A recent study (below) reminded me of a joke. First the joke (better with the visual effect):
A guy goes to his doctor. The patient says, “Doctor when I touch here on my shoulder (with index finger) it hurts, when I touch here on my leg (with index finger) it hurts, and when I touch here on my stomach (with index finger) it hurts.”
In this cross-sectional study of 7-17 year olds (n=406) with Rome III functional abdominal pain disorder (FAPD), the authors examined the frequency of pain outside GI tract over a 2 week study period. Patients were recruited from both a large academic pediatric GI practice and general pediatric offices in same hospital system.
In total, 295 (73%) children endorsed at least 1 co-occurring nonabdominal pain, thus, were categorized as having multisite pain with the following symptoms: 172 (42%) headaches, 143 (35%) chest pain, 134 (33%) muscle soreness, 110 (27%) back pain, 94 (23%) joint pain, and 87 (21%) extremity (arms and legs) pain
In addition, 200 children (49%) endorsed 2 or more nonabdominal pain symptoms
Participants with (vs without) multisite pain had significantly higher abdominal pain frequency (P < .001) and severity (P = .03), anxiety (P < .001), and depression (P < .001). Similarly, children with multisite pain (vs without) had significantly worse functional disability (P < .001) and health-related quality of life scores (P < .001).
The authors note that due to the design of their study, they cannot establish a causal association between pain symptoms and psychosocial functioning.
My take: A lot of kids with stomach pain have multisite pain as well as anxiety and depression. This study reminds us to ask about them.
A recent study (MP Jones et al. Clin Gastroenterol Hepatol 2020; 18: 360-7) provides granular data on a well-recognized phenomenon: stomach pain is more common in older children than younger children and is associated with psychosocial factors.
Design: “All Babies in Southeast Sweden” Study with 1781 children (born 1997-99). Families answered questionnaires at birth, 1 year, 2.5 years, 5 years, 8 years and 10-12 years.
Abdominal pain prevalence increased linearly with age -each year the rate increased . At 2 yrs, the prevalence was ~6%, at 5 yrs ~8%, at 8 yrs ~9.5%, and at 12 yrs ~12% (Figure 2)
Psychosocial factors associated with abdominal pain included lower emotional control at 2 yrs of age, parental concern for child at 2 yrs of age, and measures of parental stress.
My take: This study reinforces the idea that psychosocial factors increase the development of non-organic abdominal pain. If they could be addressed better, GI clinics would be less busy.
A recent study (HK Singh, LC Ee. JPGN 2019; 68: 214-7) reviewed a single center’s colonoscopy data (n=652) from 2011-15 with a focus on patients who underwent this procedure for abdominal pain.
Only 15 patients had isolated abdominal pain as an indication. In total 68 patients had abdominal pain as an indication but the majority had other ‘red flags’ such as rectal bleeding, family history of IBD or polyposis, weight loss, anemia, food allergy, or altered bowel habits
None of these 15 patients with isolated abdominal pain had organic disease
Among 36 patients with a measured fecal calprotectin and abdominal pain, all with elevated levels had positive histologic findings.
The ileal intubation rate/biopsy rate was 92.4%
I was particularly interested in this study because our group has reviewed our clinical experience in a large cohort undergoing outpatient colonoscopy (findings will be presented this fall). Our group has a similar ileal intubation rate and a low rate of organic disease in those with isolated abdominal pain.
My take: More efforts are needed to carefully select pediatric patients undergoing endoscopy to minimize low value procedures.
For refractory disease, consider rectal therapy –suppositories, transanal irritagations/enemas (~78% success for fecal incontinence/constipation). These treatments should be used prior to surgical therapy (eg. Malone antegrade continence enema/cecostomy)
The quest for the holy grail: Accurately diagnosing and treating extraesophageal reflux
Rachel Rosen Boston Children’s Hospital
It is frequent that EGD or impedance study will be abnormal, though this may not be causally-related.
No correlation with ENT exams/red airways and reflux parameters
No correlation with lipid laden macrophages and reflux parameters
No correlation with salivary pepsin and reflux parameters
Lansoprazole was not effective for colic or extraesophageal symptoms (Orenstein et al J Pediatrics 2009)
PPIs can increase risk of pneumonia/respiratory infections
Macrolides have been associated with increased risk of asthma but may be helpful for pulmonary symptoms
Fundoplication has not been shown to be effective for reducing aspiration pneumonia. Fundoplication could increase risk due to worsened esophageal drainage.
ALTEs (BRUEs -brief resolved undefined events) need swallow study NOT PPIs
POTS and Joint Hypermobility: what do they have to do with functional abdominal pain?
Miguel Saps University of Miami
Patients with POTS and joint hypermobility have frequent functional abdominal pain as well as other comorbidities
A few years ago I saw a patient with a similar rash (BF Curtis et al. Gastroenterol 2017; 153: 355-6) and texted a picture to a dermatology colleague who quickly asked me whether my patient was using heating packs/heating pads on her abdomen.
This rash, termed, “erythema ab igne,” develops due to excessive heat exposure. Also, it has been called “toasted skin syndrome.” Over time, if heat is not continued to abdomen, in most cases, the skin reverts to normal in this benign asymptomatic condition.
A recent study (C AM Zar-Kessler et al. JPGN 2017; 65: 16-21) retrospectively reviewed a single center’s 8 year experience (2005-2013) using antidepressant medications to treat nonorganic abdominal pain. Of 531 cases, 192 initiated treatment with either a selective serotonin reuptake inhibitor (SSRI) or a tricyclic antidepressant (TCA).
63 of 84 (75%) of SSRI-treated patients improved; 56 of 92 (61%) of TCA-treated patients improved. The higher response rate to SSRIs persisted after control for psychiatric factors.
A much higher percentage of SSRI-treated patients, compared to TCA-treated patients, had anxiety (49% vs 22%); an additional 15% and 5%, respectively, had combined anxiety/depression.
The most common SSRI in this study was citalopram with median dose of 10 mg (range 5-60 mg).
The most common TCA in this study was nortriptyline with median dose of 20 mg (range 10-50).
Similar numbers of patients in each group had adverse effects, include 21 (25%) of SSRI-treated patients and 20 (22%) of TCA-treated patients. 14% of SRRI-treated patients discontinue medication due to adverse effects, compared with 17% of TCA-treated patients.
Mood disturbances were higher in this study among TCA-treated patients: 14% compared with 6% of SSRI-treated patients
TCAs were prescribed by gastroenterologists in 88% of cases; with SSRIs, only 39% of prescriptions were from gastroenterologists.
In the discussion, the authors note that “all patients who experienced GI adverse effect were prescribed medications that would worsen their underlying bowel complaint…these issues may have been mitigated if more attention was paid” to this. “Specifically, TCAs should be used cautiously in those with constipation, whereas SSRIs should be avoided in those with diarrhea.”
My take: This study shows that both classes of antidepressants were associated with improvement. The conclusions about effectiveness are limited as this is a retrospective study and could not control/evaluate many variables. That being said, particularly if there is coexisting anxiety, as was frequent in this study population, a SSRI may be more effective.
Disclaimer: These blog posts are for educational purposes only. Specific dosing of medications (along with potential adverse effects) should be confirmed by prescribing physician. This content is not a substitute for medical advice, diagnosis or treatment provided by a qualified healthcare provider. Always seek the advice of your physician or other qualified health provider with any questions you may have regarding a condition.
In the first study, Hoekman et al identified 21 studies to determine the placebo response in pediatric abdominal pain-related functional GI disorders. The authors found a pooled response to placebo of 41% (improvement) and resolution with placebo occurred in 17%.
The second study examined 289 children (55% U.S., 45% Italy) comparing the frequency of functional GI disorders in children with celiac disease on a gluten free diet compared with controls. Overall, chronic abdominal pain was present in 30.9% of subjects with celiac disease compared with 22.7% of sibling controls and 21.6% of unrelated controls. This did not reach statistical significance.
A recent study (JJ Korterink et al. JPGN 2016; 63: 481-7) showed that yoga treatment may be helpful with children (8-18 years) with functional abdominal pain. The authors studied 69 subjects who received either standard medical care or standard care with yoga therapy. Pain intensity was followed with a pain dairy as was quality of life with KIDSCREEN-27. Key finding: At 1 year follow-up, 58% of the yoga group had a treatment response compared to 29% in the control group. Yoga therapy was associated with reduction in school absences as well as reduced abdominal pain.
While yoga is considered helpful in stress management and has been suggested as treatment for adults with irritable bowel, an associated editorial by Yvan Vanderplas (pg 451) notes that the scientific basis for yoga therapy remains weak. He notes that yoga trials are biased due to selection bias and the results are tainted due to lack of blinding with regard to the intervention.
My take: If families are interested in yoga therapy, this should be encouraged. Yoga therapy is safer and at least as effective as many other therapies offered for abdominal pain.