27 Flashcards
Most common cause of abdominal pain in school age children
Its dx and tx
Functional abdominal pain is the most common cause of abdominal pain in school-age children. Functional—or chronic recurrent—abdominal pain is usually nonspecific and is not life-threatening.
Functional Abdominal pain is defined as pain that is “without demonstrable evidence of a pathologic condition such as an anatomic, metabolic, infectious, inflammatory, or neoplastic disorder.” In functional abdominal pain the enteric nervous system, which envelops the gut, is thought to be in crisis with the central nervous system. This dysregulation can result in the pain. Further thought has been given to the idea that those with functional abdominal pain may have abnormal bowel reactivity to physiologic stimuli (meal, gut distension, hormonal changes), noxious stressful stimuli (inflammatory processes), or psychological stressful stimuli (parental separation, anxiety). These stimuli may interact with the enteric nervous system and result in dysregulation.
Diagnosis
Functional abdominal pain generally can be diagnosed correctly by the primary care clinician in children 4 to 18 years of age with chronic abdominal pain, without the requirement of additional diagnostic evaluation, when:
There are no alarming symptoms or signs
The physical examination is normal, and
The stool sample tests are negative for occult blood.
It is not uncommon for children with functional abdominal pain to have additional somatic complaints, such as headache, difficulty sleeping, or limb pain.
Treatment
Treatment generally consists of reassuring the parents and patient that no serious illness is present. Occasionally a child’s fear of going to school or another phobia may be so strong that removal of the pain as a defense mechanism may only lead to other symptoms. These children should be followed closely and referred for psychological evaluation and treatment, if appropriate.
Importance of growth chart
A slowing of weight gain (and especially weight loss) may be one of the first signs of a chronic illness.
A drop in the height velocity is much less common and suggests a more long-standing illness.
Causes of microcytic anemia
Three broad physiologic categories
The most common cause of microcytic anemia in children is iron deficiency. While iron deficiency is most commonly due to inadequate iron intake, blood loss may also lead to iron deficiency.
With iron deficiency, there is decreased RBC production, which leads to anemia.
Thalassemia is another cause of microcytic anemia, but is much less common than iron deficiency.
Ultimately there are three broad physiologic categories of anemias:
Anemia due to decreased production (such as iron deficiency and anemia of chronic disease)
Anemia due to increased destruction (such as hemolysis)
Anemia due to blood loss (such as in inflammatory bowel disease).
Types of IBD
Evaluation of IBD
Inflammatory bowel disease (IBD) includes both Crohn’s disease (CD) and ulcerative colitis (UC). Because the definitions of UC and CD are based on the location and characteristics of the inflammatory process within the gastrointestinal tract, evaluation for IBD involves looking for inflammation in both the upper GI tract and lower GI tract.
Ulcerative colitis
In UC, relatively generalized inflammation is confined to the mucosa, starting in the rectum and involving a variable extent of colon proximally.
Crypt abscesses are common.
Rarely, patients may have discontinuous inflammation at diagnosis or even relative rectal sparing.
Over the course of the illness, however, the inflammation becomes more confluent.
Crohn’s disease
The inflammation associated with CD may involve any portion of the alimentary tract, from mouth to anus.
Mucosal inflammation may become more generalized or remain patchy and may extend gradually into the submucosa, muscularis, and serosa.
Transmural inflammation can result in fistula formation.
The definitive diagnosis of CD or UC is established with a combination of radiography and endoscopy. It is important to make the distinction, because the treatment and prognosis of the two disorders is not the same. An upper endoscopy and colonoscopy are appropriate diagnostic tests to make this distinction. (In some centers, a small bowel series, MRI, or video capsule endoscopy might be done as well.)
CT scan is useful to look at small bowel disease and although UC is usually limited to the colon, there can be evidence of ileal inflammation called “backwash ileitis.” CT enterograph and MR enterography have replaced fluoroscopic small bowel follow-through as the modality of choice for imaging the small bowel. This imaging is essential to map disease location, assess severity, and identify complications. This imaging is often performed after endoscopic diagnosis. MRI is playing a larger role in IBD because there is no radiation exposure and it has 90% sensitivity and specificity for detecting Crohn’s disease of the small bowel.
IBD- timing of onset
Cause
Environmental and immunological factors
Timing of Onset
The onset of IBD typically occurs in the second and third decades of life:
25-30% of IBD patients develop symptoms before 20 years of age
5% before 10 years of age
A majority of affected individuals progress to relapsing and chronic disease.
Cause
The cause(s) of IBD is (are) not known. Whether UC and CD are two distinct diseases that have similar clinical manifestations or diseases that have different histopathologic and geographic localization and are causally linked also is unknown.
Family aggregation has long been recognized.
First-degree relatives of affected individuals have a relative risk of fivefold or greater.
The inheritable component seems stronger in Crohn’s disease than in ulcerative colitis.
Environmental and Immunological Factors
It is of interest that in several countries with historically low rates of IBD, a pattern of rising incidence in the past one to two decades-particularly for Crohn’s disease-has occurred, suggesting that environmental factors are also involved.
Many investigations have focused on possible infectious causes as well as on immunologic disturbances. Abnormalities in gastrointestinal immunoregulation appear to be important contributors to the pathogenesis of IBD.
Tx of crohns : goals and meds
Treatment options in pediatric IBD have changed leading to improvement of treatment goals. While initial goals focused on improving symptoms, current goals include:
- Eliminate symptoms and improve quality of life
- Restore normal growth
- Eliminate complications.
Treatment includes considering both induction therapy to bring about remission of disease and maintenance for those who need to quiet baseline disease after induction. Not all parties will require both types. Children with Crohn’s disease are often initially trialed on corticosteroids to induce remission. Other induction therapies include enteral nutrition therapy.
Immunomodulators (thiopurines, Methotrexate) are approved for maintenance therapy. Anti-TNF therapy is approved for moderate to severe CD for instance IBD refractory to corticosteroids or if they are dependent on corticosteroids despite immunomodulators. Surgery is an option, more likely in UC, however it is considered in CD when disease is refractory to medical therapy.
Aminosalicylates (5-ASA) have anti-inflammatory properties. Although once used in CD, systematic reviews no longer support their efficacy. They are effective in adults with UC but few trials have supported their use in children.
Comparison of Treatments
Ileal, ileocolonic, or colonic Crohn’s disease has commonly been treated in clinical practice with oral aminosalicylates. Despite the use of oral mesalamine (NSAID) treatment in the past, new evidence suggests that this approach is minimally effective as compared with placebo and less effective than budesonide or conventional corticosteroids.
Genetic RF In crohns
The single greatest risk factor for the development of IBD is having a first-degree relative who has the disease:
The estimated risk is 30 to 100 times greater in this case than in the general population.
Extraintestinal manifestations of Crohn’s disease
extraintestinal manifestations of Crohn’s disease, such as arthritis, uveitis, renal involvement (kidney stones), hepatic involvement, and pyoderma gangrenosum (painful nodule or pustule breaks down to form a progressively enlarging ulcer)
