It Hurts Here and Here and Here

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.”

The doctor says: “Your finger is broken.”

BP Chumpitazi et al. J Pediatr 2021; 236; 131-136. Multisite Pain Is Highly Prevalent in Children with Functional Abdominal Pain Disorders and Is Associated with Increased Morbidity

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.

Key findings:

  • 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.

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More Pictures From Atlanta Beltline West End

Neurologic Toll of Celiac Disease

A recent prospective cohort study (M Hadjivassiliou et al. Clin Gastroenterol Hepatol 2019; 17: 2678-86) shows an alarmingly-high level of neurologic deficits in 100 consecutive adults (mean age 43 years) with a new diagnosis of celiac disease.

Key findings:

  • Gait instability in 24%
  • Persistent sensory symptoms in 12%; peripheral neuropathy was identified in 2%
  • Frequent headaches in 42%
  • Abnormal results from Brain MRI in 60%; 25% had brain white matter lesions beyond expectation for age group and 46% had abnormal MR spectroscopy of the cerebellum
  • Anti-TG6 antibodies were detected in 40% of patients and this subgroup had significant atrophy of subcortical brain regions compared to patients who were Anti-TG6 antibody-negative

Some neurologic findings improve on a gluten-free diet (GFD).  In previous studies of patients with CD and headaches, 75-80% improved or subsided after a year of strict adherence to a GFD.

My take: This study indicates that early diagnosis of celiac disease along with strict adherence to a gluten-free diet is likely to prevent permanent neurologic disability.

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Something You Probably Have Not Seen with Celiac Disease and Headaches

An “image of the month” in the NEJM shows the association between celiac disease and occipital calcifications in a 24 year-old with a 10 year history of headaches, here’s the link: 

The course and explanation: Treatment with a gluten-free diet, folic acid supplementation, and carbamazepine was initiated, and the patient’s condition improved, with remission of all symptoms. The combination of celiac disease, epilepsy, and cerebral calcification is a rare condition known as the CEC syndrome. Folate malabsorption is a suggested mechanism


Also, there is a useful patient celiac education page from JAMA Pediatrics & University of Chicago: