Pediatric Gastroenterology Management and Referral ..., Study notes of Gastroenterology

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Management and Referral Guidelines

Pediatric Gastroenterology

Management and Referral Guidelines

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Management and Referral Guidelines

Chronic Abdominal Pain

Diagnoses : ICD-

Multiple (e.g. R10.10-R10.13, R10.2, R10.30-R10.33, etc.)

Target Population

• School-aged children

Clinical Findings

• The term “chronic abdominal pain” encompasses “recurrent abdominal pain,” which is classically defined by:
  1. Three or more episodes of abdominal pain occurring over a period of more than 3 months
  2. Pain that is sufficiently severe to affect activities
  3. No known or apparent organic cause.
• “Recurrent abdominal pain of childhood” is a description of symptoms rather than a diagnosis. Abdominal pain in children is very common and usually does not indicate severe underlying disease and will often resolve spontaneously.

Evaluation Recommendations

During the initial evaluation, answers to the following important questions and physical findings should be determined:

History:

• Associated signs and symptoms such as weight loss, growth failure, bleeding, vomiting and perianal disease.
• Location, frequency, severity, exacerbating factors and impact on quality of life
• Presence of constipation very common
• Exposure to NSAIDs
• Relationship to food like dairy, gluten or excess fermentable carbs (FODMAPS)
• Anxiety, stress, school and family issues

Labs and imaging evaluation to consider with annotations :

• CBC; anemia think IB, celiac disease
• TTG IgA, IgA screen for celiac disease, very important, frequently missed. Comment: to validate the TTG IgA you need to establish that the child is not IgA deficient.
• ESR, CRP; if elevated think IBD
• CMP; low albumin seen with IBD; screen for liver/biliary, renal disease and diabetes
• Amylase, lipase for severe epigastric pain
• UA; think UTI, stones
• Stool hemoccult positive, think IBD

Management and Referral Guidelines

These recommendations are designed to be used by primary care physicians wishing to refer

children with chronic low grade abdominal pain for additional evaluation and care. They are

recommendations and are based on best evidence and expert consensus.

• Probiotics like Florastor, Culturelle and/or Align. May also use yogurts with active cultures.
• Peppermint oil may relieve cramping in some (Peoples Pharmacy has this).
• Many pharmaceutical have been tried for visceral hyperalgesia and abdominal pain and included tricyclic antidepressants, gabapentin, and cyproheptadine.
• Consider referral for counselling when appropriate

Ancillary Documentation Needed

• Referral request
• All labs and imaging done
• Growth charts

Additional Information

1. DiLorenzo D, et al. Chronic abdominal pain in Children: A clinic report of Pediatric Gastroenterol and Nutr 2005; 40:245-
2. Nurko S, DiLorenzo C. Functional abdominal pain: Time to get together and move forward of Pediatric Gastroenterol and Nutr 2008; 47:679-715.

If at any time patient develops signs/symptoms that make more urgent evaluation important, please alert Gastroenterology (512-628-1810) to this change in status or go to the Emergency Department.