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Chronic Abdominal Pain and Headache in

an Adolescent Female

Ben Wright, MD, PGY-2

University of Utah

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Recurrent abdominal pain

History of at least three episodes of pain

Pain sufficiently severe to affect activities

Episodes occur over a period of three months

No known organic cause

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Prevalence 9 -15% - all comers

10-15% - PCMC GI inpatient service

70-80% - proportion of time spent by the

pediatric GI resident in these patients

rooms

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Abdominal Pain Two types of nerve

fibers

A fibers - sharplocalized pain in skinand muscle,

C fibers - transmit

poorly localized, dullpain from viscera,peritoneum, andmuscle

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Visceral Pain

Epigastrium - liver,pancreas, biliary tree,stomach, or upper

bowel Umbilicus - distal small

bowel, cecum,appendix, or proximalcolon

Suprapubic distal largebowel, urinary tract, orpelvic organs

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Words to Live ByAssume that all pediatric abdominal pain

is constipation until proven otherwise.

-Molly OGorman, attributed to Dan Jackson

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So What Do We Do? Biopsychosocial model of care

Primary goal is return to normal function, rather than

complete elimination of pain. Education of the family is an important aspect.

Cognitive-behavioral therapy

Evidence regarding the benefit of treatment with H2

receptor agonists, supplemental fiber, or a lactose-free diet is inconclusive.

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Celiac Disease 3 to 13/1,000 children or 1/300 to 1/80 children

The gliadin fraction sensitizes lamina propria

lymphocytes Concordance in monozygotic twins approaching

100%

associated with MHC class II alleles DQA1*0501 and

DQB1*0201 More common in kids with DMI and T21 (x 50)

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Celiac Disease

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The Damage Villus atrophy, crypt hyperplasia, and

damage to the surface epithelium in the

small bowel

Decreased absorptive and digestive

capacity

Relative increase in immature epithelialcells

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Histology

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Symptoms and Signs Failure to thrive 36

Diarrhea 30

Irritability 30 Vomiting 24

Anorexia 24

Foul stools 21

Abdominal pain 8

Excessive appetite 6

Rectal prolapse 3

Height

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Non-Intestinal Manifestations and

Association of Celiac Disease Dental enamel hypoplasia of

permanent teeth

Osteopenia/osteoporosis

Short stature Delayed puberty

Iron-deficiency anemia notresponding to oral iron therapy

Hepatitis (elevated liverenzymes)

Arthritis Epilepsy with occipital

calcification

Headache

Depression

Ataxia

Myelopathy

Autoimmunity

Diabetes mellitus type 1 Thyroiditis

Primary biliary cirrhosis

Addison disease

Dermatitis herpetiformis

Syndromes

Turner

Down

William

Malignancy

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Idiopathic Intracranial Hypertension

raised intracranial pressure in absence of

space-occupying lesion.

often presents as headache syndrome

can lead to permanent visual loss

opening pressure > 25 cm H20

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Irritable Bowel Syndrome Definition:

abdominal

discomfort or painassociated with

disturbed defecation

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Rome III Criteria

Recurrent abdominal pain or discomfortat least three days/month in the last

three months associated with two ormore of the following:

Improvement with defecation

Onset associated with a change in

frequency of stool

Onset associated with a change in form(appearance) of stool

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AR

ole for Integrative Therapies peppermint oil appears effective for treatment

of IBS symptoms.1

evidence is inconclusive for effectiveness ofacupuncture for IBS.2

some probiotics or probiotic mixtures may

reduce IBS symptoms.

1. Ford, et al. BMJ. 2008 Nov 13;337:a2313

2. Lim, et al. Cochrane Database Syst Rev. 2006 Oct 18;(4)

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Special thanks to Jessica Howsley and her excellent history taking

skills

Clint Nelson being able appreciate papilledema priorto a dilated optho exam

Sir Tapsalot, aka Brian Sullivan and his accurate

opening pressure

Lynn Gershan and her acupuncture needles

Pysch, GI, Social Work, Ophtalmology, and everyone

else who had a hand in caring for this patient.