Management of Functional Abdominal Pain and Irritable Bowel Syndrome in Children and Adolescents

Eric Chiou; Samuel Nurko

Disclosures

Expert Rev Gastroenterol Hepatol. 2010;4(3):293-304. 

In This Article

Abstract and Introduction

Abstract

Functional abdominal pain (FAP) and irritable bowel syndrome (IBS) are among the most commonly diagnosed medical problems in pediatrics. Symptom-based Rome III criteria for FAP and IBS have been validated and help the clinician in making a positive diagnosis. The majority of patients with mild complaints improve with reassurance and time. For a distinct subset of patients with more severe and disabling illness, finding effective treatment for these disorders remains a challenge. Over the years, a wide range of therapies have been proposed and studied. The lack of a single, proven intervention highlights the complex interplay of biopsychosocial factors probably involved in the development of childhood FAP and IBS, and the need for a multidisciplinary, integrated approach. This article reviews the current literature on the efficacy of pharmacologic, dietary and psychosocial interventions for FAP and IBS in children and adolescents.

Introduction

Functional abdominal pain (FAP) and irritable bowel syndrome (IBS), both of which typically present with chronic abdominal pain, are common complaints in the pediatric population. Estimates on the prevalence of abdominal pain are varied, but community- and school-based studies have reported that as many as 13–38% of children and adolescents experience abdominal pain weekly, with up to 24% of children reporting symptoms persisting longer than 8 weeks.[1,2] For the vast majority of patients, an underlying inflammatory, anatomic, metabolic or neoplastic cause for recurrent abdominal discomfort is not found on evaluation.[3] A significant proportion of these patients are subsequently diagnosed with FAP or IBS. Both entities are included under the larger heading of functional gastrointestinal disorders (FGIDs), which are characterized by chronic or recurrent gastrointestinal symptoms that are not explained by structural or biochemical abnormalities.[4] The diagnosis of FAP or IBS is symptom-based and new criteria have been defined by the Rome III group (Box 1).[4] In addition to recurrent abdominal pain, children with IBS also experience disturbances in defecation, ranging from lumpy or hard stools to loose, watery stools or both. Adult patients have been classified into subtypes based on the predominant stool pattern, for example IBS with constipation, IBS with diarrhea or mixed IBS.[5] It seems that these subtypes are also present in children, but there is no prospective information that has reliably determined their prevalence.

Functional abdominal pain and IBS have been associated with significant impairment in children and adolescents. Children with FAP have self-reported quality of life scores lower than healthy children and comparable to children with inflammatory bowel disease.[6] Increased rates of school absenteeism, healthcare utilization and family disruption are also common. The financial burden of FAP and IBS in children is not exactly known but is probably significant, considering the frequent need for multiple medical visits and extrapolating data, which estimate that billions of dollars are spent each year for the management of adults with IBS.[7,8]

Although most children and adolescents with mild symptoms of FAP or IBS will improve with physician reassurance and time, long-term follow-up studies have shown that a significant number continue to experience symptoms into adulthood.[9] Furthermore, those with more severe, disabling or persistent illness often present a diagnostic, as well as management, challenge for both the primary physician and pediatric gastroenterologist.

Over the years, research in FGIDs has evolved to emphasize a comprehensive, biopsychosocial model of illness, replacing the approach of identifying a single underlying biological etiology.[10] The biopsychosocial model for FGIDs is based on the complex interplay of genetic, physiological (e.g., motility, inflammation) and psychological (e.g., social support, stress) factors to conceptualize the etiology of FGIDs. Despite ongoing efforts to identify causes and contributing factors of FAP and IBS, successful management is ultimately limited by the incomplete understanding of the pathophysiology underlying these disorders. Recent efforts to categorize FGIDs in children into subtypes based on age and symptoms, such as FAP and IBS, may lead to better understanding of the causes of these disorders and promote investigation of therapeutic options.[4]

This article will focus on the experimental and clinical data regarding the management of FAP and IBS in children and adolescents using pharmacological, dietary, psychosocial and complementary/alternative approaches. Management of other subtypes of FGIDs that also present with recurrent abdominal pain, such as abdominal migraine or functional dyspepsia, is beyond the scope of this article. We acknowledge that much of the previous pediatric literature refers to the term recurrent abdominal pain (RAP), first introduced by Apley and Naish in the late 1950s.[11] However, RAP represents more of a description encompassing several different etiologies rather than a unique diagnosis. The considerable overlap between patients originally identified with RAP and those now formally diagnosed with FAP or IBS warrants the examination of articles that used RAP as an entry criterion. In addition, selected adult studies of IBS have been included for the discussion of treatment modalities for which there are currently no pediatric data.

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