OBJECTIVES VISCERAL PAIN RECEPTORS LOCATION & NATURE OF THE PAIN LOCATION OF VISCERAL PAIN RECEPTORS 4/12/2018. Nancy Brown, APRN, CPNP April 18, 2018

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1 Nancy Brown, APRN, CPNP April 18, 2018 OBJECTIVES 1. Understand the principle causes of acute abdominal pain in children. 2. Make symptom based diagnoses of functional abdominal pain in children. 3. Recognize warning signs that differentiate disease from functional abdominal pain in children. LOCATION & NATURE OF THE PAIN VISCERAL PAIN RECEPTORS SOMATOPARIETAL PAIN RECEPTORS REFERRAL PAIN LOCATION OF VISCERAL PAIN RECEPTORS Muscle and mucosa of hollow organs Mesentary tissue that attaches abdominal organs to wall of abdomen Serosal surfaces- membrane that covers the wall of the organs VISCERAL PAIN RECEPTORS 1

2 VISCERAL PAIN RECEPTORS Respond to Stretch Not always well localized 3 areas of association SOMATOPARIETAL PAIN RECEPTORS SOMATOPARIETAL PAIN RECEPTORS Respond to stretching, tearing or inflammation Better Localized One sided More intense REFERRAL PAIN Visceral fibers affect somatic nerve fibers in the CNS Occurs when visceral nerve fibers affect nerve fibers in spinal cord or CNS Pain is localized but distant from affected site HISTORY AND SYMPTOMS Onset of symptoms In what order & Progression Pain Improving or getting worse? Does eating make it better or worse? Does defecation make it better or worse? Does exercise make it better or worse? What makes it better or worse? Have you tried any treatment? 2

3 DIFFERENTIAL DX BY COLOR OF VOMITUS EMESIS Bile-colored Coffee-ground colored Bright red blood, small Bright red blood large Food or gastric Content Fecal Appearance SUGGESTED DIAGNOSIS Obstruction Midgut volvulus Esophagitis Gastritis Gastric ulcer Trauma from forceful vomiting Esophagitis Gastritis Esophageal tear, gastric ulcer Duodenal ulcer, Esophageal varices Infectious gastroenteritis, obstruction Obstruction DIFFERENCIAL BY APPEARANCE OF THE STOOL DIFFERENTIAL BY APPEARANCE OF STOOL STOOL Watery diarrhea Hard or Large Stool Decrease in stool frequency Mucus-containing SUGGGESTED DIAGNOSIS Infection: Bacterial, viral, parasitic Appendicitis with perirectal abscess Constipation Constipation or Obstruction Colitis APPEARANCE OF STOOL CONT D Stool Bright red blood, small amount Bright red blood, large amount Currant jelly stool Melena Pale, acholic stools Suggested Diagnosis Constipation Fissure Hemorrhoid, suggesting constipation Colitis Henoch-Schonlein purpura Polyp Colitis, Polyp Intussusception Intussusception Gastric or Duodenal Ulcer Biliary or Hepatic disease GUIDELINES (TIPS) TO DETERMINE SEVERITY OF THE ILLNESS Can be difficult due to individual s response to pain from the stoic to hysterical Does the patient look ill? Acute appears ill, tachypnea, fixed facial grimace Chronic often look sad, but not acute ill Symptoms improving or worsening Examination for acute abdomen 3

4 EXAM FOR ACUTE ABDOMEN Examination for acute abdomen Psoas Sign Rovsing s Sign Obturator Sign Heel Tap Sign MCBURNEY S POINT Murphy s Sign LABORATORY DIAGNOSIS In perplexing cases, laboratory studies frequently are requested, and with notable exceptions, are remarkably unhelpful. Ross, PIR 2010 Studies may include: CBC Erythrocyte sedimentation rate Urinalysis Teen female - pregnancy 4

5 RED FLAGS WHEN TO WORRY RED FLAGS Pain localized to the right upper or right lower quadrants + Acute Abdomen exam Blood in the stools Weight loss Fever Persistent vomiting ACUTE ABDOMINAL PAIN REQUIRING SURGICAL INTERVENTION APPENDICITIS Inflammation of the appendix results in distention leading to ischemia. Necrosis, perforation and peritonitis or abscess may ensue. Inflammation starts, the visceral nerves send a message of general unease, which may manifest as pain referred to umbilical region, then anorexia, nausea. Vomiting, fever, guarding, and abdominal pain with any movement (esp walking) Inflammation increases and the parietal peritoneum becomes irritated, the somatic nerves begin to signal that something is wrong. - pain McBurney Point APPENDICITIS CONT S If Appendix ruptures, may have clinical improvement, then over the next hours the child worsens due to peritonitis. Sometimes localized abscess forms instead, RLQ pain continues and a tender mass becomes palpable Diagnostic Tests CBC RLQ ultrasound CT scan BECAUSE THERE IS NO PERFECT TEST FOR APPENCICITIS OTHER THAN THE PATHOLOGY REPORT, THE BEST DIAGNOSTIC INSTRUMENT IS THE EXAMINER. (Baker PIR) SIGNS OF APPENDICITIS Tenderness at McBurney point Involuntary guarding Pain on movement Rovsing sign Percussion or palpation in the RLQ results in pain in an area approximately 2/3 of the distance from the umbilicus to the anterior superior iliac spine Abdominal wall muscle spasm to protect inflamed abdominal organs from motion Significant increase in pain with walking, hopping off of the table, or jumping up and down Pressure in the LLQ results in pain in the RLQ 5

6 SIGNS OF APPENDICITIS CONT D Rebound tenderness Psoas sign Obturator sign Anorexia, nausea, vomiting, fever Bent knees Sudden release of deep palpation of the abdomen results in a large increase in pain DO THIS LAST With the pt on h/her left side, extend the right thigh while applying stabilizing resistance to the right hip. Should cause an increase in pain due to the location of the appendix over the iliopsoas muscle Increased pain wit passive flexion and internal rotation of the right thigh The child is most comfortable while laying with knees bent PYLORIC STENOSIS INTUSSUSCEPTION SMALL BOWEL VOLVULUS REPRODUCTIVE SURGICAL EMERGENCIES Ovarian Torsion Testicular Torsion Ectopic Pregnancy MEDICAL CAUSES OF ACUTE ABDOMINAL PAIN 6

7 COMMON MEDICAL CAUSES OF ACUTE ABDOMINAL PAIN TREATMENT CONSTIPATION Diet changes Miralax 8mg/Kg 5Kg 11 lb 2 oz ¼ cap 10Kg 22 lb 4 oz ½ cap 15Kg 33lb 6 oz ¾ cap 20Kg 44lb 8 oz 1 cap Regular toilet time stool for feet Try oral clean out at home may need hospitalization OTHER ACUTE MEDICAL CAUSES OF ABDOMINAL PAIN Gastritis NSAID- Induced Dyspepsia Henoch-Schonlein Purpura Ulcer Disease Abdominal Migraine Esophagitis Hepatitis Pancreatitis Biliary Tract Disease GYN CAUSES OF ACUTE ABDOMINAL PAIN Pelvic Inflammatory Disease Mittelschmerz Ovarian Cyst CHRONIC AND RECURRENT ABDOMINAL PAIN FUNCTIONAL ABDOMINAL PAIN DISORDERS 7

8 EPIDEMIOLOGY Definition pain must occur at least 4 times each month for at least 2 months One in 10 children visits a clinician because of chronic or recurrent abdominal pain NORWEGIAN STUDY 87% of pts with abdominal pain met criteria for functional gastrointestinal disorder (FGIDs) on first visit Only 1-2% of those had diagnoses change over time to an organic disease CHANCES ARE SLIM THAT THE NEXT CHILD WHO COMES TO THE OFFICE WITH A BELLYACHE HAS A DISEASE PATHOPHYSIOLOGY OF CHRONIC AND RECURRENT ABDOMINAL PAIN Disability associated with FGID s maybe related to the child s catastrophization: the child believes the symptoms are severe and hopeless. The patient may exaggerate symptoms and believe that they cannot cope Improving the child s self-efficacy, belief they can help themselves get better, may be an important factor in symptom resolution RISK FACTORS FOR FAP HOW CAN CLINICIAN SCREEN QUICKLY FOR DISEASE? 8

9 DURATION OF EACH EPISODE If pain lasts less than 5 minutes, even many times per day is unlikely to be worrisome Pain lasting few minutes may be abdominal wall muscle cramps or colon contractions LOCATION OF THE PAIN GENERALLY THE CLOSER THE COMPLAINT OF AIN IS TO THE UMBILICUS, THE LESS LIKELY IT IS DUE TO DISEASE TIME OF DAY Usually upon awakening or going to sleep At this time the child assesses their body for discomfort Less aware of body sensations during the active day DESCRIPTION OF THE PAIN Is the Pain Constant or intermittent Constant Unrelated to events as eating or defecation likely reflects CNS pain Comes and Goes How often does it occur, how long does it last Does eating make it better, worse, no different? Does defecation make the pain better, worse, or no different? Does exercise make your pain better, or worse, or no different? PHYSICAL APPEARANCE Patient may appear to be in no distress, but may rate their pain as an 8-9 May look sad, but rarely ill No one believes that I am in pain because I look normnal INDIVIDUALS RESPONSE TO PAIN HEALTHY COPING SKILLS Poor coping skills Anxiety Depression Academic or social stress Coexisting mental health disorder 9

10 OTHER FACTORS AFFECTING GI SYMPTOMS Food, infection, inflammation, intestinal permeability, and the microbiome OTHER FACTORS AFFECTING SYMPTOMS Early childhood acute pain events FUNCTIONAL GASTROINTESTINAL DISORDERS Definition comes from Rome Criteria International GI meeting Rome I 1994 Rome IV 2016 Rome Foundation classification of FGID s is based on symptoms rather than physiological criteria FUNCTIONAL DYSPEPSIA (FD) Must include 1 or more of the following at least 4x mo for at least 2 mo Postprandial fullness Early satiation Epigastric pain or burning not associated with defecation After appropriate evaluation, the symptoms cannot be fully explained by another medical condition IRRITABLE BOWEL SYNDROME (IBS) Abdominal pain at least 4 days per month associated with 1 or more of the following Related to defecation A change in frequency of stool A change in form (appearance) of stool In children with constipation, the pain does not resolve with resolution of the constipation (if the pain resolves the child has functional constipation, not IBS) After appropriate evaluation, the symptoms cannot be fully explained by another medical condition ABDOMINAL MIGRAINE Must include all of the following occurring at least twice Paroxysmal episodes of intense, acute periumbilical, midline or diffuse abdominal pain lasting 1 hour or more (should be the most severe and distressing symptom) Episodes are separated by weeks to months The pain is incapacitating and interferes with normal activities 10

11 ABDOMINAL MIGRAINES CONT D The pain is associated with 2 or more of the following Anorexia Nausea Vomiting Headache Photophobia Pallor After appropriate evaluation, the symptoms cannot be fully explained by another medical condition FUNCTIONAL CONSTIPATION Must include 2 or more of the following occurring at least once per week for a minimum of 1 month with insufficient criteria for a diagnosis of IBS Two or fewer defecations in the toilet per week in a child of a developmental age of at least 4 years At least one episode of fecal incontinence per week History of retentive posturing or excessive volitional stool retention History of painful or hard bowel movements FUNCTIONAL CONSTIPATION CONT D Presence of a large fecal mass in the rectum History of large-diameter stools that can obstruct the toilet After appropriate evaluation, the symptoms cannot be fully explained by another medical condition More information is available at FUNCTIONAL ABDOMINAL PAIN NOT OTHER WISE SPECIFIED Must be fulfilled at least 4 times per month and include ALL of the following Episodic or continuous abdominal pain that does not occur solely during physiologic events (eg eating, menses) Insufficient criteria for IBS, FD, or abdominal migraine After appropriate evaluation, the abdominal pain cannot be fully explained by another medical condition DIFFERENTIAL DIAGNOSIS School phobia and Separation Anxiety General Anxiety Psychosomatic Abdominal wall Pain Celiac Disease Lactose Intolerance TESTING???? 11

12 THE MORE TESTS YOU DO THE MORE THE PARENT/CHILD THINKS THERE IS SOMETHING YOU HAVEN T FOUND Therapeutic alliance with the Parent Reassurance and Empathy that the pain is real Abdominal pain without disease more common that abdominal pain with disease TREATMENT TREATMENT PAIN IS REAL Cognitive behavioral therapy Dietary therapy Supplements medications TIME TO WORRY ALARM SIGNS AND SYMPTOMS PROMPTING TESTING FOR DISEASE Pain localized to the RUQ or RLQ Weight loss or Poor weight Gain Persistent vomiting Blood in Stool Slow or delayed puberty Painful swallowing Dysphagia Family Hx of IBS or celiac disease Fevers Arthritis Perianal disease: skin tags, fissures, fistulae WHEN TO SEE A SPECIALIST Treatment failure Prolonged School Absence Presence of Alarm Features Abnormal laboratory test results 12

13 PARENT RESOURCES Chromic and Recurrent Abdominal Pain Spanish: https// (English only) REFERENCES Chogle, Ashish et al. Pediatric IBS: Overview on Pathophysiology, Diagnosis and Treatment. Pediatric Annals. 2014;43(4) Fishman, Mary B. et al. Chronic Abdominal Pain in Children and Adolescents: Approach to the evaluation Hyams, Jeffrey S. et al. Childhood Functional Gastrointestinal Disorders: Child/Adolescent. Gastroenterology. 2016;150: Hyman, Paul E. Chronic and Recurrent Abdominal Pain. Pediatrics in Review. 2016;37(9) REFERENCES Ross, Albert, LeLeiko, Neal S. Acute Abdominal Pain. Pediatrics in Review. 2010;31(4) Schmulson, Max J., Drossman, Douglas, A. What is New in Rome IV. J Neurogastroentrol. 2017;23(2)