Miguel Saps

Functional Disorders: Children and Adolescents.

Characterization of childhood and adolescent functional gastrointestinal disorders (FGIDs) has evolved during the two decade long Rome process now culminating in Rome IV. The era of diagnosing a FGID only when organic disease has been excluded is waning,as we now have evidence to support symptom-based diagnosis. In child/adolescent Rome IV we extend this concept by removing the dictum that there was no evidence for organic disease in all definitions and replacing it with after appropriate medical evaluation the symptoms cannot be attributed to another medical condition. This change allows the clinician to perform selective or no testing to support a positive diagnosis of a FGID. We also point out that FGIDs can coexist with other medical conditions that themselves result in gastrointestinal symptoms (e.g., inflammatory bowel disease). In Rome IV functional nausea and functional vomiting are now described. Rome III abdominal pain related functional gastrointestinal disorders (AP-FGID) has been changed to functional abdominal pain disorders (FAPD) and we have derived a new term, functional abdominal pain -not otherwise specified, to describe children who do not fit a specific disorder such as irritable bowel, functional dyspepsia, or abdominal migraine. Rome IV FGID definitions should enhance clarity for both clinicians and researchers.

Post-Infectious Functional Gastrointestinal Disorders in Children

OBJECTIVEnTo investigate the development of functional gastrointestinal disorders (FGIDs) after an episode of acute bacterial gastroenteritis (AGE) in children.nnnSTUDY DESIGNnA cohort study of children 3 to 19 years old with a positive result on a bacterial stool culture. 44 patients in each arm (unidirectional alpha of 0.05, power of 0.80). Children presenting at two pediatric hospitals (United States and Italy) for AGE who tested positive for bacteria on stool culture (2001-2005) were contacted at least 6 months after the episode. Exposed children were matched with control subjects of similar age and sex consulting to the same hospitals for trauma or well-child visit within 4 weeks of the index case. Symptoms were evaluated with a validated questionnaire for FGIDs assessing pain, diarrhea, and disability.nnnRESULTSn88 patients (46 boys; mean age, 8.1 years; age range, 3-19 years) were recruited. Bacteria included Salmonella (54%), Campylobacter (32%), and Shigella (14%). 36% of exposed patients and 11% of control subjects complained of abdominal pain (P < .01). 87% had irritable bowel syndrome and 24% had dyspepsia. 56% reported onset of pain following the AGE.nnnCONCLUSIONnThere is a significant increase in cases of FGIDs after bacterial infections in children.

Prevalence of Functional Gastrointestinal Disorders in Colombian School Children

OBJECTIVESnTo determine prevalence for functional gastrointestinal disorders (FGIDs) in Colombian school children using the Questionnaire on Pediatric Gastrointestinal Symptoms-Rome III Version (QPGS-III) and to determine possible risk factors.nnnSTUDY DESIGNnThe QPGS-III was translated into Spanish then reverse translated by a team of bilingual physicians. Focus groups of Colombian children were conducted to assure understanding of the Spanish version. Children at 1 public school and 2 private schools in Pasto, Colombia were invited to participate in a prevalence study using the translated questionnaire.nnnRESULTSnA total of 373 children (95 private school, 278 public school), with mean age 9.9 years completed the QPGS-III. Twenty-nine percent of children were diagnosed with FGIDs. FGIDs were more common in females (OR, 1.63; 95% CI, 1.04-2.56). Functional constipation (14%) was the most common FGID. Irritable bowel syndrome was the most common abdominal pain-related FGID (5.4%). Abdominal migraine (1%) and cyclic vomiting syndrome (0.3%) were the least common FGIDs.nnnCONCLUSIONnFGIDs are common in Colombian school children.

How Reliable Are the Rome III Criteria for the Assessment of Functional Gastrointestinal Disorders in Children

OBJECTIVES:Functional gastrointestinal disorders (FGIDs) are common in children. Diagnosis of these conditions is based on the pediatric Rome criteria. In the past, we have shown that there was low inter-rater reliability (IRR) among pediatric gastroenterologists using the Rome II criteria. Since then, a new version of the criteria has been issued. The reliability of the Rome III criteria has not been established.METHODS:A total of 10 pediatric gastroenterologist specialists and 10 pediatric gastroenterology fellows were provided with 20 clinical vignettes and a list of 17 possible diagnoses (all pediatric categories of the Rome criteria plus “none of the above” or “not enough information”) and instructed to select one or more diagnosis for each vignette.RESULTS:The average percentage of agreement among the raters was 50% for the pediatric gastroenterologists and 45% for the pediatric gastroenterology fellows. The inter-rater percentage of agreement per clinical case was >50% in only 7 out of 20 (35%) vignettes for the gastroenterologists and only 6 out of 20 (30%) cases for the fellows. The inter-rater percentage of agreement was <25% in 2 out of 20 (10%) vignettes for the gastroenterologists and 4 out of 20 (20%) vignettes for the fellows. The κ coefficient was 0.45 for the specialists (P<0.0001) and 0.39 for the fellows (P<0.0001). In a subanalysis of the groups of pain and constipation-related disorders, the inter-rater percentage of agreement per clinical case ranged between 27 and 100% (mean 57%, κ=0.37, P<0.0001) for the gastroenterologists and between 36 and 80% (mean 52%, κ=0.33, P<0.0001) for the fellows in the constipation subgroup. The inter-rater percentage of agreement per clinical case for the pain subgroup ranged between 22 and 80% (mean 48%, κ=0.36, P<0.0001) for the gastroenterologists and 22 and 62% (mean 39%, κ=0.29, P<0.0001) for the fellows in the pain subgroup. The κ coefficient for specialists with expertise in FGIDs was 0.37 (P<0.0001) and for those with expertise in other gastroenterology conditions was 0.53 (P<0.0001).CONCLUSIONS:The IRR among pediatric gastroenterologists and fellows was found to be fair to moderate for the Rome III criteria. Only slight to fair agreement between raters existed for important subcategories of pain and constipation. The results from our current study are almost similar to that of the IRR study done for the Rome II criteria. This indicates the need for further refinement of the Rome criteria to make them more encompassing and user friendly.

Accuracy of pain recall in children.

Background and Aim: Chronic abdominal pain (AP) is common in children. Recall of symptoms is used clinically to determine management, to assess treatment progress, and in drug studies to assess outcomes. Limited data exist on accuracy of AP recall in children. The aim of the present study was to assess ability to accurately recall AP in children. Methods: The study was a secondary analysis of data obtained from a double-blind, randomized, placebo-controlled trial, evaluating amitriptyline in children with functional gastrointestinal disorders. Children ages 8 to 17 years with AP predominant functional gastrointestinal disorders based on Rome II criteria were recruited from 6 centers. Those with evidence of organic disease were excluded. Patients maintained AP diary daily for 1 month (presence, frequency, and intensity). At the end of the study, patients reported the number of days of AP during previous month. Agreement between daily pain reports and recalled pain was assessed. Univariate analysis was conducted with Spearman rank correlations. Results: We recruited 63 children (45 girls, mean age 12.8 years). Sixteen percent children had perfect agreement on number of days of AP. Fifty-four percent of children recalled fewer episodes of pain. The average number of days with AP by recall was 17.7/month, whereas by diary it was 23.5/month (Pu200a=u200a0.001). Correlation between patient recall of the last week of symptoms (ru200a=u200a0.47) was no better than correlation between recall of the last 30 days of symptoms (ru200a=u200a0.48). On comparing AP recall versus various pain intensities, reported AP did not reflect only AP of greater severity. Higher correlation of recall of symptoms was seen in children 11 years or younger (ru200a=u200a0.59) as compared with children older than 11 years (ru200a=u200a0.26). Conclusions: Few children can accurately recall the episodes of AP. Children commonly recall a lower frequency of AP than that assessed by prospective diary reports. Reported recall does not reflect a shorter recollection period. Recall is not related to intensity of pain. Adolescents have worse recall of symptoms.

Interobserver and intraobserver reliability of the Rome II criteria in children.

BACKGROUND:Functional gastrointestinal disorders are common in children. It has been suggested that the diagnosis of these conditions should be based on the “pediatric Rome II” criteria. The interobserver reliability for the DSM-IV, another symptom-based criteria is considered almost perfect in multiple studies. There are no studies assessing the reliability of the Rome II criteria in children.OBJECTIVES:To evaluate the reliability of the pediatric Rome II criteria.METHODS:Interobserver reliability—Ten pediatric gastroenterologists and 10 fellows in pediatric gastroenterology were provided with 20 clinical vignettes, the Rome II criteria, and a list of 15 possible diagnoses. Each of the raters was instructed to select one or more diagnoses for each vignette. Intraobserver reliability—The specialists were provided with the same set of vignettes 4 months later.RESULTS:Average percentage of agreement coefficient: 45% (specialists), 47% (fellows). In order to correct for possible agreement by chance, we calculated the kappa coefficient, a measure of pairwise agreement corrected for chance. Specialists: k = 0.37 (p < 0.0001), trainees: k = 0.41, (p < 0.0001). Physicians with a special interest in functional gastrointestinal disorders (k = 0.37, p < 0.0001), and other specialists (k = 0.38, p < 0.0001). Analysis of data in pain and constipation diagnosis subgroups revealed even lower kappa (constipation: k = 0.2, p < 0.0001; pain: k = 0.3, p < 0.0001). Intraobserver agreement: k = 0.63 (p < 0.0001).CONCLUSION:The interobserver reliability of the Rome II criteria among pediatric gastroenterologists and fellows is low. Further validation of the criteria is necessary.

Nausea Predicts Delayed Gastric Emptying in Children

OBJECTIVESnTo 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.nnnSTUDY DESIGNnFifty children (36 F), 5-18 years of age, undergoing gastric emptying scintigraphy (GES) at Lurie Childrens 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.nnnRESULTSnSeventy 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.nnnCONCLUSIONSnThe 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.

Abdominal pain and functional gastrointestinal disorders in children with celiac disease.

OBJECTIVEnTo assess whether patients with celiac disease (CD) are more likely than controls to develop abdominal pain (AP) and AP-associated functional gastrointestinal disorders (FGID) in long-term follow-up.nnnSTUDY DESIGNnIn a retrospective study, data on children (3-22 years old) with CD diagnosed between 2000 and 2010 were obtained. Parents were contacted by telephone at least 6 months after the diagnosis of CD and invited to participate in the study. Consenting parents completed: (1) a telephone questionnaire on the presence of gastrointestinal symptoms; and (2) the parent report version of the Questionnaire on Pediatric Gastrointestinal Symptoms-Rome III for cases and selected controls.nnnRESULTSnForty-nine cases (mean 11.3 years, 20 male participants) and 48 controls (mean 11.1 years, 24 male participants) were enrolled. Twelve children in the CD group (24.5%) and 7 children in the control group (14.6%) had AP at the time of the study (Pxa0=xa0.3). Nine children in the CD group (18.3%) and 4 children in the control group (8.3%) met criteria for an AP-associated FGID according to the Questionnaire on Pediatric Gastrointestinal Symptoms-Rome III (Pxa0=xa0.23).nnnCONCLUSIONnIt was found that children with CD and controls have a similar risk of AP and AP-FGIDs. Methodologic limitations prevent generalization of results, but large prospective studies should confirm the findings.

Reexamining the Factor Structure of Somatization Using the Children's Somatization Inventory (CSI-24) in a Community Sample

OBJECTIVEnPediatric somatization studies have used the 35-item Child Somatization Inventory (CSI-35) or psychometrically refined 24-item CSI (CSI-24). Exploratory factor analysis of the CSI-24 has identified a single factor that did not show good model fit in confirmatory factor analysis (CFA). Further evaluation of the CSI-24 factor structure is needed.nnnMETHODSnThe present study examined alternative factor structures of the CSI-24 in a community sample (Nu2009=u2009233, ages 8-15).nnnRESULTSnThe CFA showed good fit for a single CSI-24 factor, better fit for multiple factor models, and best fit for a single, six-item factor. Construct validity for that factor was found in significant correlations with anxiety, depression, functional disability, and quality of life.nnnCONCLUSIONSnResults are consistent with a single somatization factor, but research is needed to verify the factor structure in different, race/ethnic/demographic, and clinical groups.

Urinary tract infection in infancy is a risk factor for chronic abdominal pain in childhood

Objective: Adverse early life events are key factors for development of functional gastrointestinal disorders (FGIDs). Urinary tract infection (UTI) is associated with chronic pelvic pain in adults, a finding that has been recapitulated in murine models, but the relation between UTI and chronic pelvic and abdominal pain has not been studied in children. We hypothesized that UTI in infancy increases the risk of FGIDs and chronic abdominal pain (CAP) in childhood. Methods: The present study included children, ages 4 to 18 years, with a single UTI in the first year of life and their siblings with no history of UTI. Parents completed the Questionnaire on Pediatric Gastrointestinal Symptoms–Rome III Version (QPGS-III) by telephone. Children meeting QPGS-III criteria for FGIDs but with pain less than once weekly were considered to have CAP. Results: A total of 57 patients with UTI and 58 sibling controls were identified. Mean age at UTI was 4.8 months, and mean time since UTI was 9.3 years. At the time of survey, mean age of patients was 9.7 years (5–16 years, 40% boys) and that of controls was 9.6 years (range 4–17 years, 57% boys). FGIDs were diagnosed in 6 of 57 (11%) patients, and 1 of 58 (2%) controls (Pu200a=u200a0.06). CAP was identified in 10 of 57 (18%) patients and 2 of 58 (3%) controls (Pu200a=u200a0.02). Predominant sex (female), infecting organism (E coli), and treatment (third-generation cephalosporin) were similar in patients with UTI with and without CAP. Conclusions: We show for the first time that UTI is associated with CAP in childhood. We speculate that pelvic organ sensory convergence explains our findings.