Functional bowel disorders presenting with abdominal pain

Irritable bowel syndrome

IBS is the most common painful functional gastrointestinal disorder in children, with symptoms arising with similar incidence in both genders.5,62 Because there are no known biochemical or structural markers for IBS, the diagnosis is based on typical symptoms with the aid of negative results of a limited diagnostic evaluation. Despite their limited validation, the most widely accepted criteria for definition of all functional bowel disorders in children are the Rome II criteria (Table 14.1). The criteria for IBS require abdominal pain associated with bowel movements or with change in stool frequency or stool character-istics.63,64 Patients with IBS may be classified into those with a predominance of diarrhea, those who tend to have constipation, and those whose symptoms alternate from diarrhea to constipation.

Functional dyspepsia

According to Rome II criteria, functional dyspepsia is persistent or recurrent pain or discomfort centered in the upper abdomen. Functional dyspepsia has two presentations - ulcer-like and dysmotility-like - although considerable variation and overlap occur between the two entities. Symptoms include upper abdominal pain or discomfort, bloating, belching, early satiety, nausea, retching, or vomiting. The diagnosis is based on symptoms, as there are no biologic markers for this condition.65 A controversial issue is the requirement for a negative esophagogastro-duodenoscopy to reach the diagnosis (Table 14.1). Dyspeptic symptoms are frequent in children. An Italian school study in children 6-19 years of age revealed symptoms of dyspepsia in 45% of children.66 Although the link between Helicobacter pylori infection and the development of chronic abdominal pain is controversial, there seems to be evidence of an increased risk of dyspepsia in adult patients infected with H. pylori.67 This link has not been clearly defined in children, where it remains unknown whether H. pylori-induced gastritis (when not associated with peptic ulcer) is responsible for clinical symptoms.68

Functional abdominal pain

Although the terminology seems confusing, it should be noted that the term 'functional abdominal pain' has been considered by the Rome II committee members as one of the categories of abdominal pain, being an entity by itself (Table 14.1). This group comprises patients with pain that is usually located in the periumbilical region and is not consistently related to eating, defecation, menses, or exercise. Patients may have associated headache, dizziness, light-headedness, nausea and vomiting. As with other forms of pain of functional origin, the diagnosis is clinical.

Abdominal migraine

In some children with a personal and family history of migrainous headache, the abdominal pain may be acute, severe and non-colicky, and often associated with pallor and anorexia. This is sometimes referred to as abdominal migraine. Children with abdominal migraine are completely healthy between attacks, but suffer a feeling of intense misery during attacks, interrupting their activities, and seeking out a quiet, dark room. Pain is usually periumbilical, incapacitating and poorly defined. Bouts of pain can last from a few hours up to 2-3 days. Peak prevalence is at 10 years of age, declining rapidly thereafter, although occasionally it may persist into adulthood.69

In contrast to children, adults with migraine headaches usually do not have abdominal pain.70 Follow-up studies have shown an evolution of children with abdominal migraine into adults with migraine headaches,71 and the episodes of abdominal pain have been considered a prodrome to migraine headaches. The clinical features of abdominal migraine and cyclic vomiting syndrome (recurrent, sudden, self-limiting episodes of nausea, vomiting and lethargy) show considerable similarity; treatment of the two conditions often utilizes similar pharmacological agents.72

Functional bowel disorders presenting with abdominal pain 219

Table 14.1 Rome II criteria for functional bowel disorders associated with abdominal pain or discomfort (from reference 74)

Functional dyspepsia

In children mature enough to provide an accurate pain history, at least 12 weeks, which need not be consecutive, within the preceding 12 months of:

  • 1) Persistent or recurrent pain or discomfort centered in the upper abdomen (above the umbilicus); and
  • 2) No evidence (including upper endoscopy) that organic disease is likely to explain the symptoms; and
  • 3) No evidence that dyspepsia is exclusively relieved by defecation or associated with the onset of a change in stool frequency or stool form.

Irritable bowel syndrome

In children old enough to provide an accurate pain history, at least 12 weeks, which need not be consecutive, in the preceding 12 months of:

  • 1) Abdominal discomfort or pain that has two out of three features:
  • a) Relieved with defecation; and/or
  • b) Onset associated with a change in frequency of stool; and/or
  • c) Onset associated with a change in form (appearance) of stool; and
  • 2) There are no structural or metabolic abnormalities to explain the symptoms. The following symptoms also support a diagnosis of irritable bowel syndrome:
  • a) Abnormal stool frequency defined as more than three bowel movements per day or fewer than three bowel movements per week;
  • b) Abnormal stool form (lumpy/hard or loose/watery);
  • c) Abnormal stool passage (straining, urgency, or feeling of incomplete evacuation);
  • d) Passage of mucus with stool;
  • e) Bloating or feeling of abdominal distension.

Functional abdominal pain: At least 12 weeks of:

  • 1) Nearly continuous abdominal pain in a school-aged child or adolescent; and
  • 2) No or only occasional relation of pain with physiological events (e.g. eating, menses, or defecation); and
  • 3) Some loss of daily functioning; and
  • 4) The pain is not feigned (e.g. malingering); and
  • 5) The patient has insufficient criteria for other functional gastrointestinal disorders that would explain the abdominal pain.

Abdominal migraine: In the preceding 12 months:

  • 1) Three or more paroxysmal episodes of intense, acute midline, abdominal pain lasting 2 h to several days, with intervening symptom-free intervals lasting weeks to months; and
  • 2) No evidence of absence of metabolic, gastrointestinal and central nervous system structural or biochemical diseases; and
  • 3) Two of the following features:
  • a) Headache during episodes;
  • b) Photophobia during episodes;
  • c) Family history of migraines;
  • d) Headache confined to one side only;
  • e) An aura or warning period consisting of either visual disturbances, sensory symptoms, or motor abnormalities.

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