Pediatric Primary Care (85 page)

1.  Common cause of recurrent abdominal pain in older children and adolescents.

2.  Estimated that about 6% of middle school students and 14% of high school students may fit criteria.

D.  Clinical manifestations.

1.  Abdominal pain/discomfort, usually lower abdomen or periumbilical; relieved by defecation/onset associated with change in frequency/ appearance of stool.

2.  Otherwise well, without evidence of underlying structural/metabolic abnormalities.

3.  BMs may be predominantly loose, constipated, or fluctuate between the two.

4.  May pass mucus with stool.

5.  Stool urgency, especially in morning; occasional feeling of incomplete defecation.

6.  Abdominal bloating/distention, especially later in day.

7.  Important questions to ask:

a.  Location, timing, frequency, duration, quality of pain.

b.  BM frequency, consistency, size. Straining? Mucus or blood? Stool urgency?

c.  Does BM relieve abdominal pain? Anything that helps or aggravates symptoms?

d.  Is patient on medications? Any OTC remedies?

e.  Sensation of abdominal bloating? What time of day?

8.  Complete diet history including beverages. Any weight loss?

9.  May have functional dyspepsia symptoms such as nausea. No vomiting.

10.  Red flags in history indicating diagnosis other than IBS include growth failure, weight loss, joint symptoms, vomiting, blood in stool, fever, family history of inflammatory bowel disease (Crohn's or ulcerative colitis), dysphagia.

E.  Physical findings.

1.  Height, weight, temperature, vital signs.

2.  Complete physical exam with attention to:

a.  Abdomen: Assess for tenderness, masses, stool, hepatosplenomegaly.

b.  Rectal: Assess for fissures, skin tags, fistula.

F.  Diagnostic tests.

1.  No test to diagnose IBS.

2.  Screening studies usually necessary to be sure no underlying pathology.

a.  Stool for occult blood, ova and parasite, giardia antigen.

b.  CBC, ESR.

c.  Consider lactose breath hydrogen test to rule out lactose intolerance.

G.  Differential diagnosis.

1.  Constipation, GER.

2.  Lactose intolerance: Decreased lactase enzyme in small intestine causes malabsorption, subsequent diarrhea, abdominal pain, gas if excessive lactose ingested.

3.  Recurrent abdominal pain syndrome.

4.  Inflammatory bowel disease: Crohn's disease, ulcerative colitis: usually associated with growth delay/weight loss, anemia, diarrhea with/without blood, possibly joint pain, mouth ulcerations. Physical exam may reveal abnormal appearance to anus, abdominal tenderness.

H.  Treatment.

1.  There is currently a lack of high-quality evidence on the effectiveness of dietary interventions.

2.  High-fiber diet, consider starting fiber supplement (OTC). AAP recommends: child's age +5 grams of fiber/day.

3.  Regular meals, avoid caffeine.

4.  Ensure adequate rest and exercise.

5.  Bloating/loose stools: Reduce sorbitol and fructose in diet.

6.  Predominantly constipation: Add stool softener such as MiraLax, milk of magnesia.

7.  Cognitive-behavioral therapy, such as relaxation and biofeedback.

8.  Pharmacologic treatment reserved for continuing symptoms usually monitored by MD. Low-dose tricyclic antidepressants used with some success, probably due to effect on ENS. Antispasmodics used but little data at this time to support their use. Studies using probiotics inconclusive and ongoing at this time.

I.  Follow up.

1.  Return to clinic for any change/worsening of symptoms.

2.  Refer to counselor as needed for relaxation therapy or biofeedback.

3.  Refer to pediatric GI specialist if red flags or if treatment not successful.

J.  Complications.

1.  School absence/avoidance.

K.  Education.

1.  Discuss IBS at first visit. Explain that although diagnosis of exclusion, real diagnosis.

2.  Reassure if history consistent with IBS and physical exam and screening studies are negative, further testing not necessary.

3.  Discuss enteric nervous system and possible reasons for symptoms of IBS.

4.  Explain importance of regular meals and exercise; both can help control symptoms.

5.  Fiber supplementation may take 8 weeks to make difference.

6.  Identify psychologic triggers such as family upset/school difficulties.

7.  Insist on regular school attendance.

XII.  PYLORIC STENOSIS (PS)

A.  Gastric obstruction at pylorus muscle.

B.  Etiology.

1.  Unknown.

C.  Occurrence.

1.  Most common form of nonbilious vomiting in infants.

2.  Usually in infants after 2-3 weeks of age, up to 5 months of age.

3.  About 3 per 1000 live births in United States.

4.  Male-to-female ratio = 4:1, especially firstborn males.

5.  Caucasians > African Americans.

6.  Increased incidence if mother had PS as infant (20% of her male offspring, 10% of female offspring will develop PS).

7.  Can be associated with other congenital defects (e.g., tracheoesophageal fistula).

D.  Clinical manifestations.

1.  Nonbilious vomiting. Vomiting progressively projectile, immediately after feeding.

2.  Can occur intermittently or with every feeding.

3.  Infant hungry after emesis.

4.  As condition worsens, increased fluid losses, electrolyte imbalance, weight loss.

E.  Physical findings.

1.  Length, weight, temperature, vital signs.

2.  Assess overall hydration, activity level, signs of hunger.

3.  Abdomen: may palpate firm mass, approximately 2 cm in length, olive shaped. Usually to right of umbilicus in upper abdomen, toward midepigastrium. Easier to palpate after vomiting. Mass may not be palpable in early PS.

4.  Visible peristalsis may occur after feeding.

F.  Diagnostic tests.

1.  Abdominal ultrasound confirms majority of cases.

G.  Differential diagnosis.

1.  GERD.

2.  Gastroenteritis.

3.  Inborn errors of metabolism.

4.  Overfeeding.

H.  Treatment.

1.  Admit patient for rehydration/electrolyte management with referral to pediatric surgery (pyloromyotomy).

I.  Follow up.

1.  Post-hospitalization office visit to ensure infant regaining weight, tolerating feeds.

2.  Follow up with surgical team.

J.  Complications.

1.  Dehydration.

2.  Failure to thrive.

3.  Weight loss.

K.  Education.

1.  Reassure that infants do very well after surgical correction.

2.  Infant may resume normal feeding within 1-2 days postoperatively.

XIII. PEPTIC ULCER DISEASE (PUD)