ADOLESCENT HEALTH
| ABDOMINAL PAIN IN THE TEENAGER —John F. Pohl, MD, Assistant Professor of Pediatrics, Section of Pediatric Gastroenterology, Scott and White Hospital, Texas A&M Health Science Center, Temple, Texas |
| Where is pain? right upper quadrant—gallstones; liver disease; epigastric—peptic ulcer disease (PUD); pancreatitis; left upper quadrant—renal colic (in particular, ureteropelvic junction [UPJ] obstruction); right lower quadrant— appendicitis; infectious enteritis; periumbilical—often functional; recurrent abdominal pain (RAP); left lower quadrant—constipation; colitis; suprapubic—urinary tract infection (UTI) |
 | Ask about: location of pain; type of pain (eg, dull or sharp, constant or intermittent); association with meals (improvement with meals suggests gastritis or ulcer; if worse after eating and patient obese, suspect gallstones); nighttime awakening with pain generally pathologic (eg, peptic ulcer disease); alleviating or aggravating factors; association with headaches (abdominal migraines [cyclic vomiting]); history of school absence; functioning in school; home life; source of water; previous antibiotic use; pets (eg, turtles) can carry pathogens; vomiting history (awakening with vomiting worrisome; associated blood or bile); bowel habits; bleeding (bright red color suggests lower gastrointestinal [GI] tract; hematochezia); melena (upper GI tract); urinary symptoms or history of UTI; menstruation and sexual history; alcohol use; medical history—abdominal surgery; migraine with abdominal pain (cyclic vomiting syndrome); medications— acid blockers (H2 -receptor antagonists or proton pump inhibitors [PPIs]); treatment failure suggests diagnosis other than gastritis); ibuprofen; medications that may cause pancreatitis; family history |
| Red flags: pain localized away from umbilicus; pain associated with changes in bowel habit; pain with nighttime awakening; repetitive vomiting; constitutional symptoms (fever; weight loss); emesis with unusual headaches |
| Physical examination: growth points important, especially in inflammatory disease (first sign of Crohn’s disease [CD] often weight loss); lungs (chest x-ray if indicated; possible referred pain from pneumonia); head, ears, eyes, nose, and throat (HEENT) examination (oral lesions may be clue to CD; chronic vomiting may cause loss of dental enamel; papilledema (if physician suspects vomiting due to intracranial process); extremities (clubbing seen in patients with anemia of chronic disease, eg, inflammatory bowel disease [IBD]); abdominal examination—presence of bowel sounds; masses; enlarged liver or spleen; rebound or guarding; ascites; rectal examination; red flags—loss of weight or decreased height velocity; organomegaly; abdominal pain localized away from umbilicus; perirectal changes; joint swelling (worry is IBD); unusual rash (eg, erythema nodosum sign of IBD); indications of anemia |
| Laboratory testing: complete blood count (CBC) and erythrocyte sedimentation rate (ESR); liver function tests (if jaundice present, γ-glutamyl transpeptidase [GGT]); amylase and lipase if patient presents with epigastric pain (concern pancreatitis); if indicated, urinalysis and/or urine culture; stool for occult blood; stool tests for pathogens |
| Radiographic imaging: abdominal film helpful to detect stool, mass, or free air); upper GI to look for anatomic problems (eg, malrotation); abdominal ultrasonography (US) to detect extraluminal masses; abdominal computed tomography (CT) for imaging abscesses or intestinal thickening associated with IBD); nuclear-medicine imaging, eg, head MRI to detect brain tumor in patient with nighttime headaches and vomiting; if indicated, endoscopy |
Case 1 | Presentation: 14-yr-old girl with 6-mo history of abdominal pain; pain diffuse and worse during times of stress; no association with meals; no change in bowel habits; physical examination normal; diagnosis—functional pain (irritable bowel syndrome [IBS]) |
| Recurrent abdominal pain: generally resolves over time; clinically defined as episodes of pain that interfere with activity within period of ≥3 mo; occurs in 10% to 15% of children; slightly increased prevalence in girls; study —rare before 5 yr of age; no organic cause; usually periumbilical; self-limited; sometimes antispasmodic or fiber helpful; rarely related to meals; rarely awakens child from sleep; organicity of pain inversely proportional to number of school absences |
| Irritable bowel syndrome: RAP may develop into IBS; some children develop IBS without RAP |
| Diagnostic criteria: abdominal pain relieved with defecation; increased stool at onset of pain; alteration of stool form at time of pain (constipation or diarrhea); passage of mucus (not blood); associated bloating and abdominal distention; no pathologic cause (however, pain-nerve dysfunction probable); ask about psychologic stressors |
| Treatment: exercise; fiber (number of grams daily = child’s age + 5; maximum 20-25 g/day); IBS with no change in bowel movements—consider antispasmodic (hyoscyamine or dicyclomine); tricyclic antidepressants (TCAs; if child constipated, add osmotic laxative); selective serotonin reuptake inhibitors (SSRIs) have not “panned out” for IBS only; IBS with constipation—antispasmodics; osmotic laxatives; polyethylene glycol (MiraLax); lactulose, magnesium hydroxide (Milk of Magnesia) or mineral oil; tegaserod (Zelnorm) not approved by Food and Drug Administration (FDA) for use in children; discuss risk for potential obstruction; IBS with diarrhea—antispasmodics; TCAs (consider low-dose amitriptyline); antidiarrheal agent (eg, loperamide); new drugs—clonidine helpful in some patients; buspirone also studied; esophagogastroduodenoscopy (EGD)—negative findings can be reassuring; expensive |
Case 2 | Presentation: 16-yr-old boy with 4-wk history of nonradiating epigastric pain; no change in bowel habits; family history of PUD; marked epigastric tenderness; diagnosis—Helicobacter pylori infection |
| PUD from H pylori infection: pathogen—unipolar, spiral-shaped, gram-negative bacteria; found in adults with duodenal ulcers; may have role in gastric cancers (lymphoma; carcinoma); role in children not clear (most patients asymptomatic); does not cause IBS |
| North American Society of Pediatric Gastroenterology, Hepatology and Nutrition (NASPGHAN): gold standard for diagnosis is endoscopy and biopsy; breath test—difficult for young children; serum antibodies—not sensitive or specific; fecal antigen test—good sensitivity and specificity |
| Treatment of H pylori infection: speaker uses amoxicillin and clarithromycin (Biaxin) for 14 days and PPI for 6 wk; consider metronidazole; in adults, tetracycline; consider bismuth subsalicylate (Pepto-Bismol) in place of PPI; antibiotic resistance (high failure rate with clarithromycin); quinolones—levofloxacin (70% response when combined with amoxicillin and PPI for 2 wk) |
Case 3 | Presentation: 15-yr-old girl presents with chief complaint of long-standing abdominal pain and diarrhea; history of type 1 diabetes; many relatives with history of abdominal pain and IBS; vague abdominal pain and mild digital clubbing; diagnosis—celiac disease |
Case 4 | Presentation: 16-yr-old boy presents with 2- to 3-mo history of diarrhea and weight loss (20 lb); right lower quadrant pain; 1 to 2 episodes of rectal bleeding; anemic; ESR 45 mm/hr; diffuse abdominal tenderness, but pronounced in right lower quadrant; rectal tags; slightly hemoccult-positive; diagnosis—Crohn’s disease; inflammatory response causes fistulas and fissures; perform endoscopy; on biopsy, granulomas and patchy infiltration seen |
| Medical armamentarium: aminosalicylates; steroids; antibiotics (eg, metronidazole); mercaptopurine; antitumor necrosis factor (TNF)-α (eg, infliximab [Remicade]) |
| Two new considerations for diagnosing IBD (CD; ulcerative colitis [UC]): 1) use of perinuclear antineutrophil cytoplasmic antibody (P-ANCA) and anti-Saccharomyces cerevisiae antibodies (ASCA); 2) genetic testing focused on CARD15 (NOD2) gene |
| Can P-ANCA and ASCA be used to determine type of IBD? UC (65%-75% of patients P-ANCA-positive); CD (60% ASCA-positive) |
| Patient profiles: ASCA-positive—younger age; small-bowel disease; fibrostenotic or fistulous disease; abscesses; history of previous small-bowel surgery; P-ANCA-positive—left-sided colonic disease; crypt abscesses; less small bowel disease; high rate of colectomy |
| Study: 45 patients with IBD (UC or CD) and 74 patients with non-IBD problems; poor sensitivity, positive predictive value, and negative predictive value; recommendation—endoscopy first step; in cases of indeterminate colitis, consider laboratory testing |
| Genetic testing: in first-degree relatives, risk for IBD ≈7% (4 to 20 times higher than general population); high concordance of IBD in monozygotic twins; in 2001, gene found on chromosome 16 that encoded cytoplasmic protein caspase activation and recruitment domain (CARD15); expressed on macrophages; receptor for lipopolysaccharide; involved with nuclear factor-B activation (part of apoptosis pathway); found in families with CD; CARD15 (study)—genotype-phenotype correlation described in ileal disease and CD (especially fibrostenotic disease); CARD15 gene associated with early stricturing disease requiring surgery and strictly ileal location of disease |
Case 5 | Presentation: 12-yr-old boy with vague abdominal pain for 1 yr; initially, symptoms believed functional; diffuse hematochezia, dizziness, and hypotension; packed red blood cell (PRBC) transfusion required; technetium scan; diagnosis— Meckel’s diverticulum |
| Meckel’s diverticulum: remnant of embryonic yolk sac; rule of 2s—(2% of population; within 2 ft of ileocecal valve; 2 types of ectopic tissue (gastric and pancreatic); male to female ratio 2:1; ≈2 in long; more management tips—usually presents at <2 yr of age; massive painless bleeding; intermittent and melanotic; diagnosis requires Meckel’s scan; treatment surgical resection |
| What’s new for occult GI bleeding in children? wireless capsule endoscopy; FDA-approved for children ≥10 yr of age; bowel preparation not necessary, but may produce better images; images small bowel pathology outside range of normal endoscopy; every patient needs barium swallow follow-through to rule out stricture; in younger patients, device may get stuck in stomach |
| STD TREATMENT AND PREVENTION —Lawrence Friedman, MD, Professor of Pediatrics and Chief, Division of Adolescent Medicine, University of California, San Diego, School of Medicine |
| Why screen for sexually transmitted disease (STDs)? significant rate of infection in teenagers; often facilitate infection with HIV; evidence-based prevention can be effective; untreated STDs expensive to healthcare system |
| Barriers to screening: confusion about confidentiality laws (age of consent for screening and treatment varies by state); parent in room during history; health care provider’s discomfort in taking sexual history; lack of systematic method for office screening |
| Screening opportunities: patient request; STD treatment (screen for other STDs); sports and school physical examinations; girls—abdominal pain; vaginal bleeding; pregnancy testing |
| Setting stage: observe confidentiality protocols; assure patient that purpose of questioning to address health issues and that similar questions asked of all patients; consider asking about behavior of others first |
| Questions: have you ever been involved sexually with anyone? have you ever been involved sexually when you did not want to be? if answer “no”—affirm decision with positive feedback; educate; identify options if circumstances change; if answer “yes,” ask about—number of partners; age of partners (sex with older partners increases statistical risk for HIV infection); sex of partners; whether patient ever forced to have sex (almost all date rape occurs under the influence); method (if any) used to prevent pregnancy and STDs; desire to become pregnant; type of sex |
| Prevention trends: important to identify asymptomatic STDs to prevent transmission; preexposure vaccines (eg, hepatitis A and B); latex condoms more effective against mucosal fluid transmission of, eg, trichomoniasis, gonorrhea, chlamydia; sex education should be evidence-based |
| Trichomoniasis: new diagnostic tests; soon, urine-based polymerase chain reaction (PCR) testing will become more widespread; currently, most using wet mounts and vaginal smears (sensitivity poor); gold standard is culture, but not common; rapid antigen test requires pelvic examination |
| Chlamydia: urine PCR test now standard for chlamydia and gonorrhea; CDC recommends rescreening 3 to 4 mo posttreatment due to high rates of reinfection; azithromycin still treatment of choice; lymphogranuloma venereum (LGV) infection reemerging in Europe |
| Herpes simplex virus (HSV) infection: new testing—PCR testing increasingly available; office-based serologic tests available for HSV-2; viral culture of vesicle good method of diagnosis; vaccine—in stage 1 clinical trials |
| Gonorrhea: urine PCR testing standard; fluoroquinolones (eg, ciprofloxacin) no longer recommended by CDC |
| Syphilis: rates increasing (initially, in homosexual men); increased screening warranted; use penicillin G benzathine (bicillin L-A) |
| Human papillomavirus (HPV) infection: associated with cervical cancer; many cases self-resolve; if not, cryotherapy, laser, and podophyllin used; imiquimod (Aldera)—immune response modifier; moderately effective; vaccine development—in stage 3 clinical trials; expected to be available next year; 2 vaccines in development (both cover strains most strongly related to cervical cancer [HPV-16 and -18]); 3-injection series required; probably expensive; studied only in girls; potential to eliminate—70% of cervical cancer; 60% of high-grade cervical intraepithelial lesions; 90% of genital warts; 11- to 12-yr-old patients targeted; does not cover all HPV types; pelvic examination and Papanicolaou (Pap) test still necessary |
Educational Objectives
| The goal of this program is to educate the listener about common health concerns in adolescents. After hearing and assimilating this program, the clinician will be better able to: |
| 1. Identify specific conditions associated with regionalized abdominal pain. |
| 2. Choose appropriate therapy for pathologic and nonpathologic causes of abdominal pain. |
| 3. Describe newer endoscopic techniques. |
| 4. Prevent common forms of sexually transmitted diseases (STDs). |
| 5. Manage selected STDs. |
Discussed on This Program
Amitriptyline HCl [Elavil] Amoxicillin (several formulations and trade names) Azithromycin [Zithromax] Bismuth subsalicylate (BSS) [several formulations and trade names] Buspirone HCl [BuSpar] Ciprofloxacin [Ciloxan, Cipro, Cipro I.V., Cipro XR] Clarithromycin [Biaxin, Biaxin XL] Clonidine HCl [Catapres, Duraclon] Ibuprofen (several trade names) Imiquimod [Aldara] Infliximab [Remicade] Lactulose (several trade names) Levofloxacin [Levaquin, Quixin] Loperamide HCl (several trade names) Magnesia (magnesium hydroxide) [Concentrated Phillips’ Milk of Magnesia, Milk of Magnesia, Phillips’ Chewable, Phillips’ Milk of Magnesia] Mercaptopurine (6-mercaptopurine; 6-MP) [Purinethol] Metronidazole (several trade names) Mineral oil [Kondremul Plain, Milkinol] Penicillin G benzathine [Bicillin C-R, Bicillin C-R 900/300, Bicillin L-A, Permapen, Pfizerpen, Wycillin] Podophyllum resin (podophyllin) [Podocon-25, Podofin] Polyethylene glycol solution [MiraLax] Tegaserod maleate [Zelnorm] Tetracycline HCl (several trade names)
Resources
STD treatment and prevention: CDC.gov; Abstinence-only education: jahonline.org, cpc.unc.edu/addhealth and abstinence.net; minor’s right to confidentiality: guttmacher.org
Suggested Reading
Alfven G: One hundred cases of recurrent abdominal pain ichildren: diagnostic procedures and criteria for a psychosomatic diagnosis. Acta Paediatr 92:43, 2003; American Academy of Pediatrics Subcommittee on Chronic Abdominal Pain: Chronic abdominal pain in children. Pediatrics 115:812, 2005; Coletti JE, Guidice EL: Syphilis screening in a high-risk, inner-city adolescent population. Am J Emerg Med 23:225, 2005; Croffie JM et al: Recurrent abdominal pain in children—a restrospective study of outcome in a group referred to a pediatric gastroenterology clinic. Clin Pediatr (Phila) 39:267, 2000; Cuffari C, Darbari A: Inflammatory bowel disease in the pediatric and adolescent patient. Gastroenterol Clin North Am 31:275, 2002; Di Lorenzo C et al: Chronic Abdominal Pain In Children: a Technical Report of the American Academy of Pediatrics and the North American Society for Pediatric Gastroenterology, Hepatology and Nutrition. J Pediatr Gastroenterol Nutr. 40:249, 2005; Ford CA et al: The pediatric forum: confidentiality and adolescents’ willingness to consent to sexually transmitted disease testing. Arch Pediatr Adolesc Med 155:1072, 2001; Leung AK, Sigalet DL: Acute abdominal pain in children. Am Fam Physician 67:2361, 2003; Patel AS et al: What’s new: proton pump inhibitors and pediatrics. Pediatr Rev 24:12, 2003; Sherman P et al: Helicobacter pylori infection in children and adolescents: Working Group Report of the First World Congress of Pediatric Gastroenterology, Hepatology, and Nutrition. J Pediatr Gastroenterol Nutr 35:S128, 2002; Stanberry LR, Rosenthal SL: Genital herpes simplex virus infection in the adolescent: special considerations for management. Paediatr Drugs 4:291, 2002.
Faculty Disclosure
In adherence to ACCME guidelines, the Audio-Digest Foundation requests all lecturers to disclose any significant financial relationship with the manufacturer or provider of any commercial product or service discussed. For this issue, the faculty reported nothing to disclose.
Dr. Pohl was recorded at the Adolescent Health Conference, presented April 28-30, 2005, in San Antonio, Texas, by Scott & White and Texas A&M University System Health Science Center, College of Medicine, Temple, Texas; Dr. Friedman was recorded at Essential Topics in Pediatrics, presented April 28-30, 2005, in San Diego by the University of California, San Diego, School of Medicine and the California Department of Developmental Services. The Audio-Digest Foundation thanks Drs. Pohl and Friedman and the sponsors for their cooperation in the production of this program.
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