An 11-year-old girl presents with a 6-month history of abdominal pain and nausea. She reports pain and nausea when she wakes up most days, but no pain at night. She feels nauseous when she eats and often skips meals. She feels full even when she eats and she can’t finish her meals. She reports that her mother often calls her to stay home from school or to pick her up early from school. The patient is growing normally, his weight is stable, and there is no blood or mucus in his stool. She is a good student.
What are the most likely causes of patient complaints?
brain-gut connection
Approximately 13.2% of the world’s population suffers from a functional gastrointestinal (GI) disorder, which is one of the most common conditions seen by pediatric gastroenterologists. Although the initial symptoms of functional gastrointestinal disease can be vague, the connection between the brain and gastrointestinal tract is “undeniable,” as demonstrated by the case presentation, says MSN, APRN, PNP-PC. Charlotte Rensberger said.
So it’s important to ask the right questions, Rensburger said at the National Association of Pediatric Nurse Practitioners (NAPNAP) National Conference on Pediatric Healthcare, held March 15-18, 2023 in Orlando, Florida. mentioned in the presentation. For example, morning pain on a school day may not be related to school, but rather to waking up early and having poor sleep quality. “If you think of the device as an iPhone, it has all the electronic parts, but the app has a glitch and doesn’t work properly…The problem is in the programming.”
Categories of functional gastrointestinal diseases
There are four most common categories of functional gastrointestinal disorders (Table). The four groupings are characterized by the location of pain, the presence or absence of nausea and vomiting, and the relationship between symptoms and defecation.
table.Categories of functional gastrointestinal diseases
| Category | explanation |
| Chronic functional abdominal pain | • Pain not related to other gastrointestinal symptoms. |
| functional dyspepsia | • Upper gastrointestinal symptoms such as reflux, nausea/vomiting, early satiety, and epigastric pain. |
| irritable bowel syndrome | • Pain in the upper abdomen associated with abnormal bowel movements (constipation, diarrhea, or a combination) • Occurs in 1.2-2.9% of children |
| abdominal migraine | • Intermittent sudden severe abdominal pain. • Often accompanied by pale face, nausea, sweating, and headache. |
Rensburger, who works in pediatric gastroenterology in Kalamazoo, Michigan, points out that the stomach and intestines are constantly in motion. “Patients who don’t have functional gastrointestinal disease don’t feel anything, but in patients who do, the signals between the brain and the gut become so loud that they overwhelm the system,” she explains. did.
The Rome Foundation has published updated diagnostic criteria for functional gastrointestinal diseases. Rome IVRome IV has specific requirements for each of the four types of functional gastrointestinal disorders in children. The last requirement of all is that the symptoms after the evaluation cannot be explained by other medical conditions.
Tests are performed to rule out underlying conditions that explain the symptoms, and include blood tests such as a complete blood count (CBC), complete metabolic panel (CMP), erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), and thyroid. may be included. Cascade, celiac disease screening. Stool tests, such as an occult blood test or a fecal calprotectin screen, may be done to rule out inflammatory bowel disease or bleeding. A breath test may also be done to rule out small intestinal bacterial overgrowth (SIBO). Helicobacter pylorilactose intolerance and fructose intolerance, and imaging tests include abdominal ultrasound and upper and lower endoscopy.
“Most children with functional gastrointestinal disorders have no warning signs.” These are otherwise healthy children who are growing well and have “normal blood tests, scans, and laboratory tests.” Lensburger said. “In some cases, parents may become frustrated with the lack of a diagnosis and request further testing. This is where education is most important. Be prepared for the possibility of a negative test result. [but it] It remains valuable information as it allows you to rule out certain conditions and better guide your management plan. ”
Support management
Rensburger said treating children with functional gastrointestinal disorders doesn’t fit neatly into boxes. “It can take time to dig into each symptom and develop a treatment plan.” Symptoms can wax and wane, and can be difficult for children to articulate. Treatment options often do not provide immediate symptom relief. It may be helpful for your child to keep a food diary for a period of time to help identify triggers. “It is also important for children to maintain their normal routines, attend school and participate in extracurricular activities, and virtual school is not a consideration,” Rensburger said. “We encourage children to lead normal lives: wake up, take a shower, make their bed and practice good sleep hygiene.”
It is also important to explain the disorder in a way that patients and their families can understand and understand. “This includes reassuring them that while their child’s pain is real, it is not organic and is not causing damage or life-threatening.”
“We take a symptom-focused approach. If a patient wakes up on a school day with pain or nausea, one strategy is to put crackers by the bedside to eat when they wake up and head to school. You may consider waking up early on school days to give your body time to wake up and digest breakfast before the day. If you have pain at bedtime, try peppermint tea or capsules at bedtime. “We can also teach them about good sleep hygiene, such as looking at the screen and not having electronic devices in bed,” Rensburger said. Adding probiotics through supplements or yogurt or kefir can also help restore a healthy microbiome. ”
Counseling and treatment to identify the cause of stress and mental health problems is also important. According to Rensberger, between 42% and 85% of children have active anxiety due to functional gastrointestinal disorders, which are often severely undermanaged. Teaching children healthy ways to cope with anxiety and depression is beneficial now and as they grow up.
Medications such as acid suppressants, antispasmodics, antihistamines, and anticholinergics can help manage patients with functional gastrointestinal disorders.
The patient in this case was asked to keep a symptom diary to identify triggers. Treatment consisted of acid suppression, antispasmodics (hyoscyamine) for spasms, diphenhydramine, cyproheptadine, and amitriptyline. A dairy-free diet was introduced (after a positive hydrogen breath test) and peppermint oil was administered topically at bedtime to improve sleep hygiene. Finally, the patient began counseling.
source of information
1. Rensberger C. There is nothing “fun” about the state of the functional gastrointestinal tract. Presentation location: NAPNAP National Conference. March 15-18, 2023.Orlando, Florida
2. Di Lorenzo C, Nurco S, Pediatric Rome IV Commission. Rome IV Functional Pediatric Gastrointestinal Disorders.Disorders of gut-brain interaction. 1st edition, Volume 1. Rome Foundation.
3. Pauly RJ, Filici L. Pediatric gastrointestinal disease treatment handbook. 3rd edition Pediatric Gastroenterology and Nutrition Nurses Association.
4. Jacob D, Kroon van Diest AM, Di Lorenzo C. Functional abdominal pain in adolescents: case-based management. front line gastrointestinal tract. 2020;12(7):629-635. doi:10.1136/flgastro-2020-101572