Patient Presentation
An 11-year-old female came to clinic for evaluation of recurrent abdominal pain. She had been seen twice in the emergency room and once in the outpatient clinic for similar problems over the past two months. The episodes occurred at least once a week and would cause her to not want to go to her music lessons and she would lie down for a while. Occasionally she would take acetaminophen for the pain. She described periumbilical pain without radiation and which improved with defecation. She said that her stools were “looser” but denied any blood or mucous. The episodes were not increasing in frequency or intensity and never occurred at night. She denied any bloating, flatulance or emesis. She ate a normal, mixed diet and the pain did not appear related to meals. They had been traveling in the region where she lived for musical recitals which she enjoyed but had been drinking from municipal water supplies. She also has not been around non-domestic animals. She had not had menarche. She had not been around anyone with gastrointestinal complaints nor had taken any medications other than the acetaminophen. The past medical history revealed that she was a high achieving individual both in the classroom and in regional music competitions. The family history is remarkable for high achieving parents. The mother related that she has always had some “stomach trouble” that she watched her diet for, especially her fiber intake. There was no gastrointestinal or rheumatological diseases in the family. There was a maternal uncle with basal cell skin cancer that was treated with excision. The review of systems was negative including no weight, skin, urinary, or vision changes.
The pertinent physical exam showed a healthy female who had gained 1.5 kilograms since her well child visit several months ago and who had gained 0.5 kg since the onset of her pain. Her weight was 25% and height was 50%. Her abdominal examination showed normal bowel sounds, with no masses or splenomegaly. She had no pain with palpation and rectal examination had normal tone without masses palpable. Genitourinary examination showed a normal female with patent vaginal opening. The work-up included a complete blood count, erythrocyte sedimentation rate, electrolytes, urinalysis and stool guiac which were all negative. Because of parental concerns and the regional travel, stool cultures were also negative eventually.
The diagnosis of irritable bowel syndrome was made. The family was counseled about the etiology and natural history with an emphasis that the patient was having real pain yet there is not anything seriously wrong with her gastrointestinal tract. The family was instructed to keep consistent habits for sleep, eating, school and other activities. They were asked to keep a symptom diary. The mother said that she would especially be sure that the child had adequate fiber in her diet. “I know that this helps me, so I hope it will help her,” the mother stated. The patient’s clinical course at followup 6 weeks later showed marked improvement with only 2 episodes of pain. The diary also showed that the pain seemed to be around when she was doing more musical performances, so the family said they were try to be aware and supportive of the patient around those times.
Discussion
Abdominal pain is a common problem for children and a review can be found here.here. Functional gastrointestinal diseases are one of the most common problems not only in children but throughout the lifespan and a review can be found here.
Irritable bowel syndrome (IBS) is the most common functional gastrointestinal diseases with 10 to 15% of children suffering from IBS. The cause is unknown but it is considered a brain-gut disorder. “It is postulated that the state of disregulation exists/occurs within the enteric and the central nervous systems in patients with IBS and this results in alteration in sensation, motility, and possibly, immune system dysfunction.” It is most likely due to complex interaction between hereditary and environmental factors.
The Rome III criteria for IBS is:
- Irritable Bowel Syndrome
- Criteria fulfilled at least once per week for at least 2 months prior to diagnosis
- Must include both of the following:
- Abdominal discomfort (meaning an uncomfortable sensation not described as pain) or pain associated with two or more of the following at least 25% of the time:
- Improvement with defecation
- Onset associated with a change in frequency of stool
- Onset associated with a change in form (appearance) of stool
- No evidence of an inflammatory, anatomic, metabolic, or neoplastic process that explains the subject’s symptoms
- Abdominal discomfort (meaning an uncomfortable sensation not described as pain) or pain associated with two or more of the following at least 25% of the time:
Classically the change in bowel frequency or consistency is associated with periumbilical abdominal pain that is relieved by defecation. Symptoms will also worsen during periods of emotional distress. There are 3 non-mutually exclusive subtypes. IBSC which has constipation as a predominant symptom. IBSD which has diarrhea as a predominant symptom. And IBSA which alternates between constipation and diarrhea. Patients may have one predominant subtype and overtime have another.
A thorough history and physical examination is important to look for “red flags” possibly indicating organic disease which include:
- Growth problems and unintentional weight loss
- Significant GI complaints including emesis, diarrhea and blood in the stool
- Pain that is not periumbilical (or radiates) or pain at night
- Systemic symptoms – fever, rash, joint pain, urinary symptoms, apthous ulcers
- Family history of gastrointestinal organic disease – inflammatory bowel disease, ulcer, celiac disease
- Abnormal laboratory testing – elevated inflammatory markers, anemia, etc.
Basic laboratory testing are also important in excluding more serious disease and can include a basic metabolic panel, complete blood count, C-reactive protein or erythrocyte sedimentation rate, urinalysis and urine culture and stool guaiac. Additional testing may be indicated based on the patient’s history such as stool for ova and parasites with a history of travel or animal exposure, stool C. difficile after antibiotics or breath hydrogen testing for possible malabsorption.
Despite best clinical efforts, some patients with IBS will eventually be diagnosed with a more serious alternative diagnosis. A study of adults 18 to 75 years old diagnosed with IBS found that there was a small increased incidence of Crohn’s disease, inflammatory bowel disease and colorectal cancer. The greatest risk was in the first 6 months of diagnosis and the authors believe that this is due to timing of the diagnostic evaluation for the patients. This finding was true even for young adults in the 18 to 29 year range.
Learning Point
After a thorough history, physical examination and laboratory evaluation excludes evidence of organic causes or other functional abdominal pain etiologies, the diagnosis of IBS can be made based on the criteria above.
The most important step in treatment of IBS is explaining to the family and the child the diagnosis, the natural history and providing reassurance that there is no underlying serious pathology. This often provides adequate treatment for the child and family. However some children have more severe symptoms and therefore need further intervention.
Dietary interventions are one of the most common and generally accepted treatments for families. There is some evidence that fiber supplementation help patients with IBSC subtype disease. A low fiber diet could be beneficial for those with IBSD. Use of partially hydrolyzed guar gum may help patients with IBSA.
Probiotics have been used for adult patients with IBS. They are considered safe to use and may be helpful for patients whose symptoms were initiated as the result of an infectious etiology such as gastroenteritis.
Medications generally show weak evidence of benefit. Peppermint oil and trimebutine maleate can be helpful for some children with spasmotic pain. Antibiotics are usually not recommended but can be useful if bacterial overgrowth is suspected. The antidepressant amitriptyline is effective in adults.
Hypnotherapy and yoga have also shown some beneficial effects in children. Cognitive behavioral therapy is often prescribed but evidence is not strong to support it.
Questions for Further Discussion
1. What are the key signs and symptoms of Crohn’s disease and inflammatory bowel disease?
2. What are other functional abdominal pain syndromes?
Related Cases
- Disease: Irritable Bowel Syndrome | Abdominal Pain
- Symptom/Presentation: Abdominal Pain
- Specialty: Gastroenterology | General Pediatrics
- Age: School Ager
To Learn More
To view pediatric review articles on this topic from the past year check PubMed.
Evidence-based medicine information on this topic can be found at SearchingPediatrics.com, the National Guideline Clearinghouse and the Cochrane Database of Systematic Reviews.
Information prescriptions for patients can be found at MedlinePlus for these topics: Irritable Bowel Syndrome and Abdominal Pain.
To view current news articles on this topic check Google News.
To view images related to this topic check Google Images.
To view videos related to this topic check YouTube Videos.
Sandhu BK, Paul SP. Irritable bowel syndrome in children: pathogenesis, diagnosis and evidence-based treatment.
World J Gastroenterol. 2014 May 28;20(20):6013-23.
Paul SP, Barnard P, Bigwood C, Candy DC. Challenges in management of irritable bowel syndrome in children.
Indian Pediatr. 2013 Dec;50(12):1137-43.
Canavan C, Card T, West J. The incidence of other gastroenterological disease following diagnosis of irritable bowel syndrome in the UK: a cohort study.
PLoS One. 2014 Sep 19;9(9):e106478.
Author
Donna M. D’Alessandro, MD
Professor of Pediatrics, University of Iowa Children’s Hospital
Pediatric Education 