ABDOMINAL PAIN: GI WONDER

ABDOMINAL PAIN: GI WONDER Kathe Menown, APRN GI Nurse Practitioner October 7, 2016 © The Children's Mercy Hospital, 2014. 03/14 Acute vs. Chronic A...
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ABDOMINAL PAIN: GI WONDER Kathe Menown, APRN GI Nurse Practitioner October 7, 2016

© The Children's Mercy Hospital, 2014. 03/14

Acute vs. Chronic Abdominal Pain

© The Children's Mercy Hospital, 2014. 03/14

A Historical Perspective • Chronic abdominal pain viewed as result of either organic or non-organic causes (i.e., body or mind) • Less than 5-10% defined (traditionally) as “organic” (e.g., IBD, celiac disease) • Many providers offer reassurance only – No organic cause apparent – Child will “outgrow” it

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A More Modern View Organic vs. “Functional”

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Psychological Distress: Myth or Reality? There does not appear to be a single psychological profile for children with RAP: – ~ 45% report no psychosocial difficulties. – ~ 40% report problems with anxiety only. – Only ~15% of children with RAP report broad problems across many areas of emotional and behavioral functioning. © The Children's Mercy Hospital, 2014. 03/14

Red Flags • Fever • Weight loss • Blood in stools • Nocturnal pain • Localized pain • Rash, joint pain, apthous ulcers, dysuria • Elevated ESR or CRP

• + FH of peptic ulcer disease or Inflammatory Bowel disease • Dehydration

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Alarm Signs & Symptoms • • • • •

Hematemesis Hematochezia Chronic severe diarrhea Unexplained fever Family history of IBD

• Evaluation: CBC, ESR, CRP, celiac serology, and stool cultures, endoscopy

© The Children's Mercy Hospital, 2014. 03/14

Alarm Signs & Symptoms • Significant vomiting • RUQ pain/tenderness • Evaluation: LFTs, amylase, lipase, UA, and abdominal ultrasound

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Alarm Signs & Symptoms • Weight loss • Deceleration of linear growth • Evaluation: CBC, albumin, ESR, CRP, and celiac serology

© The Children's Mercy Hospital, 2014. 03/14

ACUTE GI CONCERNS: What to Assess and What to Do

© The Children's Mercy Hospital, 2014. 03/14

Viral Gastroenteritis (GE) • AKA “Stomach Flu” – +/- nausea or vomiting – +/- fever – +/- abdominal pain or cramping – Irritable, due to discomfort or dehydration – Headache or malaise

© The Children's Mercy Hospital, 2014. 03/14

Appendicitis! • Inflammation of the vermiform appendix, which is the blind pouch at the end of the cecum • Most common condition requiring abdominal surgery in childhood

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Appendicitis! • Abdominal pain; +psoas test, +Markle (heel jar), +McBurney sign • Pain precedes fever and vomiting – In GE, pain is later

• Low grade fever • Nausea and/or vomiting • No appetite • CBC; elevated WBC (not >15-20,000)

• Guarding of abdomen, hesitant to move © The Children's Mercy Hospital, 2014. 03/14

CHRONIC GI CONCERNS: What to Assess and What to Do

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Epidemiology • Affects 10-20% of all school-age children – Occurs weekly in 13-17%

– Interferes with daily activities in 21%

© The Children's Mercy Hospital, 2014. 03/14

Why Chronic Abdominal Pain? • Most frequently reported chronic pain problem in school aged children and adolescents (1025%)

• Greater than 50% will have symptoms that persist into adulthood

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Functional GI Disorders • Combinations of symptoms not explained by known structural or biochemical abnormalities • Pain is real, but no “blood and pus” disease • Alteration in the way the body is working or functioning • Distinction between organic and functional more unclear as more research done

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Functional Dyspepsia • Pain in upper abdomen, may include fullness, early satiety, bloating, belching, nausea, retching, or vomiting • At least 8 weeks, need not be consecutive, in the last 12 months of persistent pain above umbilicus, and • No evidence of organic disease • Not exclusively relieved by defecation

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FD-Treatment • H2RA-Zantac 3mg/kg/dose BID-TID • Antihistamine-Atarax 2mg/kg/day in 3 divided doses

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Irritable Bowel Syndrome • Abd pain assoc w/defecation or change in bowel habits • 8 weeks, in last 12 months, need not be consecutive of; • Pain w/ 2 out of 3 features a) relieved with defecation

b) onset assoc w/change in form of stool c) onset associated with change in frequency of stool

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© The Children's Mercy Hospital, 2014. 03/14

IBS-Treatment

• Antispasmodics-Bentyl or Levsin • Low dose tricyclic antidepressantsAmitriptylline (0.5-1.0mg/kg/[email protected]) • SSRIs • Fiber • Avoid triggers

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Gastrointestinal Eosinophilia • Considered a biologic contributor to pain, not “diagnosis” per se (in most situations) • Inflammatory condition caused by activation of eosinophils and mast cells in response to allergens, viruses, and stress • This activation causes the release of histamine and many other chemical irritants

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Eosinophil Products Stimuli Tissue Injury

Chemokines

Viral Infections

Eotaxin

Allergens

Ag Presentation

RANTES

MHC-II

MIP-1

B 7.2

Lipid Mediators Leukotrienes Platelet activating factor

Cytotoxic Secretory Products EPO

Cytokines

MBP

IL-2, IL-3, IL-4, IL-5

ECP

IL-6, IL-8, TGF, GM-CSF,

EDN

TNF , IFN8, IL-12 © The Children's Mercy Hospital, 2014. 03/14

Anxiety and Inflammation CRH Nerve Sensitization

Mast Cells

Nerve Stimulation Dysmotility

T Cells Nerve Destruction

Eosinophils

Nerve Sensitization Nerve Stimulation Dysmotility

© The Children's Mercy Hospital, 2014. 03/14

The Biopsychosocial Model Visceral/Nerve hypersensitivity

Biology

Inflammation Motility Gut flora

Chronic Abdominal Pain Environment

Psychology

School Peer relationships Parent/family interactions

Mood Anxiety Coping skills Sleep

© The Children's Mercy Hospital, 2014. 03/14

Medications: Inflammation Medication

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Dose

Side Effects

Singulair

5-10 mg daily

Possible mood changes

Zantac

10 mg/kg/day (BID)

Headache, sedation

Atarax

2 mg/kg/day (TID)

Sedation, anticholinergic effects

Prednisone

1 mg/kg/day for 5 days (max dose 40 mg daily)

Nervousness, weight gain, insomnia

Entocort (3 mg capsules)

9 mg daily for 3 weeks; 6 mg daily for 1 week; finally 3 mg daily for 1 week

Weight gain, headache

Gastrocrom (20 mg/5 ml)

Starting dose is 2 vials (max dose 4 vials) 4 times a day

Unpleasant taste, dizziness, headache

© The Children's Mercy Hospital, 2014. 03/14

Double Blind Placebo-Controlled Cross-Over Trial of Montelukast in Pediatric Dyspepsia Response Rate (% Patients) 90

80 70 60 50 40 30 20 10 0

Singulair

Placebo

All Patients 27

Singulair

Placebo

Eos Counts 20-29

© The Children's Mercy Hospital, 2014. 03/14

Medications: Nerve Sensitivity Medication

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Dose

Side Effects

Elavil

0.1 to 1 mg/kg at bedtime

Anticholinergic effects, sedation

Prozac (SSRI)

Starting dose of 10-20 mg daily

Headache, dizziness, restlessness, nightmares

Buspar

Starting dose of 5 mg BID

Dizziness, headache, sedation, nightmares

Melatonin

Starting dose of 3 mg at bedtime (max dose 10 mg at bedtime)

No known side effects

Ginger (for nausea)

550 mg tablets 2 tablets TID

No known side effects

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BEHAVIORAL STRATEGIES

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Typical Treatments - Biofeedback training

- Psychiatry

- School intervention

- Family therapy

- Physical therapy

- Nutrition assistance

- Alternative therapies

- Individual therapy

(e.g., massage, acupuncture)

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- Sleep hygiene

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It may be counterintuitive, but…

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Pain

School absence

Stress

Make up work

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Where does homebound fit in? • Homebound education is: – Not typically in the child’s best interest – Frequently requested by parents and/ or encouraged by school personnel – A strategy to bridge return to school, if done thoughtfully • Most appropriate following prolonged absence • “Intermittent” homebound may be helpful for children on a modified school day

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Quick is for instant oatmeal – not pain management.

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Celebrate small steps. • Improvement is first measured by increased functioning. • A patient is improving when you see an improvement in his or her day-to-day functioning.

© The Children's Mercy Hospital, 2014. 03/14

When to Refer • Prolonged lack of response to above therapies • When parents want more answers than you have • When you want or need a scope to R/O organic problems

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Contact Information • To refer patients or ask questions, please call the Nurse Line: 816-234-3066 • Providers and families can also reference the public website for additional information: http://www.childrensmercy.org/content/view.aspx?id=4087

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GE Reflux PainConservative Treatment • Acid suppression (usually start w/Zantac) • Avoid large meals • Avoid eating w/i 2 hrs. of bedtime, do not lie down right after eating • Lose weight, if obese • Avoid food triggers, such as caffeine, chocolate, acidic or spicy foods • Eliminate exposure to cigarette smoke 37

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GERD TREATMENT PROTON PUMP INHIBITOR • PREVACID /PRILOSEC/NEXIUM 1-2 MG/Kg/DAY

PROKINETIC MEDICATION REGLAN 0.1 MG/KG/DOSE QID

• BETHANECHOL 0.1-0.2 MG/KG/DOSE TID TO QID • EES 2-4 MG/KG/DOSE TID

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© The Children's Mercy Hospital, 2014. 03/14

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