Tag Archives: abdominal pain

Ketamine for chronic pain –is this a good idea?

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A recent phase 1 study explored the use of oral ketamine for chronic pain (J Pediatr 2013; 163: 194-200).

Ketamine has several mechanisms of actions in improving pain.  It is frequently used in emergency room settings because of its analgesic and dissociative amnestic qualities.  In addition, it has relatively little cardiorespiratory impact, a short half-life, and is better tolerated in children than adults.

Given the frequency of chronic pain in children and the relative paucity of treatment options, the authors aimed to determine whether ketamine in a short-term study (2 weeks) would be safe and effective.  This prospective study enrolled 12 patients who received ketamine 3 times per day at dosages of 0.25-1.5 mg/kg/dose .**

Pain diagnoses included chronic pancreatitis, Crohn’s disease, esophageal spasm, headache, joint pains, and other causes.  Median age was 16 years (range 11-19).

Results:

  • Two participants, both treated with 1.5 mg/kg/dose, experienced dose-limiting toxicities: sedation and anorexia.
  • Of the 12 patients, 5 had improvement in pain scores; 2 of these patients had complete resolution of pain which lasted >4 weeks off ketamine treatment.
  • There was evidence of norketamine accumulation in many patients.  Norketamine is the major metabolite of ketamine.

**Note: All medication dosages should be checked in standard references for individual patients.  This blog may have transcription errors with regard to dosages.

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Newsflash: constipation frequently causes abdominal pain

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From the following link (forwarded to me by Mike Hart) http://www.dailyrx.com/abdominal-pain-children-emergency-room-was-most-commonly-constipation:

A recent study found that constipation is the most common reason for abdominal pain among children going to one emergency room.

Appendicitis was diagnosed in only about 4 percent of children who went to the ER.

In addition, the researchers did not find any major differences in the treatment or outcomes of children based on their race.

“Call the pediatrician if your child has severe abdominal pain.”

The study, led by Kerry Caperell, MD, of the Department of Pediatrics at the University of Louisville in Kentucky, looked at the outcomes of children who went to the emergency room for abdominal pain.

The researchers investigated the medical records of 9,424 children, aged 1 to 18, who went to the Children’s Hospital of Pittsburgh emergency department for abdominal pain during a two-year period.

More than half of these children, a total of 5,493, ended up receiving multiple diagnoses for their complaints.

The researchers found that 1.9 percent of the African American children and 5.1 percent of the white children who visited the ER were diagnosed with appendicitis. Overall, 4.3 percent of the children had appendicitis.

Appendicitis was less common among younger children, but constipation was commonly diagnosed for all ages.

Almost 20 percent of the children were diagnosed with constipation, and more than 25 percent of the children aged 5 to 12 had constipation.

Constipation, gastroenteritis and urinary tract infections were more common among the African American patients than the white patients.

“Diagnosing causes of abdominal pain in children can often be difficult, especially the younger they are,” said Chris Galloway, MD, a dailyRx expert who specializes in emergency medicine.

“Fortunately common causes are still common and constipation is a frequent diagnosis we make in the ER, and can be quite distressing for your child,” Dr. Galloway said. “Consult your pediatrician if your child has abdominal pain.”

Older children were more likely to remain in the hospital and have an operation related to the reason they went to the ER.

The researchers did not find any differences in children’s outcomes related to their race. This finding means that all the children who went to the ER received similar evaluation and treatment and had similar outcomes regardless of their ethnicity.

The study was published May 20 in the journal Pediatrics. The research did not receive external funding, and the authors declared no conflicts of interest.

Comment: While constipation is a common entity, many of these children have underlying functional problems that are not addressed in the ER setting.

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Median Arcuate Ligament Syndrome

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PEDIATRIC SURGERY UPDATE: VOL 39 NO 03 SEPTEMBER 2012 has a concise review of Median Arcuate Ligament Syndrome (MALS) along with some references -listed with other references below (thanks to Ben Gold for this reference).  MALS occurs when a fibrous portion of the diaphragmatic crura crosses the celiac artery and compression occurs. This disorder is described as a diagnosis of exclusion.  Symptoms may include weight loss, nausea, abdominal pain, vomiting, and diarrhea.  Imaging modalities including CT angiography, MR angiography or arteriography can increase the suspicion for this disorder.

While not alluded to in this reference, one of the problems is knowing whether MALS is a spurious finding.  That is, in young individuals there is typically a robust blood supply to the intestine and it is not clear whether compression of the celiac trunk is responsible for specific symptoms as there is a compensatory blood supply.

Fortunately this disorder is very rare (or at the very least rarely recognized).  One of the most experienced vascular surgeons relayed his experience over more than three decades.  He stated that he had operated on four cases of suspected MALS –two improved with surgery.  A better batting average than Chipper Jones! –but a lot fewer at bats.

References:

  • –Median arcuate ligament syndrome – Wikipedia, the free encyclopedia “It is estimated that in 10-24% of normal, asymptomatic individuals the median arcuate ligament crosses in front of (anterior to) the celiac artery, causing some degree of compression.”
  • – Median Arcuate Ligament Syndrome – YouTube
  • -Alehan D, Dogan OF: Pediatric surgical image. A rare case: celiac
    artery compression syndrome in an asymptomatic child.  J Pediatr Surg.
    39(4):645-7, 2004
  • – Gander S, Mulder DJ, Jones S, Ricketts JD, Soboleski DA, Justinich CJ:
    Recurrent abdominal pain and weight loss in an adolescent: celiac artery
    compression syndrome. Can J Gastroenterol. 24(2):91-3, 2010
  • – Said SM, Zarroug AE, Gloviczki P, Shields RC: Pediatric median arcuate
    ligament syndrome: first report of familial pattern and  transperitoneal
    laparoscopic release. J Pediatr Surg. 45(12):e17-20, 2010
  • – Aschenbach R, Basche S, Vogl TJ: Compression of the celiac trunk caused
    by median arcuate ligament in children and adolescent subjects: evaluation
    with contrast-enhanced MR angiography and comparison with Doppler US
    evaluation.  J Vasc Interv Radiol. 22(4):556-61, 2011
  • – Ozel A, Toksoy G, Ozdogan O, et al: Ultrasonographic diagnosis of
    median arcuate ligament syndrome: a report of two cases. Medical
    Ultrasonography 14(2): 154-157, 2012
  • – Wani S, Wakde V, Patel R, et al: Laparoscopic release of median arcuate
    ligament. J Minim Access Surg 8(1): 16-18, 2012
  • – “Median arcuate ligament syndrome”.Curr Treat Options Cardiovasc Med 2008 10 (2):
  • -“Median arcuate ligament syndrome: evaluation with CT angiography”. Radiographics 2005; 25 (5): 1177–82.

Unexplained chest pain

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Not surprisingly -unexplained pediatric chest pain has a high association with anxiety/psychiatric disorders (J Pediatr 2012; 160: 320).  In this study, the authors compared patients (8-17 years) with chest pain (n=100) to a cohort referred with innocent heart murmur (n=80).  In addition to cardiology evaluation, patients had a structured interview and a child health questionnaire to assess for psychiatric disorders; also, the investigators interviewed the parent(s).

Based on DSM-IV criteria, 70% of chest pain patients had an anxiety disorder and 9% had depression.  In contrast, 33% of heart murmur patients had an anxiety disorder and none were depressed.  Among the chest pain subjects, 26% had abdominal pain and 26% had headaches -both higher than the control group, 9% and 10% respectively.  Also, 90% of patients with chest pain had psychiatric disorders which preceded the chest pain.

For pediatric gastroenterologists, a take home message from this article is that chest pain is quite similar to abdominal pain (see references below); it might be interesting to discuss with cardiologists.

  • Do cardiologists experience the same reluctance from families to seek help from mental health?
  • How much testing is required before a functional diagnosis is accepted?
  • Do they follow patients with functional chest pain or send back promptly to primary care physician?

This article does not examine parental mental health issues.  This would be interesting.  In functional abdominal pain, maternal anxiety has been ascribed as the most consistent predictor of outcome (Acta Paediatr 2007; 96: 697-701).  Another factor that would be of interest would be level of activity; exercise helps reduce symptoms of irritable bowel/abdominal pain.

At the same time, the issue of reflux is not addressed by this article and not infrequently the issue of whether reflux is causing chest pain needs to be considered.  An article (Gut 2011; 60: 1473-78) regarding chest pain in adults indicates that patients with pH-probe (or endoscopic) proven GERD often respond partially (>50% reduction in symptoms) to PPI use.  This study reviewed RCTs involving chest pain and PPIs -six met inclusion criteria.  The RR of therapeutic gain for PPI usage was 4.3 for those with proven reflux and 0.4 for those with pH-probe (or endoscopic) negative chest pain.  Interestingly, in this study, heartburn was not predictive of whether chest pain was due to GERD on pH study.

Additional references:

  • -Pediatr Emerg Care 2010; 26: 830-6.  Psychopathology among children presenting to ER with unexplained chest pain.
  • -Clin Gastro 2008; 6: 329-32.  Depressive symptoms common in RAP -45%
  • -Pediatrics 2004; 113: 817.  Anxiety & depression commonly associated with RAP.  anxiety in ~79%, depression ~43%; anxiety often precedes RAP.
  • -JPGN 2011; 53: 200. n=98. 79% of FAP responded to low dose tricyclics
  • -Gastroenterology 2009; 137: 1261, 1207– Editorial.  Amitriptyline helped in 66% vs 58% with placebo. n=90. dose 10mg <35kg, 20mg >35kg. 89% had failed Rx prior to study. ‘Inability to use placebo.. in practice may justify amitriptyline’ Rx. Consider hypnotherapy/CBT first.
  • -Gut 2011; 60: 1473-78. PPI use in unexplained chest pain.
  • -Pain 2006; 122: 43-52. (Walker LS et al), J Pain 2006; 7: 319-26.  Distraction/ignoring important.
  • -J Pediatr 2009; 154: 313 (editorial), 322. Prospective school study. n=237. Weekly prevalence of abd pain was 38%. 18% with persistence for >12 weeks.
  • -Clin Gastro Hepatol 2008; 6: 329-32.  FAP persists into adulthood in 1/3 to 1/2 of cases.
  • -Gastroenterol 2006; 130: 1459-1465.  Functional esophageal d/o.
  • -Clin Gastro & Hep 2006; 4: 558. Review.
  • -Ann Heart J 2000; 40: 367-372.  Sertraline decreased chest pain independent of mood alteration/psychological scores.

Deadly consequences of pain management

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A big part of a pediatric gastroenterologist’s daily practice is trying to help patients with recurrent abdominal pain.  The goals are to determine the reason for the pain and then to offer the best therapy.  In many cases, these goals can be quite difficult.  With regard to diagnosis, the majority of patients have ‘functional’ pain and the diagnosis is in part a diagnosis of exclusion, trying to rule out other potential etiologies.  With regard to treatment, this is also difficult.

Narcotics are not often given for pediatric abdominal pain, but are used under certain circumstances.  These medications can have unintended consequences.  One consequence of frequent narcotic usage is that individuals may tolerate pain more poorly after receiving narcotics.  A useful review of narcotic overuse was published in the New England Journal of Medicine in 2010.  (NEJM 2010; 363: 1981).

“Deaths from unintentional drug overdoses in the United States have been rising steeply since the early 1990s …and are the second-leading cause of accidental death, with 27,658 such deaths recorded in 2007.”  11,499 of the deaths in 2007 were due to unintentional narcotic overdose.  In comparison, in the same year, there were about 6,000 deaths from cocaine & 2,000 deaths from heroin.

Besides the number of deaths, the other alarming factor has been a sharp rise (10-fold since 1990) in the usage of narcotics in the past two decades.  One of the factors driving this increase has been a compassionate interest in relieving pain.  The availability of these drugs throughout the country even in remote regions allows these abusable drugs to be more accessible than illicit drugs like cocaine and heroin.   While the availability of these medications may increase the rates of suicide, most opioid-overdose deaths are tragic accidents. Often, laboratory tests identify one or more substances in addition to the opioid, indicating that the depressant effects of alcohol or other drugs were additive  in causing death.

With regard to gastroenterology/pediatric gastroenterology, another important aspect of narcotics use is the association of increased mortality risk with inflammatory bowel disease.  This has been shown by analyzing a registry for infliximab (IFX) (Lichtenstein G, DDW 2010, abstracts#T1039 & T1040.).  In the TREAT registry with 6273 patients (3334 treated with IFX), the only risk factors for increased mortality/increased infections were steroids and narcotics.  This study also showed that IFX did not increase mortality, serious infections, malignancy or lymphoma in this cohort.

Additional Reference:

Clin Gastro & Hep 2008; 6: 978. Refractory abdominal pain review.  ‘Narcotics over time increase frequency, duration and intensity of pain.’ Practical recommendations:
treat constipation, withdraw narcotics, consider mental health (CBT/hypnosis/psychotherapy/stress mgt), and possible TCA or SNRI therapy.