ABDOMINAL PAIN: GI WONDER Kathe Menown, APRN GI Nurse Practitioner October 7, 2016
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Acute vs. Chronic Abdominal Pain
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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
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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
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ACUTE GI CONCERNS: What to Assess and What to Do
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Viral Gastroenteritis (GE) • AKA “Stomach Flu” – +/- nausea or vomiting – +/- fever – +/- abdominal pain or cramping – Irritable, due to discomfort or dehydration – Headache or malaise
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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%
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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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IBS-Treatment
• Antispasmodics-Bentyl or Levsin • Low dose tricyclic antidepressantsAmitriptylline (0.5-1.0mg/kg/day@hs) • 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
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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
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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
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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
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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.
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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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