Showing posts with label abdominal pain. Show all posts
Showing posts with label abdominal pain. Show all posts

Friday, February 13, 2015

Non-Pharmacologic Treatment of Functional Abdominal Pain: What Works?


By: Lewis First, MD, MS; Editor-in-Chief

          If you read our journal or others, you are bound to run into a variety of studies trying to identify the best therapeutic approach to functional abdominal pain.  Ideally the goal is to avoid prescription pharmacologic intervention and focus on non-pharmacologic strategies like changes in diet, lifestyle, cognitive behavioral therapy, pre- and probiotics, or alternative or integrative medical approaches. 
So what works best?  Rutten et al. (doi: 10.1542/peds.2014-2123) have performed a systematic review of this topic that we are releasing this week online identifying all randomized controlled trials done in children with functional abdominal pain.  While the quality of evidence was “very low-moderate” overall, the authors did find some studies showing efficacy of some of the modalities mentioned above and a few others not yet mentioned in this blog. 
Given how common this problem is with our patients, reading this review article should not hurt at all and may result in trying some options you have not tried before, and giving up on others where the evidence is poor.  What have you found to be successful in treating your patients with functional abdominal pain?  We’d love to hear your solutions to this problem and “what works” by responding to this blog, sending us an e-letter, or commenting on our Facebook or Twitter sites.
         
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Monday, April 28, 2014

GI Symptoms and Autism: A Meta-Analysis Worth Digesting

Photo by Hey Paul Studios via Flickr
Patients with an autism spectrum disorder (ASD) often complain of gastrointestinal (GI) symptoms, or so it appears, yet just what are those symptoms, how common are they, and are they part of an underlying common pathophysiologic mechanism that links ASD with a gastrointestinal problem?

McElhanon et al. (doi: 10.1542/peds. 2013-3995) have performed a thorough meta-analysis of studies involving GI symptoms and children with ASD. The results may confirm your suspicions. They may also leave you wanting more in regard to specific GI disorders responsible for those symptoms, whether the symptoms are the result of an ASD, and how they can happen pathophysiologically. If anything, this study will show an increased prevalence of GI symptoms—and hopefully lead to even better studies to further define the causal nature of these symptoms in ASD patients.

What’s your opinion on GI symptoms in your ASD patients? Do you see them more often that you might expect? Are there some symptoms more common than others (e.g. abdominal pain)? It would be great if you did a gut check on this topic and share your thoughts via a response to this blog, an eLetter, or through Facebook or Twitter.

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Friday, January 3, 2014

Using the White Blood Cell Count to Reduce Negative Appendectomies: A Retrospective Study

Yesterday, we blogged about using a clinical pathway to predict suspected appendicitis, and today, we continue our discussion of appendicitis and ways to minimize negative appendectomies.

While surgeons may tell you they need to operate on a presumptive appendix even if that appendix may not be inflamed, so as not to miss a potential perforation, they will also want to minimize the negative appendectomy rate. Yet how can they do this?

Bates et al. (doi: 10.1542/peds.2013-2418) decided to see if the magnitude of the white blood cell count (in this case a lower one) could defer surgery and increase observation before automatically operating on a child with a presumptive acute abdomen. The authors did a retrospective review of all appendectomies performed over a 42 month period of time and looked at pre-op lab and radiographic data for all patients in this study. The authors compared this data for normal and abnormal appendices and found normal white blood cell counts (below 8,000 - 9,000) meant a reduction in negative appendectomies.

Just how much of a reduction requires you to cut into this study and decide how much you trust the results to stop surgery or at least observe longer in the setting of a low- normal white blood cell count.

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Thursday, January 2, 2014

Using a Clinical Pathway to Predict Accurately a Suspected Appendicitis: A Prospective Study

In a quest to figure out the most accurate way to diagnose an acute appendix, Saucier et al. (doi: 10.1542/peds.2013-2208) designed a clinical pathway that used a known pediatric appendix score and an ultrasound study to classify patients as low-, middle-, and high-risk for appendicitis –with the low-risk being sent home in this prospective cohort, the middle- group getting an ultrasound, and the high-risk getting operated upon.

So how good is this new guideline? Good enough to carry a high sensitivity and specificity for accurate diagnosis of appendicitis. Just thinking that an ultrasound can be used in place of a CT scan to make this diagnosis is a concept that is certain to radiate positively within all of us.

Stay tuned-- tomorrow we continue our discussion on the appendix with a look at a study that uses white blood cell count to reduce the rate of negative appendectomies.

Friday, October 18, 2013

Cognitive Behavioral Therapy and Functional Abdominal Pain: A Therapeutic Option You May Not Have Considered

When a child presents with chronic recurrent functional abdominal pain of no definitive etiology, it is frustrating for all involved—the patient, the family and the clinician trying to help. While the pain is real, in the absence of a defined cause, we are eager to try to find ways to reduce the severity of the pain—even while we continue to observe the course of the pain closely.

Photo by hellocoolworld via Flickr
Recently, cognitive-behavioral therapy has been suggested as a non-pharmacologic approach to helping children deal with their functional pain—but it was not well-studied with a randomized controlled trial until this week when we share the result of such a trial by van der Veek et al. (doi:10.1542/peds.2013-0242). The authors randomized over 100 children ages 7-18 with functional abdominal pain to get 6 sessions of cognitive-behavioral therapy taught by masters’ students in psychology or 6 visits to the pediatrician for routine diagnostic and therapeutic care.

The outcome was self-report of pain by those enrolled as well as a variety of secondary outcomes involving comorbid conditions and quality of life. The results will make you happy no matter what arm of the study you choose. If you don’t believe me (or are not a fan of CBT) be mindful of the results of this study the next time you need a treatment plan for one of your patients with functional abdominal pain—you’ll be glad you did.

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