Episode Transcript
[00:00:05] Speaker A: Welcome to ingest, the podcast series designed for primary care and brought to you by the Primary Care Society for Gastroenterology. My name's Charlie Andrews, a GP with an extended role in gastroenterology based near Bath.
INGEST is an educational podcast. It is designed to enhance your learning around gastroenterology, provide you with some useful and practical hints and tips that you can use on the front line in primary care. And we talk to specialists in a variety of different specialties about topics that are relevant to primary care in the world of gastroenterology.
In today's episode, I'm speaking to Tony Whiskin, who is a consultant pediatric gastroenterologist based in Bristol. We're going to be exploring the topic of abdominal pain in children.
Abdominal pain is quite common in children in primary care, so let's get into the episode and start learning.
So, Tony, thanks so much for joining me on INGEST today. It's great to have you here.
[00:01:06] Speaker B: Fab. Yeah, good to be here, thanks.
[00:01:08] Speaker A: Do you want to just introduce yourself to our audience a little bit, Tony?
[00:01:11] Speaker B: Yeah, so I'm a paediatric gastroenterologist at the Children's Hospital in Bristol.
So I've been here, I think, for nine years, possibly.
So, yeah, we look after kids. We've got GI problems across the whole of the Southwest and.
[00:01:32] Speaker A: Brilliant. And we first met, Tony, about, I think it's about six years ago when we recorded a podcast episode looking at IBD and children.
[00:01:40] Speaker B: Yeah.
[00:01:41] Speaker A: Which was a lot of fun, so I enjoyed recording that with you and it was a. It was a well received podcast. But today we're doing a podcast for Ingest, and we're going to be looking at abdominal pain in children and we thought we're going to focus a bit more on the chronic abdominal pain, which is what we see quite commonly in primary care.
[00:01:59] Speaker B: Yeah.
[00:01:59] Speaker A: So that's what we thought we'd look at today.
[00:02:01] Speaker B: Yeah, yeah.
[00:02:04] Speaker A: So do you want to just have a bit of a chat about abdominal pain in children? You know, what do we term kind of chronic abdominal pain in children? And then hopefully we can go on to thinking about what the GP should maybe be doing and thinking and asking when they see the child or the parent who's concerned about abdominal pain. That's been going on for perhaps a little while.
[00:02:26] Speaker B: Yeah. So, I mean, I guess, yeah, one of the things is thinking about with kids is thinking a little bit about age groups of, you know, what do you tend to see in what particular age groups? So, you know, often in. In sort of really young kids, so infants and sort of non verbal children. Then you get parents coming in saying, my kid's got tummy pain.
Then you have sort of older verbal children who might be sort of preschool or primary school age who complain of tummy pain. And often that's often not very well sort of differentiated as to where the tummy pain is. You know, it's often always para umbilical or the kid will sort of, you know, show you their whole tummy if you ask them to point to where it is. And then as you get sort of older kids, then you tend to get less sort of generalized tummy pain and more sort of specific tummy pain. I guess quite a lot of the kids that I see who've got older kids who've got more sort of chronic tummy pain type things tend to be more sort of epigastric pain.
So I guess those are perhaps sort of three starting points, really.
[00:03:46] Speaker A: Yeah, sounds good.
[00:03:48] Speaker B: So yeah, you got the sort of non verbal young kid who, their parents are convinced that it's sort of tummy pain. And so trying to unpick that is quite difficult, you know, so it's then trying to sort of go beyond that and try to think, well, what is it that your kid's doing that makes the parent think they've got tummy pain? So is it that they're, you know, drawing their knees up? Is it that they're, I don't know, that they bloated? Are they distended? Do they seem to be gassy? How frequently they're going for poo? Does that seem to be difficult, trying to unpick those, those sorts of things?
I guess then what you're really looking at is, well, does that kid seem to be thriving otherwise, you know, so looking at their height, their length, you know, in one's under two, the head circumference is often missed. But you know, interpreting the rest of their growth in light of where their head is is entirely appropriate because their head should be normal size.
That, that gives you an idea of where the, where the weight and height should be on the, where the weight and the length should be on other centaurs that are on similar centaurs to the head circumference.
So yeah, ensuring they're thriving, ensuring they've not got any other sort of red flags of anything. I mean, I guess the number one thing that I would be thinking of excluding is celiac disease. And you know, in any kid who's got recurrent tummy pain, whatever age they are, who has got wheat in their diet, you know, because we know that celiac disease, you know, prevalence should be at least 1% of the population and we don't, we don't have all of those patients. So we know there are undiagnosed cases and we know that it is a master of disguise. So you know, it is by default that anyone coming into a pediatric gastroenterology unit, any pediatric gastroenterology unit that I've worked at who they will inevitably have a celiac to screen as part of their workup because it could present with anything and nothing of course. But I think that if you've got someone who's got, you know, recurrent tummy pain then that's the sort of thing that's easy to do. And obviously one of the, one of the challenges is interpreting the results. So one note of caution is you do have to have an adequate amount of IGA in order to generate ttg. So if you have a low iga you may have a false negative ttg. So that's something to bear in mind.
And then the important thing is not to start them on a gluten free diet until they've been seen in secondary care.
Because even a positive result may not be celiac disease unless it is past the threshold of 10 times the upper limit of normal for the lab of the ttg. Because if it's just a positive result but it's not past that threshold, it can be a non specific thing. So that's a little bit of an aside about celiac but probably I think.
[00:06:56] Speaker A: It'S really helpful to sort of COVID that and I guess, you know, reflecting on other episodes that we've done on coeliac disease, if there is a family history then you know, if mum or dad have got coeliac disease I think we have to really be thinking about it quite strongly.
[00:07:08] Speaker B: Yeah, yeah, I think so. And you know, actually is one of the things that if you've got a first degree relative with celiac disease you should have a screening test for ttg. But yeah, you may have done that someone when they were four and it was fine but actually they're now nine and they've got recurrent telling it well it's perfectly reasonable to recheck it, you know, because it's not, it's not a. Well you have one test that's excluded it for life, you know your can change over time, it can evolve.
And I think there's still, you know, I don't do adult medicine but I think there's adults who you know, quite old, get diagnosed with cv, you're like, whoa, where did that come from? Is that there all the time? Who knows?
[00:07:43] Speaker A: Yeah, very, very true.
And so I'm just. I want to nail down a little bit more on this, this history and presentation, because it can be really hard knowing what pain is. And what sort of things do you come across in your clinical practice of parents describing this pain and, you know, different ways of kind of exploring it further with them.
[00:08:03] Speaker B: So in these younger kids.
[00:08:04] Speaker A: Yeah, and these younger kids.
[00:08:06] Speaker B: Yeah, I mean, often, I mean, I'm.
I think it's really, it's. It's really hard to know what actually is it, because sometimes it's just the kids distressed, you know, so, like, you get some kids who, you know, one of the things you're thinking about is what sort of time of day is it? You know, is it that actually these are kids that are hard to settle, you know, so it's around bedtime? Or is it that actually these kids are, you know, once they're awake overnight, they can't settle themselves. And actually what you're seeing is you're seeing a fairly normal sort of sleep wake cycle, but actually that's just being represented as pain when actually it's just distress.
I think one of the things that's quite interesting that I think we see more of than anything else is. Well, not more of than anything else, but I think is where we have a different lens on it is that sometimes you get kids who are either, you know, where they're bottle feeding or breastfeeding, where they're not feeding, feeding very well and they're taking in loads of air and they're not bringing that air up. So you might see that kids sort of progressively distend throughout the day and they're often really unsettled. And then they slowly sort of deflate overnight as they don't have feed. And you sort of say, well, what, you know, when they're distressed, like what, what eases that distress? And sometimes they're like, well, they do a massive fart and they all get better. Okay, maybe this is effectively they've got wind going through that is air that they've swallowed that is causing some of the distress, you know, in those, in those younger kids, reflux is always blamed. So, you know, we see huge numbers of kids where it must be reflux. But PPI hasn't worked. You're like, oh, what evidence have we got this is reflux at all? You know, this is just, well, it must be silent reflux. What the hell? Silent reflux? I don't know.
Because if it's silent and they're in pain, well, that ain't very silent. So. Yeah. What is it? So I guess, you know, you can then explore. Well, okay, feeding. What's that like? You know, and posture. What is that like? Are there clues that actually there is reflux influx with this kid bringing stuff up or, you know, actually getting distressed and swallowing and gulping? You know, is there evidence of that?
So I think those are things. And then. Yeah, stalling, you know, actually, is it that these kids just aren't pooing very frequently, but not necessarily abnormal, but actually they're kind of building up to it over a day or so. And actually passing a poo is difficult.
So, you know, I think. I think there's even a subtype on the Rome foundation of functional disorders about something to do with pain. Going for a poo in sort of infants. That is. That is a thing.
What's that? Yeah, Infant dyschasia. That is okay. Straining and crying before successful or unsuccessful passage of soft stools. You know, someone's even defined it. At some point, you have to be under nine months to make that diagnosis. Not a diagnosis I've ever made, I have to say.
So I think, you know, those are.
I guess, more often than not in those younger children. I'm sort of thinking, well, is this actually pain or is this actually just distress or discomfort that is indicating something else or nothing else that may well be part of the ordinary. But I guess, weirdly, my default as a tertiary pediatric gastroenterologist isn't necessarily. I'm quite a normalizer.
So that's perhaps a bit of a weird thing, but that's my tendency.
So that's usually what I'm looking for, is something else to explain this rather than a. Because I think GI conditions causing pain in that age group, you know, unusual, I think.
[00:11:51] Speaker A: Good to know. And I think from that I can really tell that the history is important, really. Just trying to drill down into what's actually going on and exploring that feeding process as well, because lot of problems that can arise there.
[00:12:02] Speaker B: That's right. And I think just thinking beyond, like, tummy pain.
[00:12:05] Speaker A: Right.
[00:12:05] Speaker B: He's thinking then beyond, well, what. Yeah, what is going on then? What. What. What are the dynamics of the situation? And, you know, what time it does say, what time of day is it? Mainly at night? Is everyone actually just at the end of their tether? You know, what is. What is going on there?
[00:12:20] Speaker A: And just. Just quickly, the. The sort of. The Red flags at this age group. I think we talked there about kind of the weight loss side of things, failing to. Failing to thrive. Can you just list any other sort of red flags that you would pick out from a history that would alert you to the need for these people to be seen in secondary care?
[00:12:37] Speaker B: Yeah, tricky. I mean, I think weight is going to be the main one, I guess, you know, if they've got, I mean, obviously they've got blood in their stool and pain, you're thinking more of acute things like interciception or stuff like that.
And we, you know, we said acute things like appendicitis are hard to manage at any time, but we're thinking more chronic things.
It's not masses that is coming to mind as to things that would really be worrying me about significant disease.
[00:13:13] Speaker A: And what sort of patients do you generally see from primary care being referred at this age group with these sort of more pictures? Are these people who've. Or patients, children who've kind of gone through all the gamut of treatments in primary care and nothing seems to be working? Is that, is that where you.
[00:13:31] Speaker B: Yeah, I think, I think we. Yeah, I think the ones that I end up seeing, I think are ones that maybe start off as a diagnosis of reflux or that's probably the biggest group in that sort of age where, you know, actually that's what it's been labeled as. And for us, you know, it's quite easy because we might just do a ph impedance study, which is a test where you put a probe in the nose, the end sits in the stomach, it's got sensors all the way up the food pipe and you put that down for 24 hours and so carry on as normal as if you can when you've got a tube down your nose. But, you know, and you can then record what's going on so you can actually have a genuine sense of is there reflux moving up and down? Actually, I think a lot of those tests that I do find actually kids are air swallowers.
That seems to cause a lot of their problems. But sometimes you do find some, you have got massively significant reflux who have failed medical therapy. And then you think about, well, what else do you do in that sense? And there's perhaps a couple of drugs that we might use that wouldn't necessarily get used. And you know, again, people will do things like cow's milk protein free diets because again, that's something that can help in that scenario if it hasn't been tried before.
But I think usually Those, those kids that come to us are ones where they've off, they're often not completely thriving. You know, they're not completely Bonnie looking little ones and that's the worry as to what else is going on.
[00:15:03] Speaker A: Okay. And is there anything that you recommend around the air swallowers?
[00:15:08] Speaker B: So no, if you find something, let me know.
I know it's really difficult because I think it causes huge amount of problems, but I'm, I'm not really aware of a huge amount to do for it.
[00:15:22] Speaker A: Okay, good to know that we're all in the same boat, which is helpful. Should we move on to a slightly older age group now, Tony? Should you have a think about them?
[00:15:30] Speaker B: Yeah, so I guess this is where you see probably quite a lot more.
And you know, I guess the, the thing when you were talking about, you know, this topic is around, you know, there's a, there's a study I think back from the 1950s. It's often quoted about, you know, recurrent abdominal pain in, in childhood and how the, you get the, the same sort of story and households react in one of two ways. They either go, it's just a bit tummy ache. All kids have tummy ache. Carry on. Or they go down a medical line of well, what is this tummy ache? You know, And I think that is, that still remains very, very true. And we often talk about the fact that actually, you know, adults have headaches. We don't necessarily think that every adult has got a brain tumor when they've got a headache, but some, some will, you know, and the, in the same way kids who have tummy ache, vast majority, this will be like an adult headache. And what is that? We don't really know. You know, so we talk about sort of functional GI disorders.
What does that mean? People talk about those as disorders of gut brain axis interaction.
And the, you know, I think for the vast majority of kids it is this, that that label of a functional GI disorder is likely to be what the tummy pain is due to.
And you know, my, my go to for that is often. So there's, there's something called the Rome foundation, which you've probably heard about, which is a, a group who specialize in sort of functional, functional GI disorders. And they have got, you know, criteria for children and adolescents. So it's broken down by age groups to provide sort of definitions for various different things. And so you've got a, you know, functional abdominal pain disorder which can be broken down into sort of different types.
But what, what are, what is actually driving all of Those I don't think we really understand. So, you know, I guess for the things of. Are there certain patterns that are definitive things. So one of the things that I think we see that gets referred to us is sort of a cyclical abdominal pain that may or may not have vomiting as part of it, where kids are completely fine for a period of time. And then every four to eight weeks or something there will be a pattern to it where they will then get rip roaring tummy pain as they may or may not have vomiting as part of it.
And each episode seems to be exactly the same and you know, like an adult migraine where these kids, you know, an adult migraine people may have an aura.
Episodes will be very similar. They will just want to shut themselves off from the world, lie down, chill out and do nothing until it's over.
And you see that in kids with abdominal pain or vomiting and they will just sort of not really want to do anything. We're very quiet. And it will settle on its own usually, but it might be a few hours, some kids, it might even be a couple of days and then there'll be right as rain again carrying on until the next episode. So that's a cycle to look for. And I think there's absolutely no evidence of this whatsoever. But I think the phenotype or I don't think there's any evidence the phenotype I see, I think changes. So you have really young kids who might be, you know, sort of preschool kind of age who will have sort of diarrhea and tummy pain as part of these episodes.
You then sometimes fever and you sort of start to worry, oh, could this be some sort of cyclical fever syndrome? But usually not. But sometimes I have seen a few kids who have.
And you have kids who just have tummy pain and you have often kids who have vomiting and tummy pain or just vomiting and then as they get older it sort of translates more into an adult phenotype of headache migraines than anything else.
So that is a group who do have an absolutely characteristic history. You know, they're totally fine for a period of time and then each episode is very similar.
And the thing that I do with those is if these are intrusive, like they're stopping kids getting to primary school or actually because they're vomiting so much they're having hospital admission each time or whatever, then I go, well, you can start some treatment.
And treatment success again. I'm quite, maybe I'm just pessimistic, but I sort of define treatment Success as not complete resolution of all episodes. So treatment success is that you may still have an episode, but hopefully it won't be as disabling as normal. So that means that you might feel a bit rough, but you should still be able to get to school.
And so there's different medications to use for that. I tend to use pizotifen, that seems to be my go to, but you can use amitripty, octoline, cyproheptadine.
I'm not sure beta blockers really work like they would do for adult migraines.
So that's something that you can see across the whole age range, but you might see it in some of those younger patients and that they've got a really classic history, you know, so they're. And they're quite easy to spot when you get one of those. Ah, brilliant. Yeah, super. I know what that's going to be. Don't need any tests, apart from your celiac disease test to exclude that.
But otherwise they're sort of a nicely defined group.
[00:21:12] Speaker A: And sorry just to this probably some of my ignorance around the topic, but is this, is this what we would call an abdominal migraine?
[00:21:18] Speaker B: Yeah, yeah, yeah. So you get, you know, a donor migraine and cyclical vomiting syndrome. You know, I think they're kind of two of the same boats. They often coexist or they may not do, but I think they're really a very similar entity.
So, yeah, that's something to. That's. That's a key thing to look for and I think you can start to see that in these younger, you know, early primary school or even preschool kids. It's relatively unusual, but that you can see it in that age group. And as you get, you know, towards the end of primary school type age is when you might sort of have a clear sense that that's it. But also I guess maybe that's the ones that I see because it's become obviously more intrusive and affecting schooling, you know, and it may well have been going on for a.
But that it's obviously having an impact and that's why people are doing something.
So, yeah, that's like. That's one of. That is a functional GI disorder, you know, and that is one of the type of functional GI disorders, you know, things like irritable bowel syndrome, again, have got definitions that are, you know, beyond the functional abdominal pain, which I think, you know, the definition that's given of functional abdominal pain is basically where you have pain and it doesn't meet any of the other rome Criteria, type things.
But it hasn't got any other cause. Okay. That's where I was starting with clear phenotypes, if that makes sense. So, you know, irritable bowel. Then again, what you're looking for is, well, how do you know, how do symptoms change with stalling?
So, you know, is it that actually you have tummy pain and actually that's associated with either becoming very loose or becoming slightly constipated. How does the pain relate to that? Is, are there symptoms of bloating? Bloating. So the sensation of being bloating again, you know, you need to be of an age to be able to understand what sort of bloating feels like. I think it's not a particularly accessible term, but sort of late primary school, I think. You know, can you. Does your belly feel like it's really full out? Like it's really puffed out?
You know, that sort of thing you can get a sense of.
So that's another thing.
[00:23:35] Speaker A: And we know that IBS is really common in adults. Do you. Does it still quite common in children as well?
[00:23:40] Speaker B: Well, I think so, yeah, I think so.
And the, what you're looking for there is again, the things that I'm trying to unpick are a little bit about, well, you know, so how bad is bad? How good is good in terms of bad days and good days? Because there are going to be bad days and good days and then trying to pick apart, well, what, what is different between good days and bad days? Are there patterns? And then thinking more holistically around, well, okay, so what other things could be going on that are associated with a bad time? So is that, and I use a loose term as sort of stress meaning anything. So distress on the system, like having a cough or a cold, any sort of illness will make things worse as well as thinking about emotional stress. And that can be highs and lows. So that can be. That actually kids are really excited about something positive as well as actually something really negative. All of those things can produce an effect on the gut that might well produce some IBS type symptoms.
But I, you know, I guess the number one thing is going to be how much is constipation the cause? You know, because that's probably like the number one cause of tummy pain in some of these younger patient groups.
And what are the questions that I asked to try and elucidate that? Because often, you know, you go, well, could this be constipation? If you ask that, people go, well, no, it's not. Yeah, okay. Let's go a bit beyond that.
So, you know, it's trying to think about, well, how often do kids actually go for a poo? How often does the kid think they go for a poo? Whereas how often do their parents think they go for a poo? Because those are not necessarily the same thing. Because I've had plenty of consultation. No, what? No, you go more often than that, surely. Well, when did you last go for a poo? And the kids.
Not quite sure. And obviously, you know, certainly primary school age. They may, you know, older primary school. Yeah, they should have a good idea. Younger primary school. Well, maybe not, but, you know, actually trying to get a clear story of that and then also the difference between trips to the toilet and actually producing a poo. So there are plenty of kids that have trips to the toilet thinking they need a poo, but actually nothing comes out. So, you know, I do ask questions specifically about, well, do you have a sense of needing to go for a poo where nothing comes out?
When you've been for a poo, does it feel like you've got rid of everything? And because, you know, I think there are quite a big group of kids where they just. They might be pooing of apparently normal frequency, but actually they're not getting rid of everything and they have got that sort of incomplete rectal evacuation that over time does cause things building up that actually may well be a component of why they've got quite significant tummy pain. And I guess the thing, the thing about, you know, if it is bad constipation, I think the pain is often really, really difficult to manage.
You know, you can have kids who are in A and E with. With morphine going in, who still struggling because actually, you know, they can be completely full and it's horrible, horrible pain.
So I think it can be really, really severe. And I think that's. That's something to bear in mind and also to offer as a sort of reassurance to parents that actually, yes, constipation can cause this degree of really, really severe pa, really difficult to manage until you've got rid of the poo. That's there.
So around the stall history is also thinking about, well, you know, is there loose stool? Is there suggestions of overflow when the poo comes out? What is it like sometimes? Is it like, you know, little pebbles? Is there plugs? And you can do a whole thing about constipation. But anyway, that's. So that's.
[00:27:35] Speaker A: Do you use things like the Bristol School charts? Yeah, things like that to try and illustrate to the child, particularly for the.
[00:27:41] Speaker B: Kids to, you know, go, look, you know, here's some pictures of pooh. There isn't a right or wrong. Maybe more than one. What sort of things. What sort of things does your poo look like? You know, and, yeah, get them to point at it. And often, you know, they'll usually go for quite a range, typically. But, you know, it gets you a sense. And you can then sense. Check that with the parents of. Well, does that seem about right? I do think there should be a Bristol stool chart for nappies, like, you know, because it's very different. You know, there should be a Bristol store chart for nappies because it's very different as to what it. What else it looks like. But so. And then, you know, the other things that go with that is thinking about, well, okay, what about lethargy, what about behavior? What about dietary intake? So, yeah, you see that the longer kids have been without a poo, then their behavior will be a bit more off.
They will not really want to eat and they will be more lethargic and sloth like.
And again, sort of teasing out those sorts of questions, particularly again, if you're not certain about how often they are actually going for a poo, then actually asking some of those questions gives you a sense of, well, actually, maybe they aren't pooing as often as mum and dad think they are. That actually they do seem to be going through every three, four days. They're just not really interested in food progressively over two, three days, and then actually that all gets better once they've been for a poo or their pain builds up over several days and then it gets better. And so what you're looking for there is actually that the pain may not completely go away once they've gone for a poo. But actually there is that relationship there that actually is much worse when they're pooing less.
And so that's something to look for.
And depending on how long it's been going on for, obviously there's a really good, nice guideline on constipation and how to treat it. I think is probably the best thing to go for for primary care, you know, and I think macro goals do work really, really well often for the kids. By the time they get to us, it's beyond just macro goals and they need a stimulant as well. But I think, you know, that's. That's a separate. A separate thing.
[00:29:45] Speaker A: I think that's really helpful. And one of the challenges is when you start to explore the child's diet, for example. Sometimes that can be really hard to alter because, you know, Mum will say that, you know, they won't eat anything with any roughage in and that can make it really difficult.
[00:30:01] Speaker B: Yeah, yeah. And I, I'll be honest, I don't go there.
I, I've. I sort of seems to take me enough time in the consultation to go through the actual story of where we are and, you know, trying to give my sense a real clear picture of what is. What is this child like?
I'm lucky. I work in a team with dietitians who I, you know, can refer to for that.
But actually, sometimes the thing that I'm never sure about is actually, well, how much choice of the family's got over what they're eating anyway. You know, actually is it that they eat what they can afford or what they know how to make or actually what they simply know the child will go for and they just don't want to. And the thing is with lots of those things is it's part of something so much more complex and that's one of the things with constipation is it inevitably is part of something far much more complex that makes it so blooming hard to manage.
And it is really hard to manage, yeah, segue into constipation.
[00:31:02] Speaker A: I think it's really good because actually it's just so, so common and actually just having a good chat about it is really good. Can I ask about mesenteric adenitis?
[00:31:12] Speaker B: What is that? What is that? Well, that's default when no one knows what else it is, isn't it? Okay, well, I mean, there probably is something to it, isn't it? I mean, I get. And this is, this is based on absolutely nothing whatsoever, but, you know, if you have, you're feeling a bit under the weather with like a flui earty type symptom, then you know, your glands are up in the neck and you can feel them and it's a bit uncomfortable. And well, the problem is with your gut is that it's got way more lymph nodes in it than that, you know, it is absolutely stacked full of them. So it does sort of make sense that if there is something going on that we don't know quite what it is, that that, you know, is causing a bit of a, you know, lymph nerves to be lymph nodes to be activated and doing something, then that presumably is what that is. But obviously there's no way of diagnosing that.
My thought about that, though, is that, that is more of an acute thing, right? In the same way as you, when you have your lymph nodes up with a sore throat or whatever else, you have a reason for it and it gets better. And that's like a few days a week maybe, but it's not, it's not a chronic thing.
So I don't, I don't really buy that as a sort of cause for, you know, chronic tummy pain that's going on sort of months, intermittently come and going, that, that sort of thing. I don't really buy that for that.
And I guess, you know, the. I'm not sure families do either, you know, and I think, you know, one of the things about one of the difficulties is how do you give a positive diagnosis in some of these scenarios, right? Because that's really difficult. So what you then sort of the opposite is to go, well, what are the things that I think I've ruled out?
And so you're then sort of going through, well, okay, what sort of things could this be? And what sort of things do I think it's not? So that's why celiac disease comes up, because it's an easy thing to go, well, look, we'll look for that and it will know whether it is or isn't. You know, what other things in that younger age group are you worried about? Well, there aren't really that many things about worried about. But, you know, you can go, well, I don't think this is a grumbling appendix. What's a grumbling appendix? I don't know. But, you know, you go, well, I don't think it is because you've never got any evidence that you've got appendicitis.
Is it constipation? Well, you know, I've gone through the history. I don't think it is, or if I think it is, we're going to trial some treatment and see what difference it makes and check in and go, right, well, not only has it made any difference, but do we think the treatment's actually working? Because you could start someone, some medication, they go, well, it's not made a difference. Well, has it made any difference to how often you're pooing? You know, so set your expectations of, well, what is it? I expect to change. So that's again, why that detailed history over stool output, trips to the toilet, dry runs to the toilet when nothing's coming out, that's the sort of thing you're expecting to change. First of all, before you make a Massive impact on the pain. So, you know, making it clear what you're expecting to happen with the medicines, checking in. Is it working? Thinking, right, has it made an improvement to the tummy pain?
You know, what other things have you got which are causing, you know, tummy pain in those age groups? Well, I guess some people might go, well, they might be worried that it's cancer. You know, they might be worried it's cancer. There might be a family history of it. So, again, trying to think about parents expectations of the consultation. You know, I have seen lymphoma in kids, it hasn't presented as tummy pain. I've not seen a primary gi, you know, adenocarb carcinoma type thing in a child present with tummy pain. So I think, you know, that's highly unlikely. You know, what test could you do to reassure yourself of that? Well, I'm not sure necessarily anything, but, you know, I guess you could do a full blood count. Not sure. But are they growing? Are they otherwise? Well, you know. So actually, if you've got a thriving child, you go, well, look, they've got tummy pain, but I'm not seeing any red flags of any other sort of disease process going on here. What's the role of ultrasound? You know, I think primary care can request ultrasound.
How much does that help? I think probably quite a lot of ultrasounds get done. I'd love to know what the yield of it is. You know, what are we actually looking for? Well, I guess we're looking for something solid organy. That could be a problem. Like, I don't really know what that would be.
Have they got some sort of collection or something? But you'd expect that you'd say other evidence of unwellness. You know, someone who's got. Got tummy pain from like a deep pelvic collection isn't going to be walking normally. Or they might, you know, you'd expect them to have an intermittent fever or something that would, you know, be driving towards that. We often end up with ultrasounds that come to us because they've found that someone instantly has got, you know, dilated biliary ducts that are really no consequence of anything that we then have to follow up and make sure they grow into them. So, you know, I'm not. It's. It's. So it's very difficult to give a clear thing of. Right. Well, this is what it is. Which is where I find the roam criteria can be quite helpful because. And I don't know them off by heart, but I do look them up. And I often what I, what I say to families is I go, well, look, I think this is one of these things. What I'll do is I'll put in the clinic letter what I think it matches to and you can then see what you think. And so I'll then, you know, cut and paste the relevant functional GI disorders diagnosis into the clinic. They get to go, this is what I think it is. And often when you. I will usually follow those up to go, well, how are things going? Better, worse, whatever.
And they'll go, oh yeah, that seems right. Or they go, rubbish, someone else find out.
But I think that can be quite useful. And the other thing that once you've sort of gone for one of these functional diagnoses, is talking about what you expect to see going up and down that, you know, talking about this stress side of things and actually looking for prospectively, well, when are things are getting worse, what else is going on? When things are better, what, you know that. So sometimes you'll see people later on and they'll go, well, actually, I'd never really thought about that. But actually what is happening is this is happening. I know it's when this is happening that actually I get a lot more of this, you know, okay, well, that's good. And I think probably, you know, more so now over the last few years where everyone's got anxiety, people are, you know, aware of more of a link between their emotions and GI symptoms. And I suppose that's where you're moving through more into the sort of late primary school, secondary school kind of age group, where some of those patients are more attuned to their emotions, might be, might not be, but can recognize that actually maybe there is a link between what they're experiencing and what's going on emotionally.
And, you know, I talk to families about the fact that if you take a room full of people sitting an exam, lots of them will have no gut symptoms at all. But actually quite a lot of the people sitting exam will have had a whole range of different gut symptoms, from throwing up to diarrhea, to not pooing for a week, to tummy pain, to sort of a faint butterflies feeding in their stomach. And all of that is provoked by the exam. So we know that that happens. We don't know quite how or why, but we know that does happen and that, you know, that can be a reason for tummy pain, you know, as an ongoing thing in some of these other kids.
But I think I've rambled and waffled and confused Myself what the original question was.
[00:38:47] Speaker A: That's really good. No, it's great. It's good just to think about all these functional presentations, which could be really, really difficult, but are really important to kind of try to examine. We touched there on sort of organic pathology and things that can lead to abdominal pain, and I wondered if we could just have a bit more thinking about that, if that's all right. So we've talked about things like celiac disease and we also talked about kind of abdominal malignancies.
[00:39:14] Speaker B: I think.
[00:39:14] Speaker A: I. I think. Are Wilms tumors common cause of abdominal. Not common. I hope not, but they're a cause of abdominal pain. I, I think I'm just sort of casting my mind back to.
But. And the other thing I was just thinking about was things like inflammatory bowel disease, which, as we move into that sort of teenage age group, we know that there's a bimodal presentation for this and what sort of things might sort of get you a bit more alerted to the fact that this could be inflammatory bowel disease rather than, say, irritable bowel syndrome or a more functional presentation.
[00:39:48] Speaker B: Yeah. So, yes, you've got your, you know, 11, 12, 14, 15 year old or whatever.
And the small. What you're really thinking about here is if you've just got tummy pain is, well, could this be small bowel Crohn's disease?
So because you would anticipate, if you've got colitis, you'll have obvious symptoms of colitis, loose, frequent bloody stool with urgency, you know, that. That should be fairly easy to spot.
If you've got, you know, upper GI disease or if you've got small bowel disease, then, yeah, it can be more subtle. So you're going to be thinking through, well, what other things. So growth is really important.
So have they got good height velocity? And that's where you need some previous measurements.
You know, putting that on a growth chart, seeing. Well, actually, yeah. Where. Where are they on their pubertal phase of their particularly of their growth chart. So they should be having an accelerated height velocity around puberty. They're not having that or what's going on.
So that's something to look for early satiety. So eating and appetite patterns and early satiety. So kids who have moved into a sort of snacky kind of eating because actually they just can't eat very much because they get full really quickly.
That's a slightly bothersome, you know, symptom. And that's a specific question that I'll be asking to try and Evaluate. Well, do I think this could be small bowel disease or not?
Do things taste the same? So you can get kids who, you know, alter the foods that they eat because they just don't seem to taste right. What's that about?
Asking specifically about sort of oral and sort of perianal symptoms.
So, you know, are they got mouth ulcers? Have they got swollen lips? Do they look like they've got swollen lips? Do their lips look similar to their parent that's come with them? Because you. You see some people just like, well, your top lip looks a bit fat. You know, no one else has got fat top lips. Is that you? Is that not. Oh, yeah, no, it's always like that. Okay. It's a subtle thing, but actually that's the thing that can sometimes alert you to, well, could this be Crohn's disease? Have they got clubbing? You know, so it's. It's there something we should all be looking for. But actually, kids who've got small bowel Crohn's disease, it's often, you know, quite indolent. Is that the right word? Quiet in its presentation, you know, and actually they could have had it for months and months and months. They might well just have. You know, what I. I probably call early clubbing, because I don't know what else to call it. But actually they. They lose that. That convex nature to their nail or whatever it is. You don't see that dipping.
They got that slightly gray color. And what about their weight in girls, have they started their periods and have they stopped or have they not, you know, not started their periods when they should have done so? Thinking of a lot more of those side of things. So perianal is about thinking, have they got any funny lumps or bumps around their bottom or any sort of mucus discharge or anything like that that they're not aware of?
So those are the sorts of things. And, you know, if you've got small bowel crohn's disease like that, then a full blood count and an albumin are probably the sort of key tests.
So, you know, in your full blood count, are they anemic, iron deficient? Have they got a raised platelet count? Is there albumin low as part of sort of poor absorption going on there? And they may have that despite apparently normal stores.
So where does calprotectin fit in? Where does calprotectin fit in? So I think this is the group where calprotectin is a really useful test, you know, because what you're doing with calprotectin is trying to go, right, I need to come down here on whether this is a functional problem or whether this is inflammatory bowel disease. And if it's normal, then that is. Is that going to reassure me that this is not inflammatory bowel disease? And if it's not, don't bother doing the test, you know, send the referral in, you know. But if actually you go, yeah, no, this is, this is all, this is all right, and actually a normal chaopotect, really reassure me this is okay, then that's a good time to do the test.
Obviously, if you've got colitis, don't do the test, you've got colitis, you don't need a chaotectin to tell you that you've got inflammation there, you know, you've got inflammation there and it's either going to be infective or inflammatory, probably in this age group, unlike it to be anything else. So if it ain't settling, send a referral in. Don't wait for the cow protecting because it's going to be up because blood in poo, you're going to have an elevated cow protecting.
So, you know, in these kids where they've, you know, not got blood in their stools, it's just vague tummy pain. I think it's a useful test to do and some kids will do it, other kids won't, you know, and I think that's just, that's just life. Some people just won't provide poo samples, you know, And I think, I think lots of primary care, most of primary care now, I think has got access to cow protecting in, in, you know, older children at least, you know, and the usual caveat is don't do it in kids under five, because normal, normal values, you know, normal lab ranges don't really apply.
But above that, you know, then I think it's useful. But particularly I think the secondary school age, you know, late primary school age type, that's when you're going to be thinking more secondary school age. Could this be inflammatory bowel disease? That's the thing to look for, you know, and again, you know, abdominal pain with vomiting.
Could that be foregut disease? You know, it could be.
So, you know, that's something to think about.
Other things that we sometimes get asked about is, you know, about gallstones.
So again, we're seeing more obesity that is more associated, I think, with gallstones.
A lot of the gallstones that I think we end up seeing have just been found, incidentally, on an ultrasound, rather than actually having much in the way of clear symptoms. But obviously gallstones will give you a colicky sort of right upper quadrant type pain. So again, should be a fairly sort of characteristic presentation. The same as, you know, you guys probably see far more people with symptomatic gallstones in, you know, in primary care than I do. So, you know, I think it will be a very similar presentation in kids and I guess your risk factor would be, well, are they overweight rather than anything else, you know? Yes, they might have hereditary spherocytosis or something random like that if they've got a massive spleen as well. But you know, that's your classic exam scenario rather than anything else.
[00:46:40] Speaker A: That's interesting to think about gallstones in children because it's, it's not something that would be high on my agenda to be honest with you.
[00:46:45] Speaker B: I don't think it's common. I don't think it's common but it is something that would, you know, it could be there and it would have a classic history.
[00:46:53] Speaker A: Yeah, no, it's really interesting.
We covered so much ground there, Tony. We've covered so many different topics. It's been really interesting. I wonder if we could just sort of distill things as we come to the end and just thinking about putting yourself kind of on the front line as a gp, for example. And what sort of tests do you think are useful to help tease apart. And we have talked about some of them already but you know, rational use of tests is important. What sort of tests do you think that you would, you would sort of, you would use more commonly, you know, or recommend gps to use more commonly? I'm assuming ultrasound is probably not going to be particularly high up there from what you've talked about.
[00:47:31] Speaker B: No, probably not. I mean, you know, simple things. Well, I think you start with actually clinical examination, so making sure you've seen and examined the kids tummy and you've plotted their height and weight, you know, and I think that's just a really useful baseline, you know, if you did that for everyone, probably wouldn't go far wrong, you know, that.
What other things? So yes, I think a celiac screen, you know, if this is someone who's, you know, repeatedly coming back with the same story, it's not, you know, then I think that's a reasonable thing to do.
I think, you know, otherwise there is then sort of a general fishing expedition really, isn't there? You know, so trying to do that in a targeted way of. Well, actually do I think that this is a functional thing then? Actually if I Do think this is a functional thing, then I don't actually really need to do any tests, you know, and if I can reassure myself that this is functional because it fits a good story. Yes, don't do any tests. That's absolutely fine.
And you know, again, my sort of rationing with that is in trying to explain to the families why am I not doing any tests? What do I think I've excluded clinically just from the history and the examination.
And so what, how, how does that enable me to be confident that it is not any of those things? And you might, as you're going through that go, yeah, actually, maybe I'm not that confident about that. So I will simply check a full blood count to make sure we're not missing anything, you know, more holistic that, you know, might be going on and you know, an arenal function, a liver function and, and, you know, that way I've seen actually. Yeah, everything does seem to be good. Fine. But does everybody need that? No, I don't think so.
And yeah, target use of cowprotectin of. Well, is this test, if it's negative, going to reassure me that this isn't inflammatory bowel disposal? You know, that's, that's how I would be using it.
[00:49:33] Speaker A: So sort of as a, as a. To reassure us that it's not in order to allow us to move forward with the functional diagnosis.
[00:49:39] Speaker B: Yeah.
[00:49:40] Speaker A: Okay, Tony, this is the end of the episode and at this point I generally ask my speakers to kind of give me their tips.
You've talked about so much there and it might be quite hard for you to pull out sort of your top messages for the gps who are listening. But do you want to just have a go, just see if you could think of some really key take homes that you'd like gps to leave with? I think that when you, you know, talking about those investigations and that structured approach is so helpful and is really useful. Just wonder if there's any other key take homes you'd like to, to give to our gps. It's your opportunity to speak to.
[00:50:18] Speaker B: I mean, I guess the, the common thing that comes from patients by the time they get to see me is no one's listened, which often I know is not true, but it is just a reflection of they haven't felt heard. And so what is it that part of, part of that is that we're given license by the fact that we are in a tertiary children's hospital to, you know, by the fact that they're there. They've given us agency sometimes to go well, yes. Well, you are going to be the decision maker and tell me whether this is or isn't a problem, you know, so I appreciate that some of that, is that we're given that ticket, but actually, I think it is the thing that I think we sometimes do different is we do think through, well, okay, what are the diagnoses that we're looking for here, and what have we confidently been able to exclude? You know, And I think having that approach is really useful.
I think sometimes providing a clear diagnostic label of a specific functional GI disorder can be really helpful because you are able to then give a label, whereas, actually, I think a lot of the time you're not.
And still I find that I'm not. And I'll say to them, look, this doesn't really fit a clear diagnostic box, but I'm confident it falls within this remit. There are elements of it that are this and this and this, but it is not any of these other things. And I think having that. Having that approach, I think is. Is useful.
Yeah. We never spoke about H. Pylori.
[00:51:55] Speaker A: Oh, I love H. Pylori. I'm happy to talk about it now if we want to.
[00:51:59] Speaker B: Well, I guess it's just thinking about the. The epigastric pain scenario and that. I think, you know, it is one of those things that my understanding is there's a very different approach to children than there is adults, and that is around the risk of GI cancers or gastric cancer.
And my understanding of that is that where the H. Pylori populates in the stomach is very different in adults than it is in kids. And so the risk of cancer is therefore not there in children. And so, you know, I haven't mentioned deliberately the use of doing an H. Pylori stool screen in these kids with tummy pain, because I don't do it. It.
Because what we're told, and this may well change in paediatrics, what we're told is if we find gastritis, so if we've got someone who does clearly have sort of epigastric pain, that we're thinking, well, this could be gastritis. And we then go and do an endoscopy to look for gastritis, if we find gastritis and we find associated H. Pylori, only then do we treat it. And even when we treat that, that we tell them that treating the H. Pylori may make no difference to their experience of tummy pain, because we've seen it time and time again where people got tired in knots of treating H. Pylori endlessly. And it makes absolutely no difference to their tummy pain whether they've got H. Pylori or not.
So that's the reason for sort of briefly mentioning it is that, you know, doing a stool antigen for H. Pylori is not something that we find at all helpful in this patient group. You know, specifically thinking about, has this kid got gastritis? That's a useful thing. If we think they've got gastritis, then even then we won't do an H. Pylori test. It'll only be if we do a scope and find, yes, they've got significant gastritis. Do we then even think about what we're doing with H. Pylori?
[00:53:55] Speaker A: It's quite interesting because we do get adults that we diagnose and then they ask about their children and things like that, because.
So it's something that we do get asked in primary care. So you're saying that the, the H. Pylori is unlikely to be the cause of their symptoms and the cancer risk is not, not there in children?
[00:54:11] Speaker B: Yeah, okay. Yeah, that's, that's, that's my understanding at the moment. And I think, I think it is one of these things that it may well be that actually it's endemic in households, you know, and I don't know what the adult guidance is about treating a whole household or not, you know.
[00:54:27] Speaker A: But, yeah, I think it's a minefield and I think, think. I don't think that there is guidance that we should be treating the entire household.
[00:54:34] Speaker B: No.
[00:54:35] Speaker A: We had Barry Marshall on the podcast about two years ago now, and he was talking about how in his practice he generally would consider treating the whole family in the household, you know, in his practice. But that's not what we do in the uk. I think it's one of those areas. It's a bit complicated really, and, but it does make sense that it would pass around families and households very easily.
[00:54:55] Speaker B: Yeah. It would be logical that if you've got. Got it as a problem in one patient where you're struggling with it, then actually, and you can't get rid of it, then probably treating the whole household at that point might make sense pragmatically, but whether there's any evidence of that, I don't know, but certainly that simply as a way of removing it from a household, but from a. A causing a problem in children, then we don't look for it as a cause of tummy pain.
[00:55:20] Speaker A: That's a good, good final message. And that was A little bit of a segue into a slightly different topic, but I think it was interesting. I enjoyed it and I've just really enjoyed the whole conversation. I found really interesting. Tony, so thank you so much for joining me today.
[00:55:33] Speaker B: No worries. Thank you for having me.
[00:55:37] Speaker A: Well, there's a huge amount in that episode. I'm sure you'll agree with me. Tony really is a wealth of knowledge about abdominal pain in children and you can see that he's really interested in exploring the diagnosis and exploring the history more carefully with parents in order to try to really understand what's going on. And I think those are real key take homes for me is really just focusing on that history. I always try and pick out a few key learning points from each episode and this week's episode I have picked out a few that I would like to share with you. My first take home was early on in the episode when we were talking about younger children and just thinking about how to assess for growth by assessing both head circumference as well as weight. This is something that was quite a helpful take home for me. My second one was thinking about cyclical GI symptoms with pain or nausea, for example, and having on your radar the diagnosis of something like an abdominal migraine and thinking about that. My third take home was really less of a take home, but more of a really helpful overview when Tony was talking about the targeted and rational use of blood tests and saying that really things like height and weight and examination are absolutely key, as is the history. And then we can start thinking about adding in extra layers after that. So things like the celiac screen, which we did talk about quite a lot because it's really important with children with abdominal pain. We talked a bit more about other blood tests that you could do, such as fbc, renal function, liver function and then really that targeted use of calprotectin. And that was a really helpful take home for me that a we shouldn't be using it in children under five because it can be unreliable baby. But also it's more of a rule out rather than a rule in. So if you're thinking it's ibd, we don't need to be doing it, we need to be sending them on to secondary care. But actually it's quite helpful in that setting of trying to differentiate between functional disease and something like inflammatory bowel disease. So thank you so much for joining me for this episode. I hope you found it useful and taken some really useful nuggets of information from it. As always, always keen to hear your feedback. If you want to get more episodes directly to your phone or wherever you listen to them, just click subscribe and then we'll update you whenever we bring out a new episode. Thank you so much for listening.
[00:58:01] Speaker B: By.
