Jennifer Verrill Schurman

Diagnosing functional abdominal pain with the Rome II criteria: parent, child, and clinician agreement.

Objectives: To compare the Rome II diagnoses made in children with recurrent abdominal pain by physicians and by parent and child responses on the Questionnaire on Pediatric Gastrointestinal Symptoms. Rates of diagnostic agreement and reasons for disagreement were examined to determine whether changes to the Rome II criteria are needed to improve diagnostic classification. Methods: One hundred and forty-eight children and their parents or guardians completed the Questionnaire on Pediatric Gastrointestinal Symptoms during their first visit to a pediatric gastroenterology clinic. Parent- and child-report Rome II diagnoses were based on Questionnaire on Pediatric Gastrointestinal Symptoms scoring criteria, whereas the physicians Rome II diagnosis was based on clinical impression from history and physical examination completed at this visit. Statistical comparisons involved Pearson χ2 tests and Fisher exact tests. Kappa and weighted kappa measured agreement rates. Results: Most children met the criteria for a functional gastrointestinal disorder based on the Rome II criteria. Functional dyspepsia was the most common diagnosis made by all three sources. The percentage of children classified as “no diagnosis” was small and was often a function of symptom duration (especially when diagnosis rested on the child self-report). Diagnostic agreement was fair to moderate. Diagnoses based on parent and child questionnaires agreed more often on functional dyspepsia than irritable bowel syndrome. Diagnostic disagreement was most likely to result from parent and child disagreement on defecation symptoms. Conclusions: The Rome II classification system shows promise for improving diagnosis, study and treatment of children with recurrent abdominal pain. However, further refinement and clarification of the Rome II criteria for symptom duration and frequency may be needed to improve diagnostic agreement.

Conceptualization and treatment of chronic abdominal pain in pediatric gastroenterology practice.

Objectives: The aim of this study was to examine how children with abdominal pain presently are viewed, assessed, and treated by pediatric gastroenterologists across North America, as well as how perspectives have changed since initial release of the Rome criteria for functional gastrointestinal disorders approximately 15 years ago. Patients and Methods: One hundred seventy-four full members of the North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition completed a pediatric gastroenterology practice survey designed by the authors in 2006. The responses were examined for practice patterns and specific knowledge/use of the Rome criteria. The responses were also compared with historical data from 151 North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition members who completed a similar survey in 1992. Results: There were few changes in the evaluation, treatment, or outcomes for children with abdominal pain for the past 15 years. Knowledge of the Rome criteria was common, but use in practice was not; several specific problems with the criteria were identified. A mismatch also appeared between belief in the importance of psychological factors in the creation/maintenance of pediatric abdominal pain and integration of these factors as part of standard evaluation and treatment. Finally, controversy emerged regarding both the term “functional” and the importance of histologic inflammation in the pathophysiology of pediatric abdominal pain. Conclusions: The evolution and dissemination of the Rome criteria for the past 15 years have not substantially changed evaluation or treatment practices for children with abdominal pain. Many areas of inconsistency and controversy remain. More focused research is needed to better understand this common pain condition and to establish an effective treatment program that can be disseminated across practitioners.

Symptoms and Subtypes in Pediatric Functional Dyspepsia: Relation to Mucosal Inflammation and Psychological Functioning

Objectives: The aim of the present study was to explore relations between antral or duodenal inflammatory cells and aspects of psychological functioning with clinical symptom presentation in children with functional dyspepsia (FD), as well as to determine whether histologic inflammation and/or psychopathology are differentially associated with FD subtypes as defined by the Rome II and Rome III criteria. Patients and Methods: One hundred pediatric patients with dyspepsia completed a standardized history and physical examination at initial evaluation. Patients and parents also completed a measure of psychological functioning. Subsequently, 63 of these patients underwent upper endoscopy with biopsy (4 patients excluded from analysis because of mucosal disease). Inflammatory cells in the mucosa of stomach and duodenum were enumerated. Associations between specific symptoms and FD subtypes with inflammatory cell densities and anxiety, depression, and somatization scores were examined. Results: Rome III subtypes were more robustly related to differences in mast cell densities and scores on psychologic subscales than was true for Rome II subtypes. At the individual symptom level, having pain wake the patient from sleep was associated with higher duodenal mast cell density. Bloating was associated with lower levels of general antral inflammation, as well as higher self-reported levels of anxiety and somatization. Early satiety and bothersome postprandial fullness also were associated with higher levels of self-reported anxiety and depression. Conclusions: The present study provides preliminary evidence for a relation between clinical presentation, specific types of inflammatory cell infiltrates, and aspects of psychological functioning in children with FD. Rome III subtyping, adopted for adult dyspepsia, may be relevant to the pediatric population.

A Pilot Study to Assess the Efficacy of Biofeedback-Assisted Relaxation Training as an Adjunct Treatment for Pediatric Functional Dyspepsia Associated with Duodenal Eosinophilia

OBJECTIVES To conduct a pilot study examining whether adding biofeedback-assisted relaxation training (BART) to medication treatment results in better clinical outcomes than medication treatment alone for children with functional dyspepsia (FD) associated with duodenal eosinophilia, a subgroup of children with recurrent abdominal pain. METHODS Twenty children were randomly assigned to receive a standardized medication treatment or medication plus 10 sessions of BART. Children and parents completed psychosocial functioning and quality of life measures at baseline, posttreatment, and 6 months. Children rated pain daily via PDA. Physicians provided biweekly assessments of clinical improvement. RESULTS Children receiving medication plus BART demonstrated better outcomes on pain intensity, duration of pain episodes, and clinical improvement than children receiving medication alone. CONCLUSIONS BART is a promising adjunctive treatment for pediatric FD associated with duodenal eosinophilia. Electronic daily diaries appear to be a useful approach to assessing changes in self-reported pain ratings in this population.

Montelukast in the treatment of duodenal eosinophilia in children with dyspepsia: Effect on eosinophil density and activation in relation to pharmacokinetics

BackgroundWe have previously demonstrated the clinical efficacy of montelukast in a randomized double-blind controlled cross-over trial in patients with dyspepsia in association with duodenal eosinophilia. The mechanism of this clinical response is unknown but could involve a decrease in eosinophil density or activation.MethodsTwenty-four dyspeptic patients 8–17 years of age underwent initial blood sampling and endoscopy with biopsy. Eighteen of these patients had elevated duodenal eosinophil density and underwent repeat blood sampling and endoscopy following 21 days of therapy with montelukast (10 mg/day). The following were determined: global clinical response on a 5-point Lickert-type scale, eosinophil density utilizing H & E staining, eosinophil activation determined by degranulation indices on electron microscopy, and serum cytokine concentrations. On day 21, pharmacokinetics and duodenal mucosal drug concentrations were determined.ResultsEighty-three percent of the patients had a positive clinical response to montelukast with regard to relief of pain with 50% having a complete or nearly complete clinical response. The response was unrelated to systemic drug exposure or to mucosal drug concentration. Other than a mild decrease in eosinophil density in the second portion of the duodenum, there were no significant changes in eosinophil density, eosinophil activation, or serum cytokine concentrations following treatment with montelukast. Pre-treatment TNF-α concentration was negatively correlated with clinical response.ConclusionThe short-term clinical response to montelukast does not appear to result from changes in eosinophil density or activation. Whether the effect is mediated through specific mediators or non-inflammatory cells such as enteric nerves remains to be determined.Trial RegistrationClinicalTrials.gov; NCT00148603

Variations in Psychological Profile Among Children with Recurrent Abdominal Pain

This study was designed to determine whether distinct subgroups of children with recurrent abdominal pain (RAP) could be identified based on patterns of psychological functioning. Two hundred and eighty-three children (ages 8–17 years), and a primary caretaker, completed the Behavior Assessment System for Children (BASC) during the initial evaluation of RAP at a pediatric gastroenterology clinic. Cluster analysis of BASC scores supported a 3-cluster solution, with fair agreement observed between parents and children on cluster assignment. Approximately half of the sample identified no significant psychological problems. A small percentage (13%) evidenced intense and broad-based psychological problems, while the remainder (35–45%) indicated relative elevations in anxiety only. Cluster membership did not vary systematically by age, gender, race, or functional gastrointestinal disorder diagnosis. Distinct psychological profiles appear to exist for children with RAP. Targeting treatments to these profiles may improve the effectiveness and efficiency with which health professionals address pediatric abdominal pain.

Quality of life assessment between laparoscopic appendectomy at presentation and interval appendectomy for perforated appendicitis with abscess: analysis of a prospective randomized trial

PURPOSE The current study examined the impact of immediate laparoscopic surgery vs nonoperative initial management followed by interval appendectomy for appendicitis with abscess on child and family psychosocial well-being. METHODS After obtaining Internal Review Board approval, 40 patients presenting with a perforated appendicitis and a well-formed abscess were randomized to surgical condition. Parents were asked to complete child quality of life and parenting stress ratings at presentation, at 2 weeks postadmission, and at approximately 12 weeks postadmission (2 weeks postoperation for the interval appendectomy group). RESULTS Children in the interval arm experienced trends toward poorer quality of life at 2 and 12 weeks postadmission. However, no group differences in parenting stress were observed at 2 weeks postoperation. At 12 weeks postadmission, participants in the interval condition demonstrated significant impairment in both frequency and difficulty of problems contributing to parenting distress. CONCLUSION Families experience significant parenting distress related to the childs functioning and disruption in the childs quality of life that may be because of the delay in fully resolving the childs medical condition. In addition, parents experience negative consequences to their own stress as a result of the delay before the childs appendectomy.

Antral Inflammatory Cells, Gastric Emptying, and Electrogastrography in Pediatric Functional Dyspepsia

The aims of the current study were to determine the activation states of antral eosinophils and mast cells and to evaluate the interactions of antral inflammatory cells with gastric emptying and electrogastrography (EGG) in 30 pediatric patients with functional dyspepsia. Eosinophil degranulation was moderate in 42% and extensive in 54% of patients. Mast cell degranulation was >50% in 81% of patients. Elevated mast cell density was associated with slower one hour gastric emptying and increased preprandial dysrhythmia. Mast cell density correlated with the preprandial percentage tachygastria. CD3+ cell density correlated with the preprandial percentage tachygastria also, but only in patients with increased eosinophil density. In conclusion, antral eosinophils and mast cells are significantly activated in pediatric functional dyspepsia. Mast cell density is associated with delayed gastric emptying and preprandial dysrhythmia, suggesting that there may be an interaction between antral inflammation and gastric electromechanical dysfunction in the pathophysiology of pediatric functional dyspepsia.

Volitional and Accidental Nonadherence to Pediatric Inflammatory Bowel Disease Treatment Plans: Initial Investigation of Associations with Quality of Life and Disease Activity

OBJECTIVE To examine rates of volitional and accidental nonadherence, and explore potential differential associations of each with disease activity and quality of life (QOL), in pediatric patients with inflammatory bowel disease (IBD). METHODS One hundred families (100 parents, 78 adolescents) recruited from a large Midwestern childrens hospital reported on the childs medication nonadherence and QOL. Healthcare providers supplied disease activity ratings. RESULTS Most adolescents (73.1%) and parents (70.1%) reported engaging in accidental nonadherence, whereas a smaller group (35 and 30%, respectively) reported engaging in volitional nonadherence to the childs prescribed medication regimen. Frequency of accidental nonadherence was unrelated to disease activity or any specific QOL area examined, whereas greater frequency of volitional nonadherence was associated with greater disease activity and poorer parent reported psychosocial QOL. CONCLUSIONS Nonadherence and the relationship with disease severity and QOL may be more complex for children with IBD than understood through previous work.

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.