involve altered GI function, with
dysfunction of brain-gut axis regulation
• Focus should be a return to normal function,
not complete resolution of pain.
 Take Home Message
• Abdominal complaints are common in
school age children
• Many may be a symptom of underlying
organic or functional disease
• Some may be attempts at distraction from
school work or attendance
• Early referral for evaluation is important in
cases of associated symptoms or significant
academic or social dysfunction