Journal of Pediatric Gastroenterology & Nutrition:
Gut Interactions with Brain and Environment in Children; First International Symposium on Pediatric Neurogastroenterology Capri, Italy, September 18-20, 1997
Connecticut Children's Medical Center Hartford, Connecticut, U.S.A.
Address correspondence and reprint requests to Jeffrey S. Hyams, M.D. at Division of Digestive Diseases Connecticut Children's Medical Center 282 Washington Street, Hartford, CT 06106
In the most basic sense there are three groups of children with recurrent abdominal pain (RAP): (Group 1) those in whom one can find a distinct cause for the pain (a test or specific finding exists for identification); (Group 2) those in whom there is a distinct clinical pattern to the symptoms, in whom that pattern of symptoms is common to many subjects, but for which no specific test exists, and diagnostic evaluation is directed toward excluding other disorders which may have a similar presentation; (Group 3) those in whom there is no generalizable group of symptoms and in whom no definable (by present investigations) cause can be identified.
The literature on recurrent abdominal pain often labels subjects in Group 1 as having “organic” disease and those in Group 2 as having “functional” disease. The etiology of abdominal pain in Group 3 is usually obscure although often these subjects are found to have significant psychosocial pathology. Classification systems for functional bowel disease in adults have previously been published (1). Clinical experience has suggested that many of the functional bowel disorders described in adults are also seen in children. The two most common include irritable bowel syndrome and non-ulcer dyspepsia.
Hyams et al. administered a gastrointestinal symptom questionnaire, an anxiety inventory, and a depression inventory, to 507 middle school (mean age 12.6 years) and high school (mean age 15.6 years) students in a suburban town in the United States (2). Abdominal pain was noted to occur at least weekly in 13-17% of subjects, and been severe enough to affect activities in 17-24%. Approximately 13% to 15% of students with a history of abdominal pain noted that the pain awakened them from sleep on at least one occasion. Nausea, heartburn, and acid brash were noted in 5% to 10% of all students.
Eight per cent of all students had seen a physician for abdominal pain within the previous year. The authors compared the characteristics of the abdominal pain, as well as reported defecatory habits, to a standarzided definition (3) of irritable bowel syndrome used in adults. They noted that irritable bowel syndrome-type symptoms were noted by 17% of high school students and 8% of middle school students who reported having abdominal pain, representing 14% and 6% of all high school and middle school students, respictively. Anxiety and depression scores were significantly higher for students with IBS-type symptoms compared with those without symptoms, but did not correlate with healthcare seeking.
Multiple reports have examined etiologies of RAP in children presenting for medical care. Hyams et al. characterized symptoms in 227 children over 5 years of age presenting to a pediatric gastroenterology clinic over a 16 month period (4). All subjects had a complete history, physical examination, and a battery of screening hematologic,biochemical,and urinary tests. Additional evaluation such as breath hydrogen testing, gastrointestinal endoscopy, ultrasonography, and radiographic evaluation performed at the discretion of the examining physician. Forty-six subjects had an abnormal breath hydrogen test suggesting lactose malabsorption, 9 had inflammatory bowel disease, and one had celiac disease. Of the remaining 171 patients, 117 (68%) fulfilled standarzided adult criteria for irritable bowel syndrome. Epigastric pain and pain radiating to the chest (dyspepsia) were observed in both IBS and non-IBS groups, though they were significantly more common in the latter group. Esophagogastroduodenoscopy was performed in 16/54 non-IBS patients (all 16 with dyspepsia) and 19/117 IBS-type patients (17 of 19 with dyspepsia). Significant peptic inflammation was found in 11/16 of the former group and 9/19 of the latter group. Adding these 20 subjects with peptic inflammation to those previously found to have “organic” disease raised the total of subjects with readily identifiable (via testing) disorders to 76 of 227 (35%) children seen for evaluation.
Conclusions: Symptoms consistent with irritable bowel syndrome are commonly observed in children and adolescents in a community setting as well as in those referred to a medical center for evaluation of recurrent abdominal pain. Dyspepsia is also noted in both of these populations. The generic term “RAP” may no longer be as helpful as it once was as a broad label for children with recurrent abdominal pain and we are now characterizing the clinical constellation of functional bowel disorders in children. This latter group appears to represent a heterogeneous group. Current research is reaveling newly defined causes of recurrent abdominal pain and we are now characterizing the clinical constellation of functional bowel disorders in children. This latter group appears to represent a sizable proportion of children seen in a referral clinic with recurrent abdominal pain.
1. Drossman DA, Thompson WG, Talley NJ, Funch-Jensen P, Janssens J, Whitehead WE. Identification of sub-groups of functional gastrointestinal disorders. Gastroenterol Int 1990; 3:159-72.
2. Hyams JS, Burke G, Davis PM, Rzepski B, Andrulonis PA. Abdominal pain and irritable bowel syndrome in adolescents: a community-base study. J Pediatr 1996; 129:220-26.
3. Thompson WG, Dotevall G, Drossman DA, Heaton KW, Kruis W. Irritable bowel syndrome: guidelines for the diagnosis. Gastroenterol Int 1989; 2:92-95.
4. Hyams JS, Treem WR, Justinich CJ, Davis P, Shoup M, Burke G. Characterization of symptoms in children with recurrent abdominal pain: resemblance to irritable bowel syndrome. J Pediatr Gastroenterol Nutr 1995; 20:209-14.
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