Documente Academic
Documente Profesional
Documente Cultură
DOI 10.1007/s12098-016-2111-5
REVIEW ARTICLE
Received: 22 July 2015 / Accepted: 6 April 2016 / Published online: 22 April 2016
# Dr. K C Chaudhuri Foundation 2016
Introduction
Functional gastrointestinal disorders (FGIDs) include cluster of
symptoms resulting from disorders of gastrointestinal (GI)
* Manu R Sood
msood@mcw.edu
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Functional Dyspepsia
Symptoms:
Pathophysiology
Functional abdominal pain is hypothesized to be a multifactorial disorder resulting from a complex interaction
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Subcortical centers/Hypothalamus
CRH
Pituitary Gland
ACTH
Glucocorticoids
Epinephrine
Norepinephrine
Autonomic
Nervous System
Adrenal
Gland
Enteric Nervous
System
Spinal
Neurons
Intestine
Functional brain imaging studies to evaluate brain processing of visceral afferent input in pain predominant FGIDs and
changes of attentional, affective and regulatory processing in
the brain involving cortical and sub-cortical structures have
been reported [13]. Previous studies focused on regional brain
activation of areas involved with visceral pain processing;
recently neuroscientists have used the network connectivity
approach to evaluate brain organizations in carrying out complex tasks and characterized cortical and sub-cortical areas
into large-scale networks [14]. One network called the
salience network is of particular relevance in chronic pain
disorders. This network is involved in visceral and somatic
sensory processes, modulation of attention, affective processing, autonomic regulation of the gastrointestinal state,
and motor response selection, all of which represent the
key elements in understanding brain mechanisms underlying visceral hypersensitivity in pain predominant FGIDs
[15, 16]. The salience network plays a critical role in
monitoring the salience, identifying the most relevant internal
and external sensory input, and initiating the generation of
Clinical Presentation
Functional abdominal pain is frequently located in the
periumbilical region and usually not associated with red flags
like vomiting (especially bilious), diarrhea, weight loss, nocturnal symptoms or growth deceleration.
A majority of the GI disorders presenting with abdominal
pain can be differentiated from FAP by a careful history taking
and clinical examination (Table 3). Children with constipation
and rectal fecal impaction can report postprandial pain [28].
Intolerance to lactose or sucrose or excess fructose or sorbitol
ingestion in fruit juice has been associated with abdominal
pain, bloating and diarrhea [2931]. A detailed dietary history
can help to diagnose dietary triggers and food intolerance that
can present with abdominal pain.
Usually children with periumbilical abdominal pain and no
alarm symptoms do not require investigations. If the
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Table 3
GI tract
Esophagitis (Erosive, infectious, eosinophilic)
Gastro esophageal reflux disease (GERD)
Gastritis (NSAID induced, H. pylori)
Peptic ulcer disease
Celiac disease
Disaccharidase deficiency
Carbohydrate intolerance
Parasitic infestation (Giardiasis)
Intestinal malrotation, Volvulus
Intussusception
Meckels diverticulum
Chronic appendicitis
Epiploic appendagitis
Inflammatory bowel disease
Gall bladder, hepatic and pancreatic disorders
Cholelithiasis
Choledochal cyst
Chronic hepatitis
Liver abscess (Amoebic)
Recurrent pancreatitis
Urinary /Genital disorders
Urinary tract infection
Hydronephrosis
Urolithiasis
Dysmenorrhea
Pelvic inflammatory disease
Endometriosis
Other
Familial Mediterranean fever
Malignancies
Vasculitis
Porphyria
Hereditary angioedema
Sickle cell crisis
Lead poisoning
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Treatment
When evaluating a child with FAP, it is critical to ensure sufficient time is allocated for the consult to allow the child and
family to share their concerns. It is important to explain the
pathophysiology of visceral hypersensitivity in a simple and
child friendly language. Establishing reasonable goals for improvement enables the physician to provide positive feedback
and helps to maintain trust in the physician-patient relationship.
Cognitive behavioral therapy (CBT) is established on the
belief that our thoughts, feelings and behavior interact, and
aim to reduce or eliminate physical symptoms through cognitive and behavioral modification. CBT helps patients to modify cognitive distortions or irrational, negative thinking to improve mood and functioning. Relaxation treatments guide in
reducing psychological distress by achieving physiological
state in stressful situations. Common relaxation techniques
like abdominal breathing, hypnotherapy, progressive muscle
relaxation, and biofeedback are found to be useful. Cognitive
behavioral and relaxation therapies are emerging as the first
line treatment for children with FAP, although larger and
better-designed studies in the future will help to confirm their
beneficial effect in FAP [3337].
Caffeine, large and fatty meals, lactose, carbonated drinks,
which can exacerbate pain, or cause gastrointestinal symptoms, should be identified, with an attempt to avoid or modify
them. Avoiding dietary triggers identified by the parents can
help but a recent cochrane review suggested that there is a lack
of high quality evidence on the effectiveness of dietary interventions in children with FAP [38].
Anti-secretory drugs are commonly used in children with
abdominal pain but their efficacy has not been evaluated. A
double blind placebo cross-over trial evaluated the improvement in pain and global assessment scores in 25 children with
abdominal pain. There was improvement in global assessment
scores, but not in abdominal pain scores in children treated
with famotidine compared to placebo [38]. Tricyclic antidepressants with sedative properties can help children with
sleep disruption and FAP. But their role in treatment of
FAP is controversial. A multicenter placebo-controlled
study of 90 children with FAP, irritable bowel syndrome
and functional dyspepsia compared the effect of 4-wk amitriptyline therapy with placebo [39]. Total of 63 % of
patients reported feeling better in the amitriptyline group
compared with 57.5 % in the placebo group. None of the
outcome variables were significantly different between the
two groups. A fixed dose for a relatively short period of
time was used in this trial. Future studies evaluating the
effect of an escalating dosage schedule for a relatively
longer period of time would help to clarify the role of
tricyclic antidepressants in the treatment of FAP.
Low-grade bowel inflammation and immune alteration
have been reported in adults with IBS and are also associated
with changes in the gut flora. In post-infectious IBS patients,
probiotics can help to restore the qualitative and quantitative
changes in indigenous gut flora and improve symptoms.
Lactobacillus GG therapy for 4 wk was compared to placebo
in 104 children with FAP, functional dyspepsia or irritable
bowel syndrome: 25 % of children in the Lactobacillus GG
group compared to 9.6 % in the placebo group had improvement in abdominal pain. In this study, children with IBS were
more likely to respond to Lactobacillus GG therapy compared
to children with FAP. Another study compared 8-wk
Lactobacillus rhamnosus GG therapy in 141 children with
irritable bowel syndrome and FAP with placebo [40]. At week
12, improvement in abdominal pain was achieved in 72 %
subjects in the probiotics group compared to 53 % in the
placebo group. Probiotics may be helpful in treating children
with pain associated FGIDs, but their mechanisms of action is
not well understood. Modulation of gastrointestinal lumen
towards an anti-inflammatory state and conversion of undigested carbohydrates into short-chain fatty acids may help to
improve gut function.
Conclusions
Rome symptom based criteria can help differentiate children
with FAP from other pain associated FGIDs. However, recent
studies suggest that symptom based criteria may not be very
accurate and this type of illness categorization can be result in
the same patient being diagnosed with multiple illnesses based
on Rome criteria. In addition to pain a majority of patients
have other GI and psychological symptoms which can impact
their quality of life. Since children with FAP lack identifiable
structural abnormalities of the gastrointestinal tract or diagnostic tests to evaluate alterations in gastrointestinal function,
it is pivotal to take a comprehensive history and perform a
physical examination, which can help identify red flags and
develop management plan. It is crucial to understand that psychological co-morbidities, functional disability, and parental
perception of the severity of their childs illness have important bearing on treatment outcome. Based on published evidence cognitive behavioral therapy is effective in a vast
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