SEATTLE — Proton-pump inhibitors are often the wrong choice when it comes to treating abdominal pain in children, according to Dr. Ghassan Wahbeh.
Dr. Wahbeh, director of the inflammatory bowel disease program at Seattle Children's Hospital, sees many children referred to him with gastrointestinal complaints who are on proton-pump inhibitors (PPIs) when they are not indicated. He suspects the drugs are overused.
Some PPIs are indicated for Helicobacter pylori–related gastric complications and pediatric gastroesophageal reflux disease (GERD), which has a definable triad of symptoms—chest pain, heartburn, and dysphagia—but Dr. Wahbeh said patients with abdominal pain come to him on PPIs even though they have none of those classic GERD symptoms or evidence of H. pylori infections.
On work-up, those children most often turn out to have functional constipation and functional abdominal pain, both of which are underrecognized, Dr. Wahbeh said at a conference sponsored by the North Pacific Pediatric Society.
The pain is thought to be related to gastrointestinal nerve inflammation and hypersensitivity, triggered by infection, medication reaction, or some other insult. Constipation can make it worse. The two often go together, he said.
Pain location in constipated children varies. When it's epigastric pain, it's often incorrectly presumed to be GERD related. “Epigastric pain does not mean gastroesophageal reflux. The presumed relation of epigastric pain to gastroesophageal reflux is unproven,” Dr. Wahbeh said.
“It is possible that severe reflux esophagitis with ulceration can cause upper abdominal pain. However, this is quite rarely seen in clinical practice, and if so, quite specific to children with neuromuscular disorders [such as] cerebral palsy or large diaphragmatic hernias,” he said.
But “we are harpooned by ads for acid blocker. They are imbedded in mind,” he said, so they are turned to a bit too often.
Although PPIs may have a temporary laxative effect, their use otherwise in functional abdominal pain and constipation is problematic, he said.
A month of treatment with a branded PPI can run $500, he said. Once the drug is stopped, there's the risk of oversecretion of stomach acid (Gastroenterology 2009;137:80-7).
Also, incorrectly labeling a child with a pre-existing condition like GERD can cause problems with insurance coverage later on and trap a child into an algorithm of GERD treatments.
When working up a child with suspected functional constipation and abdominal pain, a blood panel makes sense to rule out anemia, hypoalbuminemia, celiac disease, inflammatory markers, and other problems, and also to calm the nerves of patients and families. Imaging will help rule out gallstones, abdominal masses, and anatomic abnormalities, if symptoms warrant it, Dr. Wahbeh said.
Along with a comprehensive history and physical, a digital rectal exam is essential. It is the only effective and accurate way to determine if a child is constipated, but “it's not comfortable, and it's not something most of us jump at,” he said. However, if its importance is explained to patients and caretakers, it's “rarely turned down,” he added. Having a medical assistant or nurse chaperone present during the digital exam will help avoid problems in case the exam is misinterpreted by patients and families.
Functional abdominal pain and constipation can be a frustrating diagnosis for clinicians, caretakers, and children alike. It seems strange to patients and families that such severe and long-lasting pain can be caused by something as common as constipation, or made worse by fructose or lactose intolerance.
Adding to the frustration, treatment is conservative and improvements are slow in coming. Depression and anxiety during the process are not uncommon, Dr. Wahbeh said.
Because of that, he said it is essential to establish trust in the therapeutic relationship. Tell patients and caretakers that things will “get better, but not any time soon,” and that it will take a multidisciplinary approach that sometimes includes a psychologist, social worker, pain specialist, and dietician, among others, he said.
In addition to diet modifications and other interventions, a child with functional constipation will be on daily laxatives, sometimes for over a year. Biofeedback and exercise also help, and there's some support in the literature for gabapentin, amitriptyline, or clonidine to help with the presumed nerve inflammation and hypersensitivity, Dr. Wahbeh said.
Dr. Wahbeh disclosed research or grant support from Abbott Laboratories, Centocor Inc., and UCB.