1
Q
Chronic abdominal pain: intermittent or constant pain defined by what 4 criteria?
A
- ≥3 episodes
- sufficiently severe to affect activities
- period of ≥3 months
- organic or functional
2
Q
What is meant by organic chronic abdominal pain?
A
Identifiable problem within the body
3
Q
What are characteristics offunctional GI DOs?
A
- no identifiable cause in body
* (may have visceral hyperalgesia)
4
Q
Which is more common, functional or organic chronica ab pain?
A
functional
5
Q
Categories offunctional GI DOs per Rome Criteria
A
- Functional dyspepsia
- Irritable bowel syndrome
- Abdominal migraine
- Functional abdominal pain of childhood
6
Q
Do alarm features point you to organic or functional cause?
A
Organic!!!If alarm features, evaluate for organic cause.If no alarm features, usually not necessary to evaluate further (can cause unnecessary anxiety)
7
Q
What are some HISTORY alarm features of abdominal pain?
A
- Weight loss or failure to gain weight appropriately
- Unremitting abdominal pain
- Difficult or painful swallowing
- Significant vomiting
- Chronic severe or bloody diarrhea
- Black, tarry stools
- Unexplained fever
- Urinary symptoms-dysuria, hematuria, flank pain
- Back pain
- Skin changes-rash, eczema, hives
- Family HX of IBD, celiac disease
- Unstable vital signs
- Unexplained physical finding
8
Q
What are some EXAM alarm features of abdominal pain?
A
- Deceleration in linear growth, and or delayed puberty
- Oral aphthous ulcerations
- Localized RUQ;RLQ;LLQ; suprapubic tenderness
- Hepatomegaly
- Splenomegaly
- CVA tenderness
- Perianal abnormalities- fissure, skin tags, fistulae
- Guaiac positive stool
9
Q
Diagnostic criteria for functional dyspepsia
A
W/in preceding 2 mths, at least weekly occurrence of:
- Persistent or recurring pain or discomfort in upper abdomen
Pain or discomfort not relieved by defecation or assoc w/onset of change in stool frequency or form - No evidence inflammatory, anatomic, metabolic, neoplastic process to explain sx
10
Q
Diagnostic criteria for irritable bowel syndrome
A
W/in preceding 2 mths, at least weekly occurrence of:Abd discomfort/pain assoc w/2+ of following:
- Relieved w/defecation
- Onset assoc w/change in frequency of stool
- Onset assoc w/change in form of stool
No evidence inflammatory, anatomic, metabolic, neoplastic processes to explain sxmay be constipation dominant, diarrhea dominant, or mixed
11
Q
Diagnostic criteria for abdominal migraines
A
ALL of following:Organic /other causes R/Ow/in last 12mo, 2+ episodes of:
- Paroxysmal episodes of intense, acute, periumbilical pain lasting 1+ hours
- Intervening periods of usual health lasting weeks to months
- Pain interferes w/normal activities
- Pain associated w/2+ of following: anorexia, nausea, HA, photophobia, pallor
- No evidence inflammatory, anatomic, metabolic, neoplastic processes to explain sx
12
Q
Is there an association btwn abdominal migraines and migraine HAs?
A
Yes. Many go on to develop migraines as adults.
13
Q
What is the goal of mgmtfor functional GI pain?
A
Return to normal function – not complete elimination of pain.Recognize unique challenge, stress and anxiety experienced by family and children that interferes with life.
14
Q
MGMT of functional GI pain
A
- Therapeutic relationship
- Education: biopsychosocial model of pain
- Behavior modification
- Coping: relaxation, distraction, CBT, biofeedback
- MGMT of triggers, anxiety
Possible meds: SSRIs, tricyclics,short termPPI, peppermint oil capsules
15
Q
Examples of prophylactic antimigraine meds
A
Propranolol, Cyproheptadine, Prizotien
16
Q
Methods of managing functional dyspepsia
A
- Avoid high fat foods, caffeinated beverages, NSAIDS
- Small frequent meals
- H2 blocker or PPI 4-6 weeks if severe symptoms
- If sxs >2 mos, refer to GI
17
Q
Organic causes of constipation
A
Infant dyschezia, hirschsprung disease, cows milk intolerance, CF, Celiac
18
Q
Functional causes of constipation
A
- withholding feces
- Original situation: related to toilet training, dietary changes, stressful events, toilet availability, illness or busyschedules
- Delay in stooling leads to reabsorption of fluids in the colon and increase in size and hardness of thestool
- Genetics: some families are predisposed to developing constipation
19
Q
Constipation alarm signs
A
- Ribbon stools
- Urinary incontinence or bladder disease
- Weight loss or poor weight gain
20
Q
Diagnosis of constipation 4+ yo
A
For at least 2 months:
- Two or fewer stools per week
- At least one episode of fecal incontinence per week
- Stool withholding
- History of painful or hard bowel movements
- Presence of large fecal mass in rectum
- Hx of large diameter stools that
21
Q
Diagnosis of constipation infants and toddlers
A
Same as 4+yo but only one month duration necessary
22
Q
Two types of IBD
A
Ulcerative ColitisCrohn Disease
23
Q
Crohn vs UC: clinical manifestations
A
24
Q
Crohn’s vs UC: which spreads continuously?
A
UC!Crohn’s skips (muchharder to resect), may see mouth sores
25
Diagnostic lab tests for UC & Crohn’s
Serum:
* BMP/CMP: esp hypokalemia
* ESR, CRP
* CBC: anemia, elevated WBC & PLT
* Inflammatory markers
* Albumin: nutrition
* Fecal Occult blood
* Stool cultures to rule out or include C.diff (5-25% of flare cases) and other infectious process if diarrhea
* CT if emergency
* No definitive dx w/o imaging/endoscopic exam!
26
Why do endoscopic / histologic tests for UC?
* Rule out Cytomegalovirus with colonic biopsies from sigmoid colon
* Serum testing not specific for colon disease
***Full colonoscopy should be avoided during severe flares due to perforation risk
27
How can UC be treated?
Steroids, 5-ASA, Pain mgmt (hot packs to opioids – nsaids may exacerbate)
* Bowel rest not recommended – already have decreased caloric intake and does not change disease process
* Colectomy: if severe
28
How are Crohn’s and UC definitively distinguished?
combination of endoscopy and imaging of the UGI tract
29
Tx for Crohn’s
* Refer to GI
* Depends on age and classification
* Mild: aminosalicylates, antibiotics if fistula
* Mod/Severe: aggressive tx w/glucocorticoids, possible bowel rest w/TPN, transition to methotrexate or thiopurine once in remission
30
Education w/Crohn’s
Avoid triggers: meds (ibuprofen, some antibiotics), infections, seasonal changes, stress, smoking, diet
31
IBD in primary care: what to keep in mind
```
Monitoring nutritional status
Bone health
Infection risk
Immunizations
Eye examinations
Psychological issues
Transition to adult health care
Cancer surveillance
```
32
3 types of infectious colitis discussed in class
H. pylori, VRE, C. diff
33
Presenting sx of C. diff
* fever, diarrhea, abdominal pain/cramping/tenderness, dehydration
* Hx of antibiotic use or immunodeficiency
34
When to hospitalize for C. diff
* increasing systemic symptoms (fever, hypotension, increased Crt), S&S of ilius or toxic megacolon, increasing WBC (>15,000 cells/microL), severe dehydration,
* Arrhythmias
35
Diagnosis of C. diff
* Difficult. Many kids, especially under 2yo, are colonized and will have positive stool sample.
Antibiotic use is most important factor in Hx. Can be any antibiotic, but esp penicillins, cephalosporins, clindamycin, and fluoroquinolones
36
Differential Dx for c. diff
* Norovirus, rotavirus – viral is much more likely than c. diff, but watch out for hx antibiotics and immunocompromised!
* Also VRE – risk w/previous antibiotics
37
Tx for C. Diff
* Metronidazole or vancomycin PO
* Supportive measures: re-hydrate, correct electrolytes and acidosis, pain relief, probiotics, avoid PPI use, hand hygiene!
38
Presenting s/s of H. pylori
Bloating, stomach fullness, decreased appetite, N/V,Bleeding ulcers: tar colored stool, decreased Hgb and Hct
39
Diagnostic testing for H. pylori
* Stool antigen, urea breath test (if on PPIs, both stool and urea breath test can be false neg!)
* Endoscopy if suspect PUD
40
H. pylori Tx
* Triple therapy: PPIs, amoxicillin (or metronidazole) and clarithromycin.
* Quadruple therapy: add bismuth subsalicylate
41
Criteria for diagnosis of PUD
Usually Sx 2-5 hrs after a meal or on an empty stomachMay be at time of circadian stimulation of maximal acid secretion (11pm-2am) *kids rarely present with upper GI bleed or occult blood in feces, weight loss
42
PUD on PE
* Mouth: ulcers or dental enamel erosion
* Lungs: wheezing (bronchospasm can be due to or exacerbate by gastroesophageal reflux)
* Periumbilical abdominal pain
43
Causes of PUD in kids
* H. Pylori (less than adults), NSAIDs, idiopathic
| * often functional!
44
Diagnosing PUD
* HISTORY! Med use
Test for H. pylori (not recommended as a routine)
* Treat for GERD but not improving / can’t wean off med --> upper endoscopy
* Definitively shown on endoscopy
* If unsure of Dx/complications: Also CBC w/diff (anemia), ESR (inflammation), LFTs (bleeding d/t liver dz/coagulopathy?), BMP (increased BUN)
45
Tx PUD
PPI duration depends on etiologyPossible antibiotic tx if H. pylori
46
Sx of Lactose Intolerance
Diarrhea,bulky frothy watery stools, abdominal pain (periumbilical, LQ), nausea, flatuelence
47
Patho of Lactose intolerance
Can’t absorb lactose d/t missing lactase enzymeunabsorbed lactose:
* atracts fluid into bowel lumen.
* Converted to FAs and H+ gas by bacterial flora via fermentation
48
Diagnosis of Lactose intolerance
* Lactose free diet
* Hydrogen breath test (measures lactose malabsorption)
* Fecal pH: nonspecific marker
* **routine screening for LI not recommended!
49
MGMT lactose intolerance
* Restrict lactose
* Encourage consumption of calcium rich foods or calcium & vit D supplementation (lactose may enhance calcium absorption)
50
When to refer for Lactose Intolerance?
Refer to GI if secondary LI suspected (underlying intestinal d/o)
51
S/S of Celiac Dz
Gi: chronic diarrhea, anorexia, abdominal distension and pain, failure to thrive/wt loss, vomiting (rare)Non GI: poor growth & dvpt, neuro/behavioral dz, iron deficiency, dermatitis herpetiformis, bone loss
52
Diagnostic testing for celiac dz
* Serologic: IgA Abs, tissue transglutaminase (tTG-IgA); Anti endomysial Abs (EMA); Deaminated Giladin Peptide (DGP)
* Intestinal biopsy: histological changes GOLD STANDARD
* Changes in sx w/gluten free diet not conclusive to establish dx
53
MGMT of Celiac Dz
* Gluten=free diet for life
* Oats: only if guaranteed pure and free of contamination
* All referred to nutritionist
* Serologic testing at 6mo intervals until levles have normalized
54
S/S of Chronic Pancreatitis
* Pattern varies and fluctuates
* Typically epigastric pain, radiating to back, w/N/V, may be relieved by sitting upright and leaning forward, worse 15-30 min after eating
* Fat malabsorption: loose, greasy, foul smelling stools that are difficult to flush
* Clinically symptomatic vit def (fat soluble ADEK), rare
55
Diagnosis of chronic pancreatitis
* Recurrent acute pancreatitis
* Routine tests, usually normal: CBC, LFT, electrolytes
* Pancreatic enzymes elevated
* Can progress to stool fat, imaging (ERCP, abdominal CT), genetic testing, etc
56
Tx chronic pancreatitis
pain management, correction of pancreatic insufficiency, and management of complications
57
Patient education: when to call for office visit r/t abdominal pain
* Chronic constipation (less than 2-3 bowel movements per week)
* Loss of appetite, weight loss, or becoming full after small meals
58
Patient education: when to seek immediate medical attention
* Bloody stools, severe diarrhea, or recurrent vomiting
* Severe abdominal pain that lasts longer than one hour or that comes and goes for more than 24 hours
* Your child gets upset or screams when you touch their belly
* High fever (higher than 101-102) for more than 3 days
* Pain when urinating or frequent urination
* No wet diaper in a span of 4-5 hours in an infant. No urine output in 6-8 hours in an older child
* Lethargy or behavioral changes
* Refusal to eat or drink for a long period of time
59
When can a pcp diagnose functional abdominal pain (w/o need for further evaluation)?
No alarm sx, PE nl, no occult blood in stool
60
MGMT of IBS
assess contributing psych/sociologic stressors
For constipation-predominant IBS
* Increase water and fiber
* Osmotic laxatives if needed
For diarrhea-predominant IBS limit cars and non-absorbed carbs (ie sorbitol)
* Diet low in fermentalble oligo-, di- and mono-saccharides and polyols been shown to reduce IBS sxs (restrict wheat, onion, garlic, legumes and sugar free gums, some fruits and vegetables
* May need to slow motility with atropine or diphenoyxylate
61
MGMT of abdominal migraines
is supportive and preventative – avoid food and beverages (esp caffeine) helpful, sleep, lowering stress, reducing bright/flickering lights, avoid prolonged fasting
* Prophylactic propranolol and cyproheptadine (antihistamine); sumatriptan as abortive for pain and nausea
