Paeds · gastroenterology-hepatology-and-nutrition
Functional abdominal pain and irritable bowel syndrome
Also known as Functional abdominal pain disorders · Irritable bowel syndrome in children · Paediatric IBS · Functional abdominal pain not otherwise specified · Disorders of gut-brain interaction · Rome IV functional gastrointestinal disorders
Fellowship guide to paediatric functional abdominal pain and irritable bowel syndrome as disorders of gut-brain interaction: the Rome IV criteria that define functional abdominal pain-NOS and the IBS subtypes (IBS-C, IBS-D, IBS-M, IBS-U), the visceral hypersensitivity mechanism, the alarm features that separate functional from organic disease, a targeted rather than exhaustive workup, and stepwise biopsychosocial management from explanation and reassurance through cognitive behavioural therapy, gut-directed hypnotherapy, low-FODMAP diet, peppermint oil, and selective pharmacology.
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Red flags
- Involuntary weight loss, growth faltering, or delayed puberty
- Gastrointestinal blood loss, haematemesis, or melaena
- Persistent right upper or right lower quadrant pain
- Pain that consistently wakes the child from sleep
- Unexplained fever, mouth ulcers, arthritis, or perianal disease
- Nocturnal diarrhoea or persistent vomiting
- Family history of inflammatory bowel disease or coeliac disease
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- Recognises functional abdominal pain and IBS as positive Rome IV diagnoses, not diagnoses of exclusion
- Identifies the alarm features that point toward organic disease
- Explains the gut-brain model of visceral hypersensitivity to families
- Applies the Rome IV criteria to subclassify IBS into IBS-C, IBS-D, IBS-M, and IBS-U
- Selects a targeted rather than exhaustive investigation strategy
- Constructs a stepwise biopsychosocial management plan and interprets the therapy evidence
- Differentiates functional abdominal pain and IBS from organic disease
- Justifies first-line and second-line investigations
- Outlines the evidence base for psychological, dietary, and pharmacological treatment
- Takes a focused history from a child and parent with recurrent pain and altered bowel habit
- Communicates a functional or IBS diagnosis without dismissing the symptom
- Negotiates a return-to-function plan with family and school
- Stage 1: Recognition of functional abdominal pain and IBS and their red flags
- Stage 2: Rome IV subclassification and targeted workup
- Level 3: Multidisciplinary management of refractory functional pain and IBS
- Rome IV criteria for functional abdominal pain-NOS and IBS subtypes
- Pathophysiology of the gut-brain axis and visceral hypersensitivity
- Evidence base for hypnotherapy, cognitive behavioural therapy, and pharmacology
- History-taking that elicits alarm features, bowel habit, and psychosocial context
- Abdominal examination and growth assessment in a child with recurrent pain
- Structured explanation of a functional or IBS diagnosis to a family
- AAP/NASPGHAN approach to chronic abdominal pain and functional bowel disorders
- Judicious use of investigations to avoid overtesting
- Dietary, cognitive behavioural, and pharmacological management of IBS
- Positive Rome IV diagnosis of functional pain and IBS with limited testing
- Shared decision-making about therapy and school return
- Recognition and referral of organic red flags
- Canadian approach to functional abdominal pain and IBS with biopsychosocial care
- Coordinated care between primary care, gastroenterology, and psychology
- Function-focused follow-up and relapse prevention
Overview & Definition
A child who has months of tummy pain, whose bowels swing between loose and hard, who looks well and grows normally, and in whom every routine test comes back clear is describing one of the commonest problems in paediatric gastroenterology. In most such children the pain is not caused by damaged tissue but by a disordered conversation between the gut and the brain. Functional abdominal pain and irritable bowel syndrome are the two headline members of this family of disorders of gut-brain interaction. [1]
Both are now defined positively by the Rome IV criteria rather than by ruling out every possible organic cause. Functional abdominal pain-NOS describes recurrent or continuous abdominal pain that does not fit a more specific pattern, while irritable bowel syndrome is the disorder in which the pain is tied to defecation and to a change in stool form or frequency. The distinction between them rests almost entirely on the relationship between the pain and the bowels. [1]
The clinical skill that this topic trains is twofold: to recognise the positive pattern of a functional disorder or IBS so a confident diagnosis can be made after a short targeted workup, and to detect the alarm features that flag the minority with organic disease. Getting this balance right spares child harm of endless investigation while keeping serious disease from being missed. [11]
References12ShowHide
- [1]Hyams JS, Di Lorenzo C, Saps M, Shulman RJ, Staiano A, van Tilburg M Functional Disorders: Children and Adolescents. Gastroenterology, 2016.PMID 27144632
- [2]Korterink JJ, Diederen K, Benninga MA, Tabbers MM Epidemiology of pediatric functional abdominal pain disorders: a meta-analysis. PLoS One, 2015.PMID 25992621
- [3]Vlieger AM, Menko-Frankenhuis C, Wolfkamp SC, Tromp E, Benninga MA Hypnotherapy for children with functional abdominal pain or irritable bowel syndrome: a randomized controlled trial. Gastroenterology, 2007.PMID 17919634
- [4]Vlieger AM, Rutten JM, Govers AM, Frankenhuis C, Benninga MA Long-term follow-up of gut-directed hypnotherapy vs. standard care in children with functional abdominal pain or irritable bowel syndrome. Am J Gastroenterol, 2012.PMID 22310221
- [5]Kline RM, Kline JJ, Di Palma J, Barbero GJ Enteric-coated, pH-dependent peppermint oil capsules for the treatment of irritable bowel syndrome in children. J Pediatr, 2001.PMID 11148527
- [6]Saps M, Youssef N, Miranda A, Nurko S, Hyman P, Cocjin J, Di Lorenzo C Multicenter, randomized, placebo-controlled trial of amitriptyline in children with functional gastrointestinal disorders. Gastroenterology, 2009.PMID 19596010
- [7]Levy RL, Langer SL, Walker LS, Romano JM, Christie DL, Youssef N, DuPen MM, Feld AD, Ballard SA, Welsh EM, Jeffery RW, Young M, Coffey MJ, Whitehead WE Cognitive-behavioral therapy for children with functional abdominal pain and their parents decreases pain and other symptoms. Am J Gastroenterol, 2010.PMID 20216531
- [8]Rutten JM, Korterink JJ, Venmans LM, Benninga MA, Tabbers MM Nonpharmacologic treatment of functional abdominal pain disorders: a systematic review. Pediatrics, 2015.PMID 25667239
- [9]Korterink JJ, Rutten JM, Venmans L, Benninga MA, Tabbers MM Pharmacologic treatment in pediatric functional abdominal pain disorders: a systematic review. J Pediatr, 2015.PMID 25449223
- [10]Di Lorenzo C, Colletti RB, Lehmann HP, Boyle JT, Gerson WT, Hyams JS, Squires RH Jr, Walker LS, Kanda PT 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, 2005.PMID 15735476
- [11]American Academy of Pediatrics Subcommittee on Chronic Abdominal Pain Chronic abdominal pain in children. Pediatrics, 2005.PMID 15741394
- [12]Rutten JM, Benninga MA, Vlieger AM IBS and FAPS in children: a comparison of psychological and clinical characteristics. J Pediatr Gastroenterol Nutr, 2014.PMID 24897168