An 11-year-old girl presents with a 6-month history of abdominal pain and nausea. She reports that she has pain and nausea upon awakening on most days, but no pain at night. Eating makes her nauseous and she often skips meals; when she does eat, she feels full and does not finish her meal. Her mother reports that she often wants to stay home from school or will call to be picked up early from school. The patient is growing normally, weight is stable, and no blood or mucus is found in the stool. She is a good student.
What is the most likely cause of the patient’s complaint?
Brain-Gut Connection
Approximately 13.2% of the world’s population have functional gastrointestinal (GI) disorders, which is one the most common condition seen by pediatric gastroenterologists. As demonstrated by the case presentation, the initial symptoms of functional GI conditions can be vague, but the connection between the brain and GI tract “cannot be denied,” said Charlotte Rensberger, MSN, APRN, PNP-PC.
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It is therefore important to ask the right questions, Rensberger said during a presentation at the National Association of Pediatric Nurse Practitioners (NAPNAP) National Conference on Pediatric Health Care held March 15 to 18, 2023, in Orlando, Florida. For example, pain in the morning on school days may not be related to school but rather to waking up earlier and poor sleep quality. “If you think of the body as an iPhone: all of the electronic components are present, but the apps are glitching and not working the way it should be … the issue is with the programming.”
Categories of Functional GI Disorder
There are 4 most common categories of Functional GI conditions (Table). The differentiating features in the 4 groupings is the location of pain, the presence (or absence) of nausea and vomiting, and the relationship between symptoms and bowel movements.
Table. Categories of Functional GI Disorders
| Category | Description |
| Chronic functional abdominal pain | • Pain not associated with other GI symptoms |
| Functional dyspepsia | • Upper GI symptoms of reflux, nausea/vomiting, early satiety, and epigastric pain |
| Irritable bowel syndrome | • Upper abdominal pain associated with abnormal bowel movement (constipation, diarrhea, or mixed) •Occurs in 1.2-2.9% of children |
| Abdominal migraines | • Sudden, severe abdominal pain that is intermittent in nature • Is often associated with pallor, nausea, sweating, and headache |
The stomach and intestine are constantly moving, noted Rensberger, who works in pediatric gastroenterology in Kalamazoo, MI. “In patients who don’t have functional GI conditions, they don’t feel anything; but in patients who do, the signals between their brain and gut are turned up so loud it’s overwhelming their system,” she explained.
The Rome Foundation published their most recent criteria for diagnosis of functional GI disorders, Rome IV, in 2016. Rome IV has specific requirements for each of the 4 types of functional GI disorders in children. The last requirement for all is that after evaluation, symptoms cannot be explained by another medical condition.
Testing is performed to rule out underlying medical conditions that would explain the symptoms and may include blood work for complete blood count (CBC), complete metabolic panel (CMP), erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), thyroid cascade, and celiac screening. To rule out inflammatory bowel disorders or bleeding, stool studies may also be performed including occult blood tests and fecal calprotectin screening. Breath tests are sometimes completed to rule out small intestinal bacterial overgrowth (SIBO), Helicobacter pylori, and lactose and fructose intolerance and imaging tests include abdominal ultrasound and upper and lower endoscopy.
“Most children with functional GI disorders have no red flags.” These are otherwise healthy children who are growing well “and have normal blood work, scans, and tests,” Rensberger said. “Sometimes this can mean that parents are frustrated by the lack of a diagnosis and request more and more testing. This is where education is paramount. Set the stage that testing may come back negative [but it] is still valuable information because it allows us to rule out certain conditions and guide our management plan appropriately.”
Supporting Management
The treatment of children with functional GI disorders does not fit into a neat box, said Rensberger. “It can take time to drill down to each symptom and to come up with a treatment plan.” Symptoms can wax and wane and can be hard for the child to articulate. Treatment options often don’t offer instant relief. It can be helpful for the child to keep a food diary for a period of time to identify triggers. “It is also important for the children to maintain a normal routine and attend school and participate in extracurricular activities, virtual school does not count,” Rensberger said. “We advocate for them to live a normal life: get up, shower, make their beds, have good sleep hygiene.”
It is also important to explain the disorder in a way that patients and their families understand and can grasp, “This includes reassuring them that their child’s pain is real, but it is not organic, causing damage, or life-threatening.”
“We take a symptom focus approach. If the patient wakes up on school days with pain and nausea, one strategy could be to have crackers at the bedside to eat upon waking, and wake up earlier on school days to give their bodies time to wake up and digest breakfast before heading to school for the day. If they have pain at bedtime, they could try peppermint tea or capsules at bedtime and instruct them on good sleep hygiene—no electronics in the bed,” said Rensberger. The addition of probiotics, either in supplements or through yogurt or kefir, can also be helpful to restore a healthy microbiome.”
Counseling and therapy to identify sources of stress and mental health problems are also important. According to Rensberger, 42% to 85% of children have active anxiety with functional GI disorder, which is often severely undermanaged. Teaching healthy coping strategies for anxiety and depression will benefit the children now and as they grow older.
Medications can be helpful in the management of patients with functional GI disorders, including acid suppression, antispasmodics, antihistamine, and anticholinergic agents.
The patient in this case was asked to keep a symptom journal to identify triggers. Treatment consisted of acid suppression, an antispasmodic (hyoscyamine) for cramps, diphenhydramine, cyproheptadine, and amitriptyline. A no-dairy diet was instituted (after a positive hydrogen breath test) and she was given topical peppermint oil at bedtime to improve sleep hygiene. Lastly, the patient began counseling.
Sources
1. Rensberger C. Nothing “fun” about functional GI conditions. Presented at: NAPNAP National Conference; March 15-18, 2023; Orlando, FL.
2. Di Lorenzo C, Nurko S, Pediatric Rome IV Committee. Rome IV Functional Pediatric Gastrointestinal Disorders. Disorders of the Gut-Brain Interaction. 1st ed, vol 1. The Rome Foundation.
3. Pauley RJ, Philichi L. Clinical Handbook of Pediatric Gastroenterology. 3rd Ed. The Association of Pediatric Gastroenterology and Nutrition Nurses.
4. Yacob D, Kroon Van Diest AM, Di Lorenzo C. Functional abdominal pain in adolescents: case-based management. Frontline Gastroenterol. 2020;12(7):629-635. doi:10.1136/flgastro-2020-101572
