Tag Archives: abdominal pain

Abdominal Pain -Placebo Effect and Celiac Effect

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Briefly noted:

  • DR Hoekman et al. J Pediatr 2017; 182: 155-63.
  • M Saps et al. J Pediatr 2017; 182: 150-54.

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.

Related post: Is functional pain more common with celiac disease?

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Yoga Therapy for Abdominal Pain

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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.

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Advice on Abdominal Pain for Everyone Who Cares for Children

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A recent editorial (MK Farrell. J Pediatr 2016; 177: 16-17) provides many useful pointers from a master clinician along with commentary on an epidemiology study of recurrent abdominal pain (ML Lewis et al. J Pediatr 2016; 177: 39-43).

The main finding of the study which used an internet survey of mothers (children 4-18) was that 23% of US children met the Rome III criteria for a functional GI disorder.  Constipation was the most common.

Key points in commentary:

  • John Apley’s monograph The Child with Abdominal Pains “should be read by all who care for children.”
  • Worldwide prevalence of functional GI disorders has been estimated to be 13%. Peak ages were 4-6 years and early adolescence with a greater prevalence in females
  • “A variety of phamacologic and nonpharmacologic treatments have been proposed, but none have been consistently effective except perhaps cognitive behavioral therapy and hypnotherapy.”
  • “Negative studies are not reassuring” [to families]

Pithy observations from Apley:

  • “The more time the doctor spends on the history, the less time he is likely to spend on treatment.”
  • “Doctors who treat the symptoms tend to file a prescription. Doctors who treat the patient are more likely to offer guidance.”
  • “It is a fallacy that a physical symptoms always has a physical cause and needs a physical treatment.”
  • “Anxiety like courage is contagious.”

My take: Dr. Farrell urges more research focus on interventions (diet, behavioral, alternative therapies, medical treatments) to improve outcomes and less focus on epidemiology.

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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.

The Lawn, University of Virginia

The Lawn, University of Virginia

 

Slipping Rib Syndrome

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The entity, of “Slipping Rib Syndrome,” which could be mistaken for a gastronomical error at The Boathouse, is also called Cyriax syndrome.  A recent brief report (L Calvete et al. J Pediatric 2016; 172: 216) describes a typical case.  This teenager had a 1-year history of “brief, episodic, sharp upper left abdominal pain, accompanied by a [subtle] chest wall deformity, which started after physical activity.”

Key points:

  • This disorder is most common in middle-aged females but can occur at any age
  • It can result from hyper mobility of the false ribs, allowing “the affected rib to sublet or ‘slip’ under the adjacent rib,..and cause pain
  • The disorder can be elicited with the ‘hooking’ maneuver.  “In this test, the patient lies in the supine position, while the clinician hooks his or her fingers beneath the costal margins of the affected side, displacing them upward and anteriorly pulling gently.  A positive test reproduces pain.”
  • Treatment: avoidance of displacement and mild analgesics

My take: I’ve only seen this condition once but think it is important to consider in patients presenting with intermittent abdominal pain.

Atlanta Zoo 2016

Atlanta Zoo 2016

Burden of GI Diseases in U.S.

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A useful article (AF Peery et al. Gastroenterol 2015; 149: 1731-41) provides data on the huge impact that GI & Liver diseases have.

Here are some key findings:

Leading GI symptoms (Ambulatory visits) in 2010 (Table 1):

  • Abdominal pain 27.1 million
  • Diarrhea 5.6 million
  • Vomiting 5.5 million
  • Nausea 4.7 million
  • Bleeding 3.6 million

Most Common Diagnosis from Hospital Admissions in 2012 (Table 5):

  • GI hemorrhage 507,440 admissions
  • Cholelithiasis with cholecystitis 389,180 admissions
  • Acute pancreatitis 275,170 admissions
  • Intestinal obstruction 256,775 admissions
  • Appendicitis 248,080 admissions
  • Chronic liver disease/viral hepatitis 243,170 admissions

Causes of Death in U.S. in 2012 (Table 7):

  • Colorectal cancer 51,139
  • Pancreatic cancer 38,797
  • Liver/bile duct cancer 22,973
  • Cirrhosis 17,495
  • Alcoholic liver disease 17,419
Gastroenterology Cover

Gastroenterology Cover

Improving ER Performance for Suspected Constipation

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While the ultimate goal would be for most constipation to be prevented or managed by primary care physicians, the reality is that a lot of children are seen in the ER setting.  Particularly in the hospital setting, many practitioner’s have relied on abdominal xrays (AXRs) and this practice has been criticized previously (What’s Wrong with Ordering an AXR for Constipation in the …).

It is gratifying that efforts are underway to reverse this tendency.  A recent study (J Kurowski et al. J Pediatr 2015; 167: 706-10) document the effect that a 10 minute training session can have.

In this retrospective chart review, the researchers examined a 2 month baseline period and then a 2 month period after institution of a 10-min educational module for ER healthcare providers.  The module included the following:

  1. Rome III criteria for constipation  -at least 2 criteria weekly for >2 months:
    • ≤2 defecations in the toilet per week
    • at least 1 episode of fecal incontinence per week
    • history of retentive posturing or excessive volitional stool retention
    • history of painful or hard bowel movements
    • presence of a large fecal mass in the rectum
    • history of large stools which may obstruct toilet
  2. Review of the lack of utility of abdominal radiographs
  3. Use of rectal exam

Patients were identified who were discharged from the ER (without hospital admission)  with a diagnosis of constipation and with a chief complaint of abdominal pain.  In the baseline period, there were 105 patients and in the followup period, there were 91 patients.

Key findings:

  • Digital exams increased: 22.9% —>47.3%
  • AXR decreased: 69.5% –>26.4%

This study has numerous limitations; these include retrospective study and patient selection. Nevertheless, it makes several useful points.  If constipation is suspected, better care at a lower cost can be achieved by including a digital exam.  The authors note that “there is no strong evidence to support the utility of radiographs for this diagnosis [constipation] or even reliable standards to evaluate the normal stool burden across different ages.”

My take: The lessons from this study are applicable to primary care physicians and gastroenterologists as well as to ER physicians.  While this educational module is a good start, if I were designing a module, I would include information on irritable bowel syndrome which is often confused with isolated constipation.

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Not Happy With Functional GI Diseases

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A recent study (J Pediatr 2015; 166: 85-90, editorial 11-14) finds that children with functional gastrointestinal diseases (FGID) had more impaired “quality of life” than children with organic gastrointestinal diseases.  For those of us taking care of these children, this finding does not come as a surprise, but there is a lot to learn from this study nonetheless.

Using the Pediatric Quality of Life Inventory 4.0 Generic Core Scales, the authors completed a 9-site study with 689 families for patients with physician-diagnosed GI disorders including functional problems like irritable bowel syndrome and dyspepsia as well as organic diseases like Crohn’s disease and ulcerative colitis.  These patients were compared with a healthy control sample of 1114 families.

In addition to obtaining health-related quality of life (HRQOL) data, the authors reported information on school days missed, days in bed, parent missed workdays, and healthcare utilization.

Key findings:

  • FGID and organic GI diseases demonstrated lower HRQOL than healthy controls across all measures (emotional, physical, social, and school; P<0.001 for all) with larger effect sizes for FGID.
  • FGID and organic GI diseases also had more school days missed, days in bed, parent missed workdays, and healthcare utilization, again with larger effect sizes for FGID.

The associated editorial tries to work through the reasons why the impact of FGID is greater than an organic disease.

The authors hypothesize that two factors play a big role:

1. Issue of control:

  • FGID -the cause is less evident
  • FGID -very few effective treatments
  • These factors may contribute to families feeling helpless and ‘out of control’

2. Issue of response shift:

  • The authors explain that response shift indicates a circumstance in which a “patient is compelled to adjust to this new reality.”
  • Response shift often involves a change in expectations
  • Response shift often involves a change in prioritization
  • Thus, response shift could explain why patients with organic GI disease have higher quality of life scores.

In addition, the authors note that with many FGID, that physicians often “suspect constipation is the cause…when laxative therapy is not helpful, this leads to more frustration.”  They advocate shifting the focus for these families from “finding a cure to managing day-to-day symptoms.”

In my view, there are a lot of other factors at play that may help explain why HRQOL is lower in patients with FGIDs. This can include a high incidence of emotional disturbances (eg. anxiety, depression) and poor coping skills (eg. catastrophizing).  This study also is another example showing that the physical severity of the medical disease does not correlate with the severity of the impact.

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Fructose Malabsorption and Recurrent Abdominal Pain

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Even before the popularity of a low FODMAPs diet, most pediatric gastroenterologists were aware that a significant number of children would develop pain if their diet included too much high fructose corn syrup.  A recent study shows that a breath hydrogen test (BHT) for fructose malabsorption may predict patients who will improve with a low-fructose diet (JPGN 2014; 58: 498-501).  Here’s a link to the abstract: 

Design: Retrospective study reviewed a single center experience.  Fructose BHT (1 g/kg fructose to max of 25 g) was administered to 222 patients who presented with recurrent abdominal pain.  An abnormal test was defined by a breath hydrogen >20 ppm over baseline.  If positive, families met with a nutritionist for instruction on a low-fructose diet.

Key result: 121 of 222 (54.5%) had positive BHT.  Of these 121 patients, 93 (77%) reported resolution of symptoms on a low-fructose diet.  Among those with a negative BHT, 54% reported resolution of symptoms without a low-fructose diet.

Take-home message: High fructose corn syrup and fructose malabsorption can contribute to abdominal pain; though, in clinical practice, a BHT is not needed to institute a trial of a low-fructose diet.

 

What’s Wrong with Ordering an AXR for Constipation in the ER?

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My understanding is that shortly before my twin and I were born, a nurse used a pencil test to predict our genders.  Though my mother is quite smart, she believed the nurse knew what she was doing.  However, shortly thereafter, it turned out that I had a twin brother not a twin sister.

ER doctors often perform a similar service to the pencil test when they use an abdominal radiograph (AXR) to determine if their patients have constipation.  A new pediatric study from Toronto highlights this phenomenon and current recommendations (J Pediatr 2014; 164: 83-8).

Background:  this retrospective cohort study of children <18 years took place between 2008-2010.  As part of the study, a single pediatric radiologist (blinded to participant classification, assigned Leech scores to all misdiagnosis AXRs along with 20% of the remaining AXRs.  From a total of 112,381 ER visits, the review identified 3987 where constipation was the discharge diagnosis (3.5% of all visits).  In the cohort diagnosed with constipation, the mean age was 6.6 years.

Key findings:

  • Only 9% of children returned within 7 days.  20 of these (0.5%) had a significant misdiagnosis based on the authors definition, including 7 with perforated appendix, 2 with intussception, and 2 with bowel obstruction.  Other misdiagnosis included ovarian torsion, thalamic brain tumor, acute lymphoblastic leukemia, cardiomyopathy, ileal volvulus, and pancreatitis.
  • Children with a misdiagnosis had similar amounts of stool on AXR as those who were not misdiagnosed.
  • AXR was performed more frequently in those with a misdiagnosis (75% vs. 46%).
  • Rectal examination was documented in only 9% of those with a diagnosis of constipation (low frequency rectal examination has been shown in other ED-based studies).
  • Abdominal pain and tenderness were more common in those with a misdiagnosis.

Why I think this study is important:

While the authors point out that 1 in 200 children ultimately required a surgical or radiologic  intervention within 7 days, I do not think that this error rate or diagnostic delay is particularly high.  What is important is that this study reiterates the fact that AXRs are not useful for the diagnosis of constipation.  The authors note “reviews have concluded that there is no evidence of an association between clinical symptoms of constipation and fecal loading on AXR.”  Furthermore, AXRs may lead ER physicians to a cognitive diagnostic error.

Also, the misdiagnosis rate is much greater than reported in the study due to the definition adopted by the authors.  The authors did not include treatable infectious diseases (e.g.. pneumonia, urinary tract infection) as well as a large number of other medical diagnosis. Other “incipient” disease processes may have been missed including inflammatory bowel disease and celiac disease.

The authors imply that using a more standard definition of constipation would be useful, namely the Iowa criteria which requires the presence of 2 of the following:

  • ❤ stools/week,
  • ≥1 episoded of fecal incontinence/week
  • large stool palpable on rectal/abdominal examination
  • passing large stool which obstructs toilet
  • withholding posturing
  • painful defecation

The authors reference a study which indicated that AXRs should be restricted to patients with high-yield clinical features: prior abdominal surgery, foreign body ingestion, abnormal bowel sounds, addominal distention, and peritoneal signs.

Bottomline: AXRs do not establish a diagnosis of constipation.  Yet, after families have been told their child is constipated because of an AXR it is not easy to convince them that an AXR is about as useful as a pencil test for this diagnosis.

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