Assessment of gastric motor function in childhood functional dyspepsia and obesity

Imaging in pediatric disorders of the gut-brain interactions: current best practice and future directions

INTRODUCTION

Disorders of Gut-Brain Interactions (DGBI) are a common clinical problem in children and pose significant challenges to the attending pediatrician. Radiological investigations are commonly ordered to evaluate these children.

AREA COVERED

This review focuses on the current best practice of using radiological investigations in DGBIs and how novel radiological investigations could revolutionize the assessment and therapeutic approach of DGBI in children.

EXPERT OPINION

We believe imaging in DGBI is still in its early stages, but it has the potential to revolutionize how we diagnose and treat children with DGBI. As the understanding of the gut-brain axis continues to grow, we can expect to see the disappearance of conventional imaging techniques and the emergence of more sophisticated imaging techniques with less radiation exposure in the future which provide more clinically meaningful information regarding the gut-brain axis and its influence on intestinal function. Some of the novel imaging modalities will be able to broaden our horizon of understanding DGBI in children providing more useful therapeutic options to minimize their suffering.

Nausea is the only symptom associated with delayed gastric emptying in pediatric functional dyspepsia patients

OBJECTIVES

Functional dyspepsia (FD) is a heterogeneous functional gastrointestinal disorder (FGID) with a highly prevalent symptom complex. The aim of our study is to investigate the relation between symptoms of FD and results of gastric emptying (GE) breath test in children.

METHODS

This study included patients (6-17 years old) presented at the general gastroenterology outpatient clinic with dyspeptic symptoms (Rome IV criteria) and underwent careful history taking with clinical examination. A GE breath test with a 13 C-octanoic acid labeled (250 kcal) solid meal was performed and dyspepsia symptom scores, clarified using pictograms for postprandial fullness, bloating, belching, nausea, vomiting, epigastric pain and burning, were obtained every 15 min ranging from 0 to 4 for a total of 240 min. The severity of the complaints (overall and individual symptoms) as displayed by the symptom questionnaire was compared between normal and delayed GE groups. The relationship between GE time and the severity of FD symptoms was assessed using Mann-Whitney test.

RESULTS

Thirty nine FD patients (55% girls; mean age: 11.9 ± 3.3 years) participated in the study. Of these, 43% had delayed GE. The overall symptom severity in patients with delayed GE was similar to the symptoms of patients with a normal GE rate (149.5 ± 12.7 points vs. 123.9 ± 9.0; p = 0.19). Individual symptoms scores showed only nausea to be significantly increased in the group with delayed GE (21.5 ± 1.9 points vs. 33.2 ± 4.6; p = 0.048, p < 0.1).

CONCLUSION

Especially in children with nausea as presenting symptom of FD, a low threshold should be withheld to perform a GE breath test.

Review of paediatric gastrointestinal physiology relevant to the absorption of orally administered medicines

Despite much progress in regulations to improve paediatric drug development, there remains a significant need to develop better medications for children. For the design of oral dosage forms, a detailed understanding of the specific gastrointestinal (GI) conditions in children of different age categories and how they differ from GI conditions in adults is essential. Several review articles have been published addressing the ontogeny of GI characteristics, including luminal conditions in the GI tract of children. However, the data reported in most of these reviews are of limited quality because (1) information was cited from very old publications and sometimes low quality sources, (2) data gaps in the original data were filled with textbook knowledge, (3) data obtained on healthy and sick children were mixed, (4) average data obtained on groups of patients were mixed with data obtained on individual patients, and (5) results obtained using investigative techniques that may have altered the outcome of the respective studies were considered. Consequently, many of these reviews draw conclusions that may be incorrect. The aim of the present review was to provide a comprehensive and updated overview of the available original data on the ontogeny of GI luminal conditions relevant to oral drug absorption in the paediatric population. To this end, the PubMed and Web of Science metadatabases were searched for appropriate studies that examined age-related conditions in the oral cavity, esophagus, stomach, small intestine, and colon. Maturation was observed for several GI parameters, and corresponding data sets were identified for each paediatric age group. However, it also became clear that the ontogeny of several GI traits in the paediatric population is not yet known. The review article provides a robust and valuable data set for the development of paediatric in vitro and in silico biopharmaceutical tools to support the development of age-appropriate dosage forms. In addition, it provides important information on existing data gaps and should provide impetus for further systematic and well-designed in vivo studies on GI physiology in children of specific age groups in order to close existing knowledge gaps and to sustainably improve oral drug therapy in children.

The gastrointestinal tract in hunger and satiety signalling

BACKGROUND

Different peripheral pathways are implicated in the regulation of the food ingestion-digestion cycle.

METHODS

Narrative review on gastrointestinal mechanisms involved in satiety and hunger signalling.

RESULTS

Combined mechano- and chemoreceptors, peripherally released peptide hormones and neural pathways provide feedback to the brain to determine sensations of hunger (increase energy intake) or satiation (cessation of energy intake) and regulate the human metabolism. The gastric accommodation reflex, which consists of a transient relaxation of the proximal stomach during food intake, has been identified as a major determinant of meal volume, through activation of tension-sensitive gastric mechanoreceptors. Motilin, whose release is the trigger of gastric Phase 3, has been identified as the major determinant of return of hunger after a meal. In addition, the release of several peptide hormones such as glucagon-like peptide 1 (GLP-1), cholecystokinin as well as motilin and ghrelin contributes to gut-brain signalling with relevance to control of hunger and satiety. A number of nutrients, such as bitter tastants, as well as pharmacological agents, such as endocannabinoid receptor antagonists and GLP-1 analogues act on these pathways to influence hunger, satiation and food intake.

CONCLUSION

Gastrointestinal mechanisms such as gastric accommodation and motilin release are key determinants of satiety and hunger.

Functional dyspepsia in children: A study of pathophysiological factors

BACKGROUND AND AIM

Functional dyspepsia (FD) is common in children, and treatment targeted towards the altered pathophysiology can improve outcome. We evaluated FD children for abnormality of gastric accommodation and emptying, psychological stressors (PS), Helicobacter pylori (HP) infection, and post-infectious FD.

METHODS

Diagnosis of FD was based on ROME III criteria. Clinical evaluation including dyspeptic symptom scoring and assessment for PS was performed. Satiety drink test for gastric accommodation, gastroscopy with biopsy for HP infection, and solid meal gastric emptying were performed. Sixty-seven healthy children were enrolled for assessing PS and satiety drink test.

RESULTS

Fifty-five FD children (33 boys, age 12 [6-18] years) with symptoms for 4 (2-48) months and dyspeptic score of 5 (1-13) were enrolled. PS were more common in FD than in controls (46/55 vs 9/67; P < 0.001). Median satiety drink volume was 360 mL (180-1320 mL); no patients had satiety drink volume of < 5th centile of healthy children. The frequency (98% vs 85%; P = 0.01) and severity (65 [10-175] vs 50 [5-130]; P < 0.001) of postprandial symptoms were higher in FD than in controls. Of the postprandial symptoms, pain (20.3% vs 0%; P = 0.000) was present only in FD. Delayed gastric emptying was present in 6.5%, HP infection in 11%, and post-infectious FD in 13% cases. Etiological factor was identified in 87% children, with 20% having multiple factors.

CONCLUSIONS

Abnormality of gastric sensorimotor function is seen in one-fourth of FD cases. HP infection and post-infectious FD are present in 11% and 13% cases, respectively.

Paediatric functional abdominal pain disorders

Paediatric functional abdominal pain disorders, currently referred to as disorders of gut-brain interaction, comprise irritable bowel syndrome, functional dyspepsia, abdominal migraine and functional abdominal pain not otherwise specified, as defined by the Rome IV diagnostic criteria. Functional abdominal pain disorders are common disorders with a prevalence of 3-16% depending on country, age and sex. A greater understanding of aetiopathogenesis and pathophysiology is emerging and includes intestinal components (inflammation, motility and the microbiota), central factors (psychological aspects, sensitization and/or differences in connectivity or activity of certain brain regions) as well as extrinsic factors (infections). In particular, the timing of disruption of the microbiota-gut-brain axis seems to be important. Diagnosis is challenging but is primarily based on clinical symptoms and exclusion of other organic causes, with an emphasis on avoiding unnecessary invasive diagnostic procedures. The available pharmacological interventions are limited in children and, therefore, management has focused on combined approaches, including mind-targeted interventions (hypnotherapy and cognitive behavioural therapy), diet (probiotics) and percutaneous electrical nerve field stimulation. The evidence for their clinical efficacy, although limited, is favourable, with positive impacts on symptoms and overall quality of life. The coming decades hold promise for improved understanding and management of these enigmatic disorders.

Electrogastrographic and autonomic nervous system responses to solid and liquid meals in youth with functional dyspepsia

BACKGROUND

Meal-related symptoms are common in paediatric functional dyspepsia (FD). There are only a small number of paediatric studies assessing mechanisms for meal-related symptoms, and these have not utilized Rome IV criteria. The aim of the current study was to assess gastric myoelectric and autonomic nervous system (ANS) responses to both liquid and solid meals in youth with Rome IV-defined FD.

METHODS

In healthy controls (N = 14) and youth with FD (N = 12), we recorded electrocardiograph (to assess heart rate variability; HRV) and electrogastrograph (EGG) signals before and after two test meals, one liquid and one solid. EGG parameters and HRV were assessed for the entire pre- and postprandial periods and in short time intervals. Additionally, liquid gastric emptying was assessed utilizing a ¹³ C-acetate breath test.

KEY RESULTS

During the EGG, the dominant power increased with both meals in controls but not patients with FD. During HRV assessment, the low frequency to high frequency ratio was higher after the liquid meal in controls, despite being similar preprandial, as compared to patients with FD. In controls, both standard deviation of normal to normal waves (SDNN) and root mean square of successive ECG R peaks (R-R interval) differences (rMSSD) increased after the liquid meal (but not after the solid meal) in controls but not patients with FD.

CONCLUSIONS AND INFERENCES

Youth with Rome IV-defined FD lacks the normal postprandial EGG dominant power response or autonomic nervous system response following a liquid meal. The latter appears to indicate a lack of ANS flexibility.

Autonomic functions and gastric motility in children with functional abdominal pain disorders

BACKGROUND

Abdominal pain-predominant functional gastrointestinal disorders (AP-FGIDs) are the most common cause of recurrent abdominal pain in children. Despite its high prevalence, the underlying pathophysiology of this condition is poorly understood.

AIM

To assess the role of gastric dysmotility and autonomic nervous system dysfunction in the pathophysiology of AP-FGIDs.

METHODS

One hundred children, fulfilling Rome III criteria for AP-FGIDs, and 50 healthy controls, aged 5 to 12 years, were recruited after obtaining parental consent. All patients were investigated for underlying organic disorders. Gastric motility and cardiovascular autonomic functions were assessed using validated non-invasive techniques.

RESULTS

The main gastric motility parameters assessed (gastric emptying rate [45.7 vs 59.6 in controls], amplitude [48.7 vs 58.2], frequency of antral contractions [8.3 vs 9.4], and antral motility index [4.1 vs 6.4]) were significantly lower in children with AP-FGIDs (P < 0.05). The post-prandial antral dilatation at 1 min after the test meal significantly correlated with the severity of abdominal pain (P < 0.05). Assessment of autonomic functions in AP-FGID patients showed neither a significant difference compared to the control group, nor a correlation with gastric motility abnormalities (P > 0.05). The duration of pain episodes negatively correlated with the parasympathetic tone (maladaptive parasympathetic tone) (P < 0.05).

CONCLUSION

Children with AP-FGIDs have abnormal gastric motility but normal cardiovascular autonomic functions. There is no relationship between abnormal gastric motility and autonomic functions. The pathogenesis of AP-FGIDs is not related to cardiovascular autonomic dysfunction.

Nutrient drink test: Normative values in Indian children

BACKGROUND

Nutrient drink test (NDT) is a simple, non-invasive method to assess gastric function including accommodation. However, data on normal satiety drink volume (SDV) in children is scanty with no information about postprandial symptoms (PPS). Our aims were to establish normal values of NDT in healthy children and evaluate its correlation with age, gender, and anthropometry.

METHODS

Six- to 18-year-old healthy children underwent the NDT. The nutrient drink (0.94 kcal/mL) was given at a constant rate of 15 mL/min in 6-12-year-old subjects and at 30 mL/min in 13-18-year-old subjects till satiety score of 5 was reached. Postprandial symptoms (30 min) of fullness, nausea, bloating, and pain were scored using a visual analogue scale (0-100 mm) individually and as aggregate score.

RESULTS

Sixty-seven children (40 boys, age 12 [6-18 years]) were enrolled. Median SDV was 360 [180-960 mL], higher in 13-18-year-olds in comparison to 6-12-year-old children (360 [240-1002] vs. 300 [148-960] mL; p=0.005). SDV showed significant correlation with age, weight, and height. SDV was higher in boys than girls (450 [240-1074] vs. 330 [240-480] mL; p=0.02) in the older children (13-18 y), but it was similar in the younger children. Mild fullness (40 [0-80]) was the only PPS seen in 85% children and none had pain. PPS were not different between boys and girls or younger and older children.

CONCLUSION

The study provides normative data of SDV and PPS by NDT in 6-18-year-old children. SDV correlated with age and was higher in adolescent boys than girls.

The Intragastric Pressure Measurement: A Novel Method to Assess Gastric Accommodation in Functional Dyspepsia Children

BACKGROUND

Impaired gastric accommodation (GA) is proposed as a main pathophysiological mechanism for functional dyspepsia (FD). At present, the gastric barostat is the criterion standard to measure GA. Hence, this procedure is invasive and it may alter gastric physiology. Recently, we proposed the measurement of intragastric pressure (IGP) by means of high-resolution manometry during nutrient intake as a potential alternative for assessing GA in adults.

OBJECTIVES

Our aim was first to study the feasibility of the IGP measurement with nutrient tolerance in children with FD and second to compare these results with young healthy adults.

METHODS

A high-resolution manometry probe and a feeding tube were positioned in the proximal stomach. The IGP was measured before and during intragastric infusion of a nutrient drink (ND, 300 kcal, 60 mL/min). Subjects were asked to score their satiation and epigastric symptoms. The test ended when the subjects scored maximal satiation.

RESULTS

A total of 15 healthy volunteers (HVs, 21.7 ± 4.7 years, 21.1 ± 0.3 kg/m) and 17 patients with FD (14.4 ± 0.7 years, 19.6 ± 0.7 kg/m) participated. Patients with FD experienced mainly from postprandial fullness (86%), epigastric pain (71%), and bloating (62%). In both groups, intragastric infusion of ND induced a drop in IGP (area above the IGP curve FD: -15.5 ± 3.5 mmHg vs HVs: -18.0 ± 8.7 mmHg; P = 0.57). Patients showed impaired nutrient tolerance compared with HVs (587.6 ± 80.2 vs 936 ± 66.2 kcal; P = 0.003). All patients and HVs tolerated the catheters and could finalize the study.

CONCLUSIONS

The measurement of IGP during intragastric ND infusion was well tolerated in children. Nutrient tolerance was reduced in children with FD compared with HVs. In the future, this may be a useful tool to assess GA accommodation and nutrient tolerance in children.

Do Distinct Functional Dyspepsia Subtypes Exist in Children?

BACKGROUND AND AIM

Two different subtypes of functional dyspepsia (FD) are recognized in adults: epigastric pain syndrome (EPS) and postprandial distress syndrome (PDS). The aim of the study was to assess the presence of FD subtypes in childhood at diagnosis and to observe changes at follow-up.

METHODS

A total of 100 patients with a diagnosis of FD based on pediatric Rome III criteria were consecutively enrolled. FD subtypes were successively classified through adult Rome III classification. Children were revaluated after 6 months of follow-up (T1).

RESULTS

At T0, 17 (17%) of 100 patients were classified as EPS, whereas 47 (47%) of 100 patients fulfilled criteria for PDS. In 36 (36%) of 100 children an overlap between the 2 subtypes was identified. Nausea was significantly higher in PDS and overlap groups when compared with EPS (χ = 21.7, P = 0.0001; χ = 20.7, P = 0.0001). Headache was significantly increased in PDS and overlap groups compared with patients with EPS (χ = 9.8, P = 0.001; χ = 13.1, P = 0.0001, respectively). At T1 among children belonging to PDS group at enrolment, 9 of 47 (19.1%) changed to EPS group, and 9 of 47 (19.1%) changed to the overlap group. Five (29.4%) of 17 patients and 2 (11.8%) of 17 children diagnosed as having EPS at T0 switched to PDS and overlap group, respectively. Of the 36 patients with overlap at enrollment, 11 (30.6%) satisfied criteria for PDS, and 7 (19.4%) switched to EPS group.

CONCLUSIONS

Two distinct FD subtypes are identifiable in pediatric population. A high percentage of overlap and a variation of subtype over time were found, suggesting a common pathophysiologic mechanism.

Abdominal migraine in children: association between gastric motility parameters and clinical characteristics

Background

Approximately 0.2–1 % of children suffers from abdominal migraine (AM). Pathophysiology of AM has not been adequately studied. This study evaluated gastric motility in children with AM.

Methods

Seventeen children (6 boys), within an age range of 4–15 years, referred to a tertiary care paediatric unit, North Colombo Teaching Hospital Ragama, Sri Lanka, from 2007 to 2012, were screened. Those fulfilling Rome III criteria for AM were recruited after obtaining parental consent. None had clinical or laboratory evidence of organic disorders. Twenty healthy children (8 boys), with an age range of 4–14 years, were recruited as controls. Liquid gastric emptying rate (GE) and antral motility parameters were assessed using an ultrasound method.

Results

Average GE (41.6 % vs. 66.2 %, in controls), amplitude of antral contractions (A) (57.9 % vs. 89.0 %) and antral motility index (MI) (5.0 vs. 8.3) were lower and fasting antral area (1.8 cm² vs. 0.6 cm²) was higher in children with AM (p < 0.01). No significant difference in the frequency of antral contractions (F) (8.8/3 min vs. 9.3/3 min, p = 0.08) was found between the two groups. Scores obtained for severity of abdominal pain had a negative correlation with A (r = −0.55, p = 0.03). Average duration of abdominal pain episodes correlated with GE (r = −0.58, p = 0.02). Negative correlations were observed between duration of AM and A (r = −0.55), F (r = −0.52), and MI (r = −0.57) (p < 0.05).

Conclusions

GE and antral motility parameters were significantly lower in children with AM. A significant correlation was found between symptoms and gastric motility. These findings suggest a possible role of abnormal gastric motility in the pathogenesis of AM.

High Prevalence of Nausea among School Children in Latin America

OBJECTIVES

To evaluate the prevalence of nausea and its association with functional gastrointestinal disorders (FGIDs) in a large-scale, population-based study of Latin American school children.

STUDY DESIGN

This cross-sectional study collected data from children in 3 Latin American countries. A Spanish version of the Questionnaire on Pediatric Gastrointestinal Symptoms-Rome III Version (QPGS-III) was administered to school children in Central and South America. Subjects were classified into FGIDs based on Rome criteria (QPGS-III). Students from 4 public and 4 private schools in the countries of El Salvador, Panama, and Ecuador participated in this epidemiologic study.

RESULTS

A total of 1137 school children with mean age 11.5 (SD 1.9, range 8-15) years completed the QPGS-III (El Salvador n = 399; Panama n = 321; Ecuador n = 417). Nausea was present in 15.9% of all school children. Two hundred sixty-eight (24%) children met criteria for at least 1 FGID. Nausea was significantly more common in children with FGIDs compared with those without: El Salvador 38% vs 15% (P < .001); Panama 22% vs 7% (P < .001); Ecuador 25% vs 13% (P = .004). Among children with FGIDs, those with functional constipation had a high prevalence of nausea. Nausea was significantly more common in girls and children attending private schools.

CONCLUSIONS

Nausea is commonly present in Latin American school children. FGIDs are frequently associated with nausea.

Current concepts in functional gastrointestinal disorders

PURPOSE OF REVIEW

Functional gastrointestinal disorders (FGIDs) are some of the most common and challenging disorders in pediatrics. Recurrent abdominal pain is the central feature of pain-associated FGIDs such as irritable bowel syndrome. A thorough understanding of current pathophysiological concepts is essential to successful management.

RECENT FINDINGS

The brain-gut axis, role of microbiota and the biopsychosocial model are emerging concepts in FGIDs. The biopsychosocial model focuses on the interplay between genes, environment, and physical and psychosocial factors. Interactions between microbiota and the central, enteric and autonomic nervous systems form the link between gut functions and conscious perceptions. Irritable bowel syndrome is the most extensively studied and prototypical pain-associated FGIDs. An aberrant processing of pain or physiologic signals originating from the gut causes a state of visceral hypersensitivity - a central mechanism of functional pain. Psychosocial and autonomic influences also play large roles. Therapy is tailored to the individual patient and comorbid symptoms.

SUMMARY

This review highlights the complex mechanisms and the aberrant brain-gut neural connections forming the basis of FGIDs. Successful management of FGIDs requires knowledge of the underlying pathophysiology coupled with a multidisciplinary treatment approach. Management should focus on cognitive behavioral therapy, dietary factors along with gastrointestinal motility and psychotropic drug therapy.

Water Load Test in Childhood Functional Abdominal Pain: No Relation to Food Intake and Nutritional Status

This cross-sectional study evaluates the relations between the water load test in childhood functional gastrointestinal disorders with food intake and nutritional status. Patients with functional dyspepsia required a lower maximum water intake to produce fullness (n = 11, median = 380 mL) than patients with irritable bowel syndrome (n = 10, median = 695 mL) or functional abdominal pain (n = 10, median = 670 mL) (P < 0.05). Among patients who ingested ≤560 mL (n = 17) or >560 mL (n = 14) in the water load test, there was no relation between the maximum drinking capacity and food intake, body mass index, or height.

Gastric emptying scintigraphy results in children are affected by age, anthropometric factors, and study duration

BACKGROUND

A standardized 4-h adult-based gastric emptying scintigraphy (GES) protocol is increasingly being used in children to evaluate for gastroparesis. We sought to determine the effect of age, anthropometrics, and study duration on GES results using this protocol in children.

METHODS

Retrospective review of children who underwent a 4-h solid-meal GES study at a tertiary care center. GES results and anthropometric data (e.g., weight, stature, body surface area [BSA]) were systematically captured.

KEY RESULTS

Of 216 children, 188 (87%) were able to complete the study meal. Children unable to complete the meal were younger and smaller. In multivariate analysis, only increasing BSA was identified as being positively associated with ability to complete the meal (odds ratio: 19.7; p < 0.001). Of those completing the meal, 48 (26%) had delayed emptying (4-h retention value >10%). These children were significantly younger and smaller than those with normal emptying. In multivariate analysis of those completing the meal, only increasing BSA (odds ratio: 0.26; p = 0.006) was identified as being negatively associated with delayed emptying. There was a progressive increase in the positive predictive value for identification of delayed gastric emptying as the duration of the study increased (0.25, 0.60, and 0.71 at 1, 2, and 3 h, respectively) using the 4-hr value as a comparator.

CONCLUSIONS & INFERENCES

Young children have more difficulty completing the GES meal. Childhood gastric retention is affected by age and anthropometric factors, primarily BSA. The standardized 4-h GES protocol may need to take these factors into account in children.

Childhood functional abdominal pain: mechanisms and management

Chronic abdominal pain is one of the most common clinical syndromes encountered in day to day clinical paediatric practice. Although common, its definition is confusing, predisposing factors are poorly understood and the pathophysiological mechanisms are not clear. The prevailing viewpoint in the pathogenesis involves the inter-relationship between changes in hypersensitivity and altered motility, to which several risk factors have been linked. Making a diagnosis of functional abdominal pain can be a challenge, as it is unclear which further diagnostic tests are necessary to exclude an organic cause. Moreover, large, well-performed, high-quality clinical trials for effective agents are lacking, which undermines evidence-based treatment. This Review summarizes current knowledge regarding the epidemiology, pathophysiology, risk factors and diagnostic work-up of functional abdominal pain. Finally, management options for children with functional abdominal pain are discussed including medications, dietary interventions, probiotics and psychological and complementary therapies, to improve understanding and to maximize the quality of care for children with this condition.

Visceral hypersensitivity and electromechanical dysfunction as therapeutic targets in pediatric functional dyspepsia

Functional gastrointestinal disorders (FGID) are common clinical syndromes diagnosed in the absence of biochemical, structural, or metabolic abnormalities. They account for significant morbidity and health care expenditures and are identifiable across variable age, geography, and culture. Etiology of abdominal pain associated FGIDs, including functional dyspepsia (FD), remains incompletely understood, but growing evidence implicates the importance of visceral hypersensitivity and electromechanical dysfunction. This manuscript explores data supporting the role of visceral hypersensitivity and electromechanical dysfunction in FD, with focus on pediatric data when available, and provides a summary of potential therapeutic targets.

Chronic idiopathic nausea

Chronic nausea is a prevalent but poorly described symptom in adolescents. It often co-occurs with other functional gastrointestinal disorders (FGIDs) but may also present in isolation. A multitude of triggers and complex neural pathways underlie the sensation of nausea. These include gastrointestinal and blood-borne insults, dysmotility, vestibular or central nervous system pathways, an aberrant autonomic nervous system, and psychosocial factors. Although clinical algorithms are lacking, diagnosis is typically made on the basis of a thorough clinical history and without extensive testing. Treatment is mainly empiric and may be directed at comorbid symptoms such as migraine, delayed gastric emptying, orthostatic intolerance, and visceral hypersensitivity. Chronic idiopathic nausea is an increasingly prevalent symptom that needs careful clinical assessment and individualized treatment plans.

Nausea predicts delayed gastric emptying in children

OBJECTIVES

To assess whether the gastroparesis cardinal symptom index (GCSI), or any individual symptom, is associated with delayed gastric emptying in children, and to assess understanding of symptoms associated with delayed gastric emptying.

STUDY DESIGN

Fifty children (36 F), 5-18 years of age, undergoing gastric emptying scintigraphy (GES) at Lurie Children's Hospital in Chicago, Illinois, completed Likert-type GCSI and symptom comprehension questionnaires. Correlation of GES results (normal or abnormal) with questionnaire results using the Wilcoxon rank sum test.

RESULTS

Seventy percent of subjects had a normal GES. Children reported understanding most terms of GCSI (average score 2.59, range 0-3). The GCSI was not associated with delayed gastric emptying. Nausea was associated with delayed gastric emptying only (numerical P = .04, word P = .02). Results were not altered when poorly understood terms were excluded.

CONCLUSIONS

The GCSI is not associated with delayed gastric emptying in children. Lack of association does not seem to be related to lack of understanding. Nausea alone was the only symptom that showed an association with delayed gastric emptying on GES.

Effect of nutritional rehabilitation on gastric motility and somatization in adolescents with anorexia

OBJECTIVE

To examine gastric function, as well as the presence of somatic complaints, anxiety symptoms, and functional gastrointestinal disorders (FGIDs), in adolescents with anorexia nervosa (AN) before and after nutritional rehabilitation.

STUDY DESIGN

Sixteen females with AN and 22 healthy controls with similar demographic profiles were included. Gastric emptying (measured as residual gastric volume) and gastric accommodation (measured as postprandial antral diameter) were assessed with abdominal ultrasonography. Participants completed the Children's Somatization Inventory (CSI), the Screen for Child Anxiety-Related Emotional Disorders, and the Questionnaire on Pediatric Gastrointestinal Symptoms-Rome III version. All testing was repeated 3-4 months later.

RESULTS

Body mass index in the AN group improved over time (P = .012). Fasting gastric parameters were similar in the 2 groups. Maximum postprandial antral diameter was significantly greater in controls compared with the AN group (P = .008). Only adolescents with AN demonstrated a significant increase in maximum postprandial diameter at repeat testing (P = .009). There was no difference in residual gastric volume between the 2 groups. Initial CSI scores were higher in adolescents with AN (P < .0001), including higher scores for nausea and abdominal pain. CSI scores were significantly lower in adolescents with AN (P = .035). Initial scores on the Screen for Child Anxiety-Related Emotional Disorders were significantly higher in adolescents with AN (P = .0005), but did not change over time. Adolescents with AN met significantly more criteria for FGIDs (P = .003).

CONCLUSION

Adolescents with AN have impaired gastric accommodation that improves after nutritional rehabilitation, have significantly more somatic complaints, and meet more criteria for anxiety disorders and FGIDs. After nutritional rehabilitation, somatization improves and FGIDs become less common, but symptoms of anxiety persist.

Gastric emptying and antral motility parameters in children with functional dyspepsia: association with symptom severity

BACKGROUND AND AIMS

Functional dyspepsia (FD) is an important gastrointestinal problem with obscure etiology. Abnormal gastric motility is suggested as a possible pathophysiological mechanism for symptoms. The main objective of this study was to assess gastric motility in Sri Lankan children with FD.

METHODS

Forty-one children (19 [46.3%] males, age 4-14 years, mean 7.5 years, SD 2.6 years) referred to the Gastroenterology Research Laboratory, Faculty of Medicine, University of Kelaniya, from January 2007 to December 2011, were screened. Those fulfilling Rome III criteria for FD were recruited. None had clinical or laboratory evidence of organic disorders. Twenty healthy children were recruited as controls (eight [40%] males, age 4-14 years, mean 8.4 years, SD 3.0 years). Liquid gastric emptying rate (GE) and antral motility parameters were assessed using an ultrasound-based method.

RESULTS

Average GE (45.6% vs 66.2% in controls), amplitude of antral contractions (58.2% vs 89.0%) and antral motility index (5.1 vs 8.3) were lower and fasting antral area (1.5 cm(2) vs 0.6 cm(2)) was higher in patients with FD (P < 0.01). Frequency of antral contractions (8.8 vs 9.3) did not show a significant difference (P = 0.07). Scores obtained for severity of abdominal pain negatively correlated with GE (r = -0.35, P = 0.025). Children with FD, exposed to stressful events had higher fasting antral area (1.9 cm(2)) than those not exposed to stress (1.0 cm(2)) (P = 0.02).

CONCLUSIONS

GE and antral motility parameters were significantly impaired in children with FD compared with controls. GE negatively correlated with severity of symptoms. This study points to disturbances in gastric motility as an etiological factor for FD.