Recurrent abdominal pain in childhood

[Application of ultrasound-guided endoscopic retrograde appendicitis therapy in children with appendix-related chronic abdominal pain]

OBJECTIVES

To study the clinical efficacy of ultrasound-guided endoscopic retrograde appendicitis therapy in children with appendix-related chronic abdominal pain.

METHODS

A retrospective analysis was performed on the medical data of 30 children with the chief complaint of chronic abdominal pain who were admitted from August 2019 to May 2021. All the children were found to have inflammation of the appendix or intracavitary stool and fecalith by ultrasound and underwent ultrasound-guided endoscopic retrograde appendicitis therapy. The medical data for analysis included clinical manifestations, endoscopic findings, white blood cell count, neutrophil percentage, length of hospital stay, and cure rate.

RESULTS

Among the 30 children with chronic abdominal pain, there were 13 boys (43%) and 17 girls (57%), with a mean age of (9±3) years (range 3-15 years) at diagnosis. The median duration of the disease was 12 months, and the median length of hospital stay was 3 days. The children had a median white blood cell count of 6.7×109/L and a neutrophil percentage of 50%±13%. Fecalith and a large amount of feces were flushed out of the appendix cavity for 21 children (70%) during surgery. The follow-up rate was 97% (29/30), and the median follow-up time was 11 months (range 5-26 months). Of the 29 children, abdominal pain completely disappeared in 27 children (93%).

CONCLUSIONS

Ultrasound-guided endoscopic retrograde appendicitis therapy is effective in children with chronic abdominal pain caused by feces or fecalith in the appendix cavity.

DeepBiomarker: Identifying Important Lab Tests from Electronic Medical Records for the Prediction of Suicide-Related Events among PTSD Patients

Identifying patients with high risk of suicide is critical for suicide prevention. We examined lab tests together with medication use and diagnosis from electronic medical records (EMR) data for prediction of suicide-related events (SREs; suicidal ideations, attempts and deaths) in post-traumatic stress disorder (PTSD) patients, a population with a high risk of suicide. We developed DeepBiomarker, a deep-learning model through augmenting the data, including lab tests, and integrating contribution analysis for key factor identification. We applied DeepBiomarker to analyze EMR data of 38,807 PTSD patients from the University of Pittsburgh Medical Center. Our model predicted whether a patient would have an SRE within the following 3 months with an area under curve score of 0.930. Through contribution analysis, we identified important lab tests for suicide prediction. These identified factors imply that the regulation of the immune system, respiratory system, cardiovascular system, and gut microbiome were involved in shaping the pathophysiological pathways promoting depression and suicidal risks in PTSD patients. Our results showed that abnormal lab tests combined with medication use and diagnosis could facilitate predicting SRE risk. Moreover, this may imply beneficial effects for suicide prevention by treating comorbidities associated with these biomarkers.

Treatment for Pediatric Functional Abdominal Pain: An Initial Examination of Reciprocal Associations Between Pain, Functional Impairment, and Parental Distress

OBJECTIVE

While cross-sectional studies underline that child and parent factors in pediatric chronic pain are reciprocally related, so far, little is known on their prospective relationship, especially in treatment contexts. This study aims to analyze directions of influence between child and parental outcomes using data from an intervention study.

METHODS

The sample covered 109 families with children aged 7-13 years diagnosed with functional abdominal pain (FAP). Child outcomes included pain and impairment, and parental outcomes covered caregiver-specific distress including both parental personal time burden (i.e., less time available for personal needs) and emotional burden due to child's pain (i.e., increased worries). Cross-lagged panel analyses examined the directions of the relations between child and parental outcomes across time (pretreatment T1, post-treatment T2, and 3-month follow-up and 12-month follow-up T3/T4).

RESULTS

First, a significant improvement over time in all measures was observed. Cross-lagged effects were found for less parental personal time burden at T2, predicting both less pain (β = -0.254, p = .004) and less impairment (β = -0.150, p = .039) at T3. Higher baseline pain was predictive for higher parental emotional burden after treatment (β = -0.130, p = .049) and, reversely, for less emotional burden at 12-month follow-up (β = 0.261, p = .004).

CONCLUSIONS

Addressing parental personal time burden in FAP treatment might possibly support the improvement on the child level. Replication of results in larger samples is warranted to gain more insight into the directions of influence and, in that way, to optimize treatment for pediatric FAP.

Validation of the Health-Related Felt Stigma and Concealment Questionnaire

OBJECTIVE

Stigma is associated with many health conditions, including chronic pain. Research on health-related stigma is limited by the lack of validated instruments that distinguish among various stigma-related constructs. We aimed to develop and validate such a measure for pediatric functional abdominal pain (FAP). Felt stigma (FS) was defined as comprising both perceived and internalized stigma. Stigma concealment (SC) was defined as efforts by stigmatized individuals to prevent others from learning of their condition.

METHODS

Using a theory-driven approach, we adapted items from existing self-report measures of stigma to construct the health-related FS and Concealment Questionnaire (FSC-Q). Patients with FAP (N = 179, ages 11-17) completed the preliminary FSC-Q and health-related measures hypothesized to be associated with stigma. Cognitive interviewing and exploratory factor analysis (EFA) informed the final version of the measure.

RESULTS

EFA identified a 2-factor model comprised of FS and SC. The FS and SC scales exhibited good internal consistency and construct validity. Consistent with study hypotheses, both factors were significantly associated with anxiety, depression, pain catastrophizing, pain threat, physical symptoms, and pain interference/disability. Higher FS was associated with higher mental healthcare utilization. The subset of participants meeting criteria for irritable bowel syndrome (IBS) reported higher FS and SC compared with those without IBS.

CONCLUSION

The FSC-Q may help advance research on health-related stigma in FAP and other chronic health conditions by allowing for assessment of distinct stigma-related constructs.

Evaluating the effects of probiotics in pediatrics with recurrent abdominal pain

BACKGROUND

Recurrent abdominal pain (RAP) is one of the frequent complaints in general practice, particularly in pediatrics and is among the common cause of referral to gastroenterology clinics.

PURPOSE

This study is designed to investigate the effects of probiotics for the treatment of RAP and desired therapeutic outcomes.

METHODS

One hundred twenty-five children with the diagnosis of RAP according to Rome III criteria for irritable bowel syndrome (IBS), functional abdominal pain (FAP), functional dyspepsia (FD), and abdominal migraine (AM), were enrolled in this double-blind randomized controlled trial.

RESULTS

Sixty-five subjects received probiotics, and others received placebo treatment for 4 weeks. Lactobacillus reuteri was therapeutically effective in 32 patients compared to 8 patients, responding to the placebo treatment. Compared to baseline, all pain-related variables showed a significant reduction for the IBS and FD at the end of the 4th week. However, it did not respond well in FAP and AM groups. Pain-related outcomes such as, frequency of the pain, severity, and duration of the pain were decreased following the probiotic treatment. No therapeutic response was seen in AM group after the administration of probiotics. L. reuteri significantly led to pain relief in the overall population, and also in FAP, FD, and IBS subgroups.

CONCLUSION

L. reuteri probiotics are likely to lead to RAP relief and can be recommended for the treatment of functional gastrointestinal disorders.

STATE OF COGNITIVE FUNCTIONS IN CHILDREN WITH PATHOLOGY OF DIGESTIVE ORGANS, WHO LIVE AT RADIOACTIVE CONTAMINATED TERRITORIES OF UKRAINE

OBJECTIVE

to study the state of cognitive functions in children who were born and permanently live at radioactive contaminated territories (RCT) with pathology of the upper digestive tract, using pathopsychological testing; to increase the effectiveness of treatment and prophylactic measures aimed at preserving and restoring the health of RCT residents.

DESIGN, PATIENTS AND METHODS

A randomized blind controlled clinical trial was conducted. There were examined, a total of 90 persons aged 6 to 17 years (35 boys and 55 girls) who were divided into two groups: the control group (I) included 30 persons of the conventional «clean» territories, and the main group (II) - 60 patients with patho- logy of the digestive organs who were born and live at the RCT. The study program included: the collection of anam- nesis, complaints; clinical and instrumental examinations. The following tests were applied by us: «What things are hidden in the drawings», Toulouse-Pieron, Raven, and Luria testing. For detecting the anxiety level, and the subjec- tive signs of autonomic dysfunctions were used the Spilberg-Hanin self-diagnosis and the Wein questionnaire, respectively.

RESULTS

It was shown that in children aged 6-11 years, according to the results of the Toulouse-Pieron test, speed of cognitive information-processing was significantly decreased by 7.17 conventional units, while on the back- ground of the etiopathogenetic treatment of the digestive tract - by 10.24 conventional units relative to the va- lues of the control group. The long-term memory was statistically significantly decreased in the examined children of senior school age (from 12 to 17 years). A significant increase in reactive anxiety and a reverse correlation between the personal anxiety (PA) and speed of cognitive information-processing (r = -0.331) were recorded in patients aged 6-11 years. In older patients, PA was increased.Сonclusions. The obtained results indicate that the state of cognitive functions was characterized by a decrease in speed of cognitive information-processing, long-term memory and a high level of anxiety in children aged from 6 to 17 years residents of RСT with pathology of digestive organs, according to the used testing.

Comparison of child abuse history in patients with and without functional abdominal pain: a case-control study

BACKGROUND

Gastrointestinal (GI) disorders are ranked first amongst medical diseases as a trigger of requests for mental health counselling. Child abuse has been regarded as one of the main causes of the development of functional abdominal pain (FAP) in children. This study aimed, therefore, to compare the prevalence of child abuse experience among two groups of patients with and without FAP.

METHODS

A case-control study of children in Arak, Iran, in which experience of child abuse was compared in children with (n = 100) and without functional abdominal pain (n = 100). Three categories of child abuse - emotional abuse, physical abuse, and neglect - were assessed using the Child Abuse Questionnaire. The data were analyzed using Stata software.

RESULTS

After adjusting for potential confounders, there were group differences in emotional abuse (96% vs. 81%, aOR = 5.13, 95% CI: 1.3-20.3, p = 0.017), neglect (28% vs. 8%, aOR = 4.27, 95% CI: 1.8-11.8, p = 0.001) and total child abuse score (98% vs. 84%, aOR = 8.2, 95% CI: 1.5-43.8, p = 0.014) but not in physical abuse (57% vs. 46%, aOR = 1.47, 95% CI: 0.81-2.60, p = 0.728).

CONCLUSIONS

As the prevalence of child abuse is higher in patients with FAP, child abuse appears to be related to the occurrence of FAP in children. However, the results of this study cannot be generalized to Iranian society generally and further longitudinal studies are recommended.

The association of recurrent abdominal pain and Helicobacter pylori infection in correlation with esophagogastroduodenoscopy findings

Abstract: Aim: The aim of this research was to determine the association of recurrent abdominal pain and Helicobacter pylori (H. pylori) infection in childhood, in correlation with the finding of an upper endoscopy. Introduction: Recurrent abdominal pain (RAP) was defined according to Apley and Naish's criteria from the year 1959 as at least three or more episodes of abdominal pain lasting longer than three months in children older than 3 years, and severe enough to prevent normal activities in child. The association of RAP and H. pylori has been analyzed in several different researches, and there are conflicting results about their interconnection. However, the etiological association of the presence of H. pylori with the onset and development of acute and chronic active gastritis and duodenal ulcer is known. Material and method: The research protocol included a total of 77/183 (42.07%) children divided by age into three subgroups: preschool age (3 to 6.9 years), school-age (7 to 10.9 years) and adolescent age (11 to 15 years) in whom the diagnosis of RAB was determined by meeting the criteria according to Apley and Naish (1959), and the American Academy of Pediatrics (2005). H. pylori infection was confirmed by enzyme-linked immunosorbent assay (ELISA), while esophagogastroduodenoscopy was performed by the device for upper endoscopy type Olimpus GIF Type Q156, in the endoscopic cabinet of the Clinic for Internal Medicine, University Clinical Center Tuzla. Results: Of the total number of examined children (77), the analyse of Helicobacter pylori infection presence showed the biggest number of positive findings in school age 91.3%, in adolescent age 78.0%, while the smallest number was in preschool age (25.0%). The most common findings of upper endoscopy and microscopic findings were described as: antritis acuta in 16%, gastritis chronica activa et erosiva in 32%, and duodenitis acuta (12%). Conclusion: A significant association of H. pylori infection and RAP are confirmed by positive finding of esophagogastroduodenoscopy, leading to conclusion that immunological testing for the presence of this bacteria is justified. After obtaining a positive finding with confirmed infecion, it is necessary to start with the treatment.

Roles of Lactose and Fructose Malabsorption and Dietary Outcomes in Children Presenting with Chronic Abdominal Pain

Intolerance to lactose or fructose is frequently diagnosed in children with chronic abdominal pain (CAP). However, the causal relationship remains a matter of discussion. A cohort of 253 patients, aged 7–12 years, presenting with unexplained CAP received standardized diagnostics. Additional diagnostic tests were performed based on their medical history and physical and laboratory investigations. Fructose and lactose hydrogen breath tests (H₂BT) as well as empiric diagnostic elimination diets were performed in 135 patients reporting abdominal pain related to the consumption of lactose or fructose to evaluate carbohydrate intolerance as a potential cause of CAP. Carbohydrate malabsorption by H2BT was found in 55 (41%) out of 135 patients. An abnormal increase in H2BT was revealed in 30% (35/118) of patients after fructose consumption and in 18% (20/114) of patients after lactose administration. Forty-six percent (25/54) reported pain relief during a diagnostic elimination diet. In total, 17 patients had lactose malabsorption, 29 fructose malabsorption, and nine combined carbohydrate malabsorption. Carbohydrate intolerance as a cause of CAP was diagnosed at follow-up in only 18% (10/55) of patients with malabsorption after the elimination of the respective carbohydrate. Thus, carbohydrate malabsorption appears to be an incidental finding in children with functional abdominal pain disorders, rather than its cause. Therefore, testing of carbohydrate intolerance should only be considered in children with a strong clinical suspicion and with the goal to prevent long-term unnecessary dietary restrictions in children suffering from CAP.

Significance of Perianal Lesion in Pediatric Crohn Disease

PURPOSE

Despite the increasing incidence of pediatric Crohn disease (CD) in Korea, data on the characteristics of perianal lesions are scarce. Therefore, we aimed to investigate the characteristics of pediatric CD with accompanying perianal lesions in Korea.

METHODS

We retrospectively reviewed the medical records of children (age ≤18 years) with confirmed CD at Gachon University Gil Medical Center between 2000 and 2014. Patients were classified into two groups based on the presence or absence of any perianal lesions including skin tags. Additional analysis was performed according to the presence or absence of perianal perforating lesions.

RESULTS

Among the 69 CD children (mean age, 15.4 years) include in the analysis, 54 (78.3%) had a perianal lesion and 29 (42.0%) had a perianal perforating lesion. The median duration of chief complaints was longer in pediatric CD with any accompanying perianal lesions (5.40 months vs. 1.89 months, p=0.02), while there was no difference between pediatric CD with and without perianal perforating lesions (5.48 months vs. 4.02 months, p=0.18). Perianal symptoms preceded gastrointestinal symptoms in 13 of 29 (44.8%) patients with perianal perforating lesions.

CONCLUSIONS

CD should be suspected in children with perianal lesions, even in circumstances when gastrointestinal symptoms are absent.

Therapeutic Response for Functional Abdominal Pain in Children with Occult Constipation: Laxatives versus Prokinetic Drugs

The relationship between functional abdominal pain (FAP) and occult constipation (OC) in children who did not meet the Rome III criteria for constipation has rarely been reported. This study aimed to estimate the prevalence of OC in patients with FAP and to compare the effectiveness of prokinetic drugs and laxatives for FAP and OC. Pediatric outpatients (n = 212; aged 4-15 years) who satisfied the Rome III criteria for childhood FAP were divided into 2 groups based on Leech scores: group 1 < 8; group 2 ≥ 8. Group 2 received either prokinetic drugs or laxatives and pain severity was assessed after 2 weeks, 1 month, and 3 months. A total 52.4% (111/212) of patients had OC in this study. More patients who received laxatives had reduced pain scores compared with those who received prokinetic drugs. Those treated with laxatives in group 2 had a better response than those treated with prokinetic drugs throughout the study period (P < 0.001, P < 0.001, and P = 0.002 after 2 weeks, 1 month, and 3 months, respectively). OC was frequently encountered in children with FAP. Laxatives can be more effective than prokinetic drugs for relieving symptoms of FAP in children with a Leech score ≥ 8 and suspected OC.

[Pediatric general practitioners and tertiary care structures for pain therapy. A qualitative study on the need for networking]

BACKGROUND

Despite the urgency of the problem of chronic pediatric pain and the importance of early interventions, many children experience intermittent episodes of pain over a long period of time. One aim of this study was to investigate the need of structured diagnostic tools and therapies of chronic pediatric pain in pediatric general practices. Another aim was to describe the aims, services and challenges of a network between pediatric practices and a tertiary pediatric pain centre, from the perspective of general pediatric practitioners.

MATERIAL AND METHODS

A qualitative research design was selected and 20 general pediatric practitioners were interviewed using a semistructured interview guide. Interviews were analyzed by use of qualitative content analysis according to Mayring.

RESULTS

Generally, the idea of a network between pediatric practices and the German Pediatric Pain Centre was rated positively by pediatric general practitioners. From the results of the analysis three categories were identified: (i) expectations from the network (ii) desire for cooperation in the network and (iii) recommendations for improved patient care.

CONCLUSION

A network with a centre for tertiary care was preferred by the general pediatric practitioners. To optimize the care of children with chronic pain further education for general pediatric practitioners as well as structured diagnostic tools and therapies of frequent pediatric chronic pain diseases are warranted.

Inflammatory bowel disease in pediatric patients: Characteristics of newly diagnosed patients from the CEDATA-GPGE Registry

BACKGROUND

Inflammatory bowel disease (IBD) can arise at any age, with peak incidence in adolescence and young adulthood. A registry of pediatric cases of IBD offers the opportunity to document their diagnosis and treatment, with the ultimate aim of improving diagnosis and treatment in the future.

METHODS

In the German-language CEDATA-GPGE registry, 3991 cases of IBD in patients less than 18 years of age were documented from 2004 to 2014. The 1257 patients who were prospectively included in the registry upon diagnosis and whose further course was documented for at least three months were analyzed in two separate groups--under 10 years old, and 10 years and above--with respect to the type and duration of their symptoms until diagnosis, the completeness of the diagnostic evaluation, the disease phenotype, and the initial treatment.

RESULTS

Of the 958 patients for whom full documentation was available, 616 (64.3%) had Crohn's disease (CD), 278 (29%) had ulcerative colitis (UC), 64 (6.7%) had an unclassified IBD, and 23.2% were under 10 years old. The latency to diagnosis was longer for CD than for UC (0.5 versus 0.3 years), regardless of age. 62.5% of the CD patients had ileocolonic involvement, and more than half had involvement of the upper gastrointestinal tract. 71% of the patients with UC had subtotal colitis or pancolitis. Continuous improvement was seen in diagnostic assessment according to published guidelines. For example, in 2004/2005, 69% of patients were evaluated endoscopically with ileocolonoscopy and esophagogastroduodenoscopy; this fraction had risen to nearly 100% by 2013/2014. Similarly, the percentage of patients who underwent a diagnostic evaluation of the small intestine, as recommended, rose from 41.2% to 60.9% over the same period. The most common initial treatments were 5- amino - salicylates (86.8% CD, 100% UC) and glucocorticoids (60.6% CD, 65.6% UC). 32% of the patients with CD received exclusive enteral nutrition therapy.

CONCLUSION

Most of these pediatric patients with IBD, whether in the younger or the older age group, had extensive bowel involvement at the time of diagnosis. The registry data imply that improvement in clinical course may be achieved by shortening the time to diagnosis and by closer adherence to the diagnostic and therapeutic guidelines.

Stop the pain: study protocol for a randomized-controlled trial

BACKGROUND

Functional abdominal pain (FAP) is not only a highly prevalent disease but also poses a considerable burden on children and their families. Untreated, FAP is highly persistent until adulthood, also leading to an increased risk of psychiatric disorders. Intervention studies underscore the efficacy of cognitive behavioral treatment approaches but are limited in terms of sample size, long-term follow-up data, controls and inclusion of psychosocial outcome data.

METHODS/DESIGN

In a multicenter randomized controlled trial, 112 children aged 7 to 12 years who fulfill the Rome III criteria for FAP will be allocated to an established cognitive behavioral training program for children with FAP (n = 56) or to an active control group (focusing on age-appropriate information delivery; n = 56). Randomization occurs centrally, blockwise and is stratified by center. This study is performed in five pediatric gastroenterology outpatient departments. Observer-blind assessments of outcome variables take place four times: pre-, post-, 3- and 12-months post-treatment. Primary outcome is the course of pain intensity and frequency. Secondary endpoints are health-related quality of life, pain-related coping and cognitions, as well as self-efficacy.

DISCUSSION

This confirmatory randomized controlled clinical trial evaluates the efficacy of a cognitive behavioral intervention for children with FAP. By applying an active control group, time and attention processes can be controlled, and long-term follow-up data over the course of one year can be explored.

TRIAL REGISTRATION

DRKS00005038 (date: 25 July 2013); NCT02030392 (date: 7 January 2014).

Functional bowel disorders in adults

BACKGROUND

Chronic abdominal pain, bloating, constipation, diarrhea, and stool irregularity are common symptoms in primary care and gastroenterology. A routine diagnostic evaluation fails to reveal any underlying somatic condition in about half of the affected patients, who are therefore said to have a functional bowel disorder. Physicians are often unsure how extensive the work-up must be to exclude a somatic cause.

METHODS

This review is based on a selective review of the literature, including published guidelines from Germany and abroad.

RESULTS

Functional bowel disorders are diagnosed on the basis of a typical constellation of symptoms and the absence of pathological findings that would adequately explain them (exclusive criteria). The basic diagnostic assessment, consisting of a physical examination, basic laboratory tests, abdominal ultrasonography, and (in women) a gynecological examination, is supplemented by further testing that depends on the patient's symptoms. Colonoscopy is obligatory to rule out underlying pathological abnormalities. By communicating the diagnosis of irritable bowel syndrome to the patient, the physician shows that the patient's symptoms and concerns have been taken seriously. The mainstays of treatment are patient education on the benign course of the disease and the encouragement of a salubrious lifestyle. Further treatment options include dietary measures, time-limited symptomatic treatment with drugs, and psychotherapy.

CONCLUSION

The diagnosis of a functional bowel disorder is based on a thorough history (positive criteria) and a small battery of diagnostic tests to exclude somatic disease. Both the diagnostic assessment and the treatment should be carried out in accordance with published guidelines.