RAP IN CHILDREN –PANEL SESSION

TNISG -21.3.2015

CAP = Common causes DR.Nirmala

Functionl ( 70-75%) Psychogenic (12-15%) Organic( 10-15%

Constipation

Reflux Dyspepsia

Abd migraine

CVS

IBS =D/IBS-C/IBE-M

FAP

FAP Syndrome

Attention seeking

School phobia ( stress , change of school , peer conflicts , dyslexia)

Sib jealousy, rivolry

↑parental concern

Parental separation

Death of close one

Complaint modelling

Infantile colicCMPA Vs Lactose IntoleranceErosive gastritis(Drugs , rarely Hpylori )

Pancreatitis ( Ac relapsing / ch)Vasculitis

PCOD

Ch appendicitisIntest obstructionObstructed Hernia“Abd is a temple of SURPRISE ”

How to handle a constipated child?

DR.SUMATHY

• Time of onset of constipation?

• How hard and how often?

• Is it painful? Any blood in stools?

• In what posture does he pass stool?

• What is his diet like?

•

Constipation:5 IMPORTANT QUESTIONS

4 year old child : Abdominal pain - 10 mths & bed wetting 6mths

vomits feeds + Leaky stools / fecal soiling

Pain periumblical and left lower quadrant , colicky ,

irregular bowel habits – timing , rhythm and straining –

defecation phobia in view of pain due to hard pellets

O/E faecal lumps per abd , faecal soiling , circumcised 2yrs ago

On antacids , PPI , regularly antispasmodics , by many drs - no relief

Investigations: CBC, x-ray chest, Mx, stools(EH cyst),

urine routine & C & S – Normal USG; Ba Meal – Normal

Surgical opinion : Nil surgical What next?

.

Case scenario

PR : anal crack , dry pellets needing disimpaction - rewarding

G E opinion -Faulty diet Ch hab constipationStool history & with impaction + Defecation habits voiding dysfunctionAbdominal ScyballaPR - pasty pellets

soiling +

-

Causes of constipation

NEWBORN & LESS THAN 3 MTHS OF AGE

• Meconium plug syndrome – cystic fibrosis

• Anorectal malformations

• Hirschsprung’s disease

• Hypothyroidism

TODDLER AND SCHOOL GOING

• Functional idiopathic constipation

• Hirschsprung’s disease

• Drugs:Anticonvulsants,antipsychotic,codeine

containing, antidiarrheal

• Neurological: myelomeningocoele, muscle disease,

cerebral palsy, etc

• Rare causes: CMPI, celiac, intestinal neuronal

dysplasia, idiopathic slow transit constipation

Causes of constipation

OLDER CHILD AND ADOLESCENT

• Solitary Rectal Ulcer Syndrome

• Irritable bowel syndrome

• Drugs ( anticholinergics, iron,aluminium antacids,

Antidiarrhoeals, anticonvulsants ,vincristine/vinblastine )

• Spinal cord disease

• Diabetes Mellitus

• Psychological

Causes of constipation

Beware …….red flag signs

• Unintentional weight loss

• Anemia

• Rectal bleeding

• Family H/o colon cancer

• Change in stool caliber

• Pain

Examine for fissure ,soiling , scars , fistulae & haemorrhoids

Look for perineal descent with patient bearing down to identify

excessive descent

( Below the plane of ischial tuberosity or > 3.5 cm ) indicates

laxity of perineum ( defecation disorder )

PR for fecal impaction, stricture, mass, sphincter toneat rest, &

during voluntary contraction

Test perineal sensation in severe constipation (spinal cord

pathology)

INVESTIGATIONS

• Good history & physical examination

• PR is essential

• <5%- organic-tests rarely needed

• X-ray abdomen in loaded colon

• Barium enema – Dilatation from Anal vergein habit constipation.

Transition Zone in

Hirschsprung disease

Rarely to look for strictures

Management: Recommendations for Infants

A Medical Position Statement of NASPGAN

Disimpaction:

By glycerine suppositories

Enemas to be avoided

Maintenance:

Juice containing sorbitol(prune,pear,apple)

Lactulose or sorbitol as laxative

Mineral oil & stimulant laxative: not recommended

J Ped Gastro Nutr 1999;29:612-626

Management: recommendations for children

• Disimpaction: Either by oral or rectal medication,

including enemas

• Maintenance:

Diet: A balanced diet,containing whole grains,

fruits, vegetables

Laxative: Lactulose,sorbitol,magnesium hydroxide,

mineral oil

Behavioral therapy: Toilet training ( 5 min after meal )

Rescue therapy: Short course of stimulant laxative

Intractable constipation: Bio-feedback therapy

J Ped Gastro Nutr 1999;29:612-626

•High fiber diet

•Bowel training

•Close follow up

Drug Dosage Side effects

Lactulose 1-3ml/kg/day, 1-2 doses. Adjust dosage to response seen

Abdominal cramps, flatulance

Milk of magnesia

1-3ml/kg/day,1-2 doses Adjust dose to response seen

Over dose-hypermagnesemia, hypophosphatemia, hypocalcemia

Sorbitol 1-3ml/kg/day,1-2 doses Abdominal cramps, flatulance

Mineral oil (Liquid Paraffin)

Disimpaction 15-30ml/year of age.(max 240ml) Maintenance-1-3 ml/kg/day

Lipoid pneumonia

LAXATIVES

Drug Dosage Side effects

PEG (Poly Ethylene Glycol)

Disimpaction-25ml/kg/hour Maintenance-5-10ml/kg/day or 0.5-1g/kg/day

Nausea, bloating, cramps, vomiting, anal irritation.

Senna syrup: 8.8 g sennoside/ 5 mL 2–5 years: 2.5–7.5 mL/day in two divided dosages. 6–12 years 5–15 mL/day in two divided dosages (Tablets and granules available)

Idiosyncratic hepatitis, melanosis coli, hypertrophic osteoarthropathy, analgesic nephropathy, abdominal cramping. Melanosis coli improves after medication stopped

Bisacodyl 5 mg tablets, 1–3 tablets/dosage 1–2 times daily.

10 mg suppositories, 0.5–1 suppository, 1–2 times daily

Abdominal cramping, diarrhea, hypokalemia

LAXATIVES Contd.

RAP: how to handle a child with organic pain ?

DR. HEMA VIJAYALUXMI

Term CAP is current & RAP is out- dated

“ Pain details pays dividends for diagnosis ”

At least 3 episodes over 3mths at onset with clinical

variation - time frame of 1-2 months - affecting daily activity

Site , extent & radiation

Type (colicky/ gnawing /dull ache/ vague & nondescriptive)

Severity: sleep awakening , disturbed daily activity & special

postures any during pain for temporary relief

Presence of “red flags of organic disorders ” or psychic triggers ?

Constant / intermittent - Intervals-asymptomatic / symptomatic?

Relation to food, defecation , school examn ,working/holidays?

Milieux & critical stressful events any with headaches ?

What relieves & aggravates ?

Location & presentaton of abd.pain : Diagnostic clue

*Organic ( any age ) : Well localized , colicky ,at specific sites & radiating ( +/-) & +ve red flag . Positive physical signs

Specific investigations diagnostic support

__________________________________________________________

* Psychological (> 5yrs) : Vague , inconsistent , school going child

Physical examination NAD –Fake pain

Day time pain , +VE Psychic triggers

Investigations not contributory

__________________________________________________________

* FAP (> 5 yrs of age ) : Centri-abdominal /epigastric , paroxysmal nonradiating pain , unrelated to food or physical activity , varying severity & affecting daily activity = FAP (> 5 yrs of age )

Physical exam NAD but “ Real pain without any identifiable cause

All investigations not contributory

Location & type of abd. pain : Diagnostic clinical clue

• Ch constipation : Periumbilical / LLQ abd colic /pricking / defaecation issues

• Cholecystitis : RUQ pain + Murphy’s sign +ve

• Ch pancreatitis : Epigastric pain boring to mid back, recurrent & tenderness

• Small bowel obstruction(worms , Stricture or adhesion ) : Centri abdominal colic , distension & VIP

• Functional dyspepsia / GERD / PUD / H pylori or NSAID gastritis: Food related epigastric pain /gnawing ,retching , regurgitation, early satiety .

•

Location & type of abd. pain : Diagnostic clue

Abd wall pain (parietal pain) : Carnett sign +ve

Cystitis & Voiding dysfunction : Hypogastric ache & tenderness

Ch appendicitis , Ileo-caecal TB , Crohn’s disease : RLQ intermittent colic with constant finger point tenderness

Red flag signs(Specific history , +ve physical

sign & lab spport )

History Physical examination

Localized pain ,often colickyaway from umbilicus

Consistent RUQ/ RLQ pain & tenderness

Weight loss Growth retardation (deceleration)

Pain awakens the sleep Abnormal postures& finger points

Copious biliuos vomit / GI bleed Pallor & Stool occult blood +ve

Unexplained fever , arthralgia ,Rash , urinary symptoms , ch. severe diarrhoea, lethargy

OrganomegalyLymphadenopathy

Abd. distension ,obstipation Abd. scars with visible bowel loops Hernia of abdominal wall

Family h/o IBD / PUD H/O Abd surgery - scars with visible bowel loops Hernia of abdominal wall

Faecal load –rectosigmoid Faecolith )+ve in 30% appendicitis

Renal calculus ileocaecal subacute obstruction Ureteric calculus

Pancreatic calculi

Don’t forget x-ray abdomenMore useful than USG abd.

Diagnosis arrived by ultrasonogram

Hepatobiliary: Gallstones / Choledochal cyst

Pancreatic: Ch.pancreatitis / pancreatic stones

Urinary Tract: Stones / hydronephrosis

GI tract : Duplication cysts of bowel

Pelvic : PCOD

Day to day burning issue ? * Silent GB stones

* Mesenteric adenitis

* Appendicitis

CT diagnosis of appendicitis 1. Incomplete filling with contrast material or air exceeded 6mmin cross sectional diameter2) Appendiculolith or adjacent extraluminal air,

complex fluid collection 3) Mass ( USG detects)

Nonvisualisation of appendix in many normal casesAJR;175: 2008

Asymptomatic GB stones :Invariably resolve in due courseReassure & review with 6monthly USG abdomenProphylactic lap-chole in haemolytic statesLap- chole for typical biliary symptomsUDCA – medical resolution not beneficial

Ujjal Poddar , Indian Pediatr 2010;47 : 945 -953_______________________________________________________

Significance of mesenteric adenitis in USG / CT( incidental )Size : short axis diameter >10mm ( N = < 5mm – 10mm )Shape : rounded mostlyNumber : clustering of > 3 nodesSite : central / peripheral Echogenicity:altered( caseation , abscess or calcification)Cl correlation - if no red flags = unrelated to CAP( Often due to subclinical rec infections / bowel stasisReassure & review with 6 monthly USG / CT(resolve mostly)

AJR 2002; vol 178 (4) & aium July 2013 ; 32 (7)

_________________________________________________

Antispasmodics for colicks

Drotovarin can be used <6yrs of age

Dicyclomine hydrochloride

Hyoscine butyl bromide >6yrs of age

How to handlea child with FAP in children?

DR.RAJESH

FAP : Characteristic presentation

3 or more episodes over 3 mthsSymptom free intervals between pain episodes not mandatoryDaily activity affected. Not sleep awakening necssarilyNo cause found. Unrelated to meals & daefecationReal pain, variable intensity , clustering / paroxysmal (3 > mts)gradual in onset , nature & site not often clear, centri abdominal mid epigastric . Pt keeps entire hand over the area( cf : away from umbilicus in organic & inconsistent in psychic )Nausea , vomit ,head ache , pallor , fatigue may be +( Bilious vomit with red flags+ in organic pain )Clinical examination NADInvestigations not supportive but rules out organic causes when suspected with red flags ?

Role of lab tests in FAP-how far to investigate ?* Unnecessary if the history & physical examn. = diagnosis of FAP

* Investigations done in cases of “ red flag signs ” only* Medical tests reassure the pt & family & at times the physician

if there is significant functional disability & poor quality of life* Basic screening tests : CBC , urine & stool routine , stool occult blood ,CRP ,basic

chemistry panel(blood sugar, urea, creatinine)urine C & S,

Food allergy tests : Celiac serology & CMPA specific IgE AbElevated stool caloprotectin = Inflammatory pathologyEmpiric Symptomatic therapy: H2RA,PPI, Prokinetics X 2 wks.Role of Plain x-ray abdomen & Ba study

USG abdomen to rule out organic causeCT/ MRI abdomenOGD / Esophageal ph Beware of any burning issues USG abd reports?

Functional Dyspepsia: Investigations

OGD scopy when empiric treatment fails or Red flag

symptoms present

24 hr ph study of Oesophagus for GERD

when medical treatment fails & on request by distressed

parents to the extent of surgery or GERD with EE issues

*CECT abd can pick up Crohn’s, koch’s abd,microliths, nodes

Role of UGI scopy only

when empiric treatment fails or red flag s/s +ve

In children with pain epigastrium - UGI scopy helps to

detect esophagitis, gastritis and duodenal ulcer.

Little evidence to suggest that use of USG, UGI scopy

or esophageal pH monitoring will yield a clue of

organic disease in the absence of alarm symptoms

PEDIATRICS 2005; 115: 370-81

Counselling parents …

• Acknowledge: Your child feels pain

• Reassure: Your child has no serious

organic disease. Liken it to a headache

• Counsel: Your child has a very

sensitive gut.The gut’s little brain feels

pain much more than others

• We have medicines which will make

him feel better

CAP : Real pain No positive phy findings , no identifiable cause , lab test, USG,CT etc.& endoscopy normal – lap

appendicectomy status- parental concern & puzzled doctor - how do you explain the pain ?

Possible pathogenesis of FAP : Gut-brain interaction

↓

Visceral hypreralgesia

↑

1. Abnormal bowel activity (IBS-D , IBS-C , IBS- Mixed)

2. Physiological stimuli(meal,gut distension,hormonal)

3.Noxious stressful stimuli ( inflammatory process)

4.Psychological stressful stimuli (parental separation,anxiety )

Case Snippet : When to suspect abdominal migraine ?(In the preceding 12 mths , 2 or more times)

1. When episodes of paroxysmal acute & intense centriabd pain -

1-2 hrs associated with nausea ,vomiting ,anorexia , uni /bi-temporal throbing headaches , photophobia & pallor (any two) .

2. Complete recovery between episodes

3. Strong family h/o migraine=diagnostic credibility (not always +ve)

4. Pain interferes with normal activity

5. Clinical examn. NAD

CECT , MRI BRAIN not supportive

CAP-Presentation:Clinical ,Red Flags & basic lab tests

+ve ( any age ) -ve ( > 5 yrs of age )↓

Look for organic Psychic Cause. ↙ Trigger ↘

+ve -ve↓

Counseling

Functional Gastro intestinal disorders↓

Functional constipation / Funct dyspepsia / IBS /Abd migraine / FAP/ FAPsyndrome/ CVS

DR.VSS

Symptom overlap – a challenge

Child with chronic pancreatitis may develop a psychological overlay due to chronic depression

Child with functional abdominal pain may develop appendicitis

Current concept : In some children CAP pain may be a combination of functional abdominal pain with somatic/ Psychic triggering elements

Role of drugs in FAP

Nausea, satiety & bloating = gastroparesis Erythro / prokinetics

Postprandial epigastric pain,Belching , wt loss = gastric hypersensitivity Amitryptaline

Functional dyspepsia = functional dysmotility : clonidineProkinetics,LSM,

(eg. GOR , NUD & for pain -Sumatriptan ,Buspirone

Abd distension = hypersensitivity to acids / lipids AmitryptalineAlosetron , clonidine

Organic painPUD like = Hpylori infection 2 antibiotics &1PPIx2wks

DR.Nirmala

Practitioner’s learning points ? DR.VSS

• Strip clothings during phy examn not to miss rashes , hernia etc.

• Avoid empiric antispasmodics for all types of abdominal pain

esplly in HSP / urticarial vasculitis , chronic constipation & int.obst.

• Ask for top ( head ache) , mid ( abd colic) & bottom ( constipation)

• Empiric antacids / PPI for dyspepsia & not for colonic symptoms

• Check when was anthelmintics given before prescribing

• Don’t advice treament through phone without naked eye exam

( many miss intussusception , subacute intestinal obstruction )

Practitioner’s learning points( contd) DR.VSS

• FAP ( common ) , Psychogenic ( less common) & organic(rare)

• Focus on pain details , red flags & psychic triggers

• Common causes for CAP : Retentive constipation , GERD , erosive

gastritis , abdominal migraine , dysmenorrhoea , pancreatitis PCOD , lactose intolerance / food allergy SRU ,UTI , Crohn’s , psychogenic

* Diagnosis not that easy in children < 4 years of age , lot of issues ??

• Be clear about incidental GB stoes , mesenteric RLQ lymphadenitis

& probe tenderness RLQ (appendicitis ) in USG abd reports

• Clinical dignosis more useful than lab investications in FAP

TAKE HOME MESSAGE

The wise clinician will make a careful

evaluation based first & foremost on a

thorough history & physical exam

supplemented as appropriate by prudently

targeted investigations

Thank you