Assessment of gastric sensorimotor function in paediatric patients with unexplained dyspeptic symptoms and poor weight gain

Percutaneous Electrical Nerve Field Stimulation in Children and Adolescents With Functional Dyspepsia-Integrating a Behavioral Intervention

OBJECTIVES

Functional dyspepsia (FD) includes postprandial distress and epigastric pain syndrome. Percutaneous electrical nerve field stimulation (PENFS) in addition to behavioral interventions (BI) has shown benefits in children with functional abdominal pain but not specifically in FD. We aimed to assess the efficacy of PENFS for treating FD and compare the outcomes with those who received the combination of PENFS + BI.

MATERIALS AND METHODS

Charts of patients with FD who completed four weeks of PENFS were evaluated. A subset of patients received concurrent BI. Demographic data, medical history, and symptoms were documented. Outcomes at different time points included subjective symptom responses and validated questionnaires collected clinically (Abdominal Pain Index [API], Nausea Severity Scale [NSS], Functional Disability Inventory [FDI], Pittsburgh Sleep Quality Index [PSQI], Children's Somatic Symptoms Inventory [CSSI], Patient-Reported Outcomes Measurement Information Systems [PROMIS] Pediatric Anxiety and Depression scales).

RESULT

Of 84 patients, 61% received PENFS + BI, and 39% received PENFS alone. In the entire cohort, API (p < 0.0001), NSS (p = 0.001), FDI (p = 0.001), CSSI (p < 0.0001), PSQI (p = 0.01), PROMIS anxiety (p = 0.02), and depression (p = 0.01) scores improved from baseline to three weeks and at three months. Subjective responses showed nausea improvement (p = 0.01) and a trend for improvement in abdominal pain (p = 0.07) at week three. Abdominal pain subjectively improved at week three and three months (p = 0.003 and 0.02, respectively), nausea at week three and three months (p = 0.01 and 0.04, respectively), and a trend for improvement in sleep disturbances at week three and three months (p = 0.08 and p = 0.07, respectively) in the PENFS + BI group vs PENFS alone.

CONCLUSION

Abdominal pain, nausea, functioning, somatization, sleep disturbances, anxiety, and depression improved at three weeks and three months after PENFS in pediatric FD. Subjective pain and nausea improvement were greater in the PENFS + BI group than in the group with PENFS alone, suggesting an additive effect of psychologic therapy.

Nausea is the only symptom associated with delayed gastric emptying in pediatric functional dyspepsia patients

OBJECTIVES

Functional dyspepsia (FD) is a heterogeneous functional gastrointestinal disorder (FGID) with a highly prevalent symptom complex. The aim of our study is to investigate the relation between symptoms of FD and results of gastric emptying (GE) breath test in children.

METHODS

This study included patients (6-17 years old) presented at the general gastroenterology outpatient clinic with dyspeptic symptoms (Rome IV criteria) and underwent careful history taking with clinical examination. A GE breath test with a 13 C-octanoic acid labeled (250 kcal) solid meal was performed and dyspepsia symptom scores, clarified using pictograms for postprandial fullness, bloating, belching, nausea, vomiting, epigastric pain and burning, were obtained every 15 min ranging from 0 to 4 for a total of 240 min. The severity of the complaints (overall and individual symptoms) as displayed by the symptom questionnaire was compared between normal and delayed GE groups. The relationship between GE time and the severity of FD symptoms was assessed using Mann-Whitney test.

RESULTS

Thirty nine FD patients (55% girls; mean age: 11.9 ± 3.3 years) participated in the study. Of these, 43% had delayed GE. The overall symptom severity in patients with delayed GE was similar to the symptoms of patients with a normal GE rate (149.5 ± 12.7 points vs. 123.9 ± 9.0; p = 0.19). Individual symptoms scores showed only nausea to be significantly increased in the group with delayed GE (21.5 ± 1.9 points vs. 33.2 ± 4.6; p = 0.048, p < 0.1).

CONCLUSION

Especially in children with nausea as presenting symptom of FD, a low threshold should be withheld to perform a GE breath test.

Gastric accommodation: Physiology, diagnostic modalities, clinical relevance, and therapies

BACKGROUND

Gastric accommodation is an essential gastric motor function which occurs following ingestion of a meal. Impaired gastric fundic accommodation (IFA) is associated with dyspeptic symptoms. Gastric accommodation is mediated by the vagal pathway with several important physiologic factors such as duodenal nutrient feedback playing a significant role. IFA has been described as a pathophysiologic factor in several gastrointestinal disorders including functional dyspepsia, diabetic gastropathy, post-Nissen fundoplication, postsurgical gastrectomy, and rumination syndrome. Modalities for gastric accommodation assessment include gastric barostat, intragastric meal distribution via scintigraphy, drinking tests (eg, water load), SPECT, MRI, 2D and 3D ultrasound, and intragastric high-resolution manometry. Several treatment options including sumatriptan, buspirone, tandospirone, ondansetron, and acotiamide may improve symptoms by increasing post-meal gastric volume.

PURPOSE

Our aim is to provide an overview of the physiology, diagnostic modalities, and therapies for IFA. A literature search was conducted on PubMed, Google Scholar, and other sources to identify relevant studies available until December 2020. Gastric accommodation is an important gastric motor function which if impaired, is associated with several upper gastrointestinal disorders. There are an increasing number of gastric accommodation testing modalities; however, each has facets which warrant consideration. Evidence regarding potentially effective therapies for IFA is growing.

The Intragastric Pressure Measurement: A Novel Method to Assess Gastric Accommodation in Functional Dyspepsia Children

BACKGROUND

Impaired gastric accommodation (GA) is proposed as a main pathophysiological mechanism for functional dyspepsia (FD). At present, the gastric barostat is the criterion standard to measure GA. Hence, this procedure is invasive and it may alter gastric physiology. Recently, we proposed the measurement of intragastric pressure (IGP) by means of high-resolution manometry during nutrient intake as a potential alternative for assessing GA in adults.

OBJECTIVES

Our aim was first to study the feasibility of the IGP measurement with nutrient tolerance in children with FD and second to compare these results with young healthy adults.

METHODS

A high-resolution manometry probe and a feeding tube were positioned in the proximal stomach. The IGP was measured before and during intragastric infusion of a nutrient drink (ND, 300 kcal, 60 mL/min). Subjects were asked to score their satiation and epigastric symptoms. The test ended when the subjects scored maximal satiation.

RESULTS

A total of 15 healthy volunteers (HVs, 21.7 ± 4.7 years, 21.1 ± 0.3 kg/m) and 17 patients with FD (14.4 ± 0.7 years, 19.6 ± 0.7 kg/m) participated. Patients with FD experienced mainly from postprandial fullness (86%), epigastric pain (71%), and bloating (62%). In both groups, intragastric infusion of ND induced a drop in IGP (area above the IGP curve FD: -15.5 ± 3.5 mmHg vs HVs: -18.0 ± 8.7 mmHg; P = 0.57). Patients showed impaired nutrient tolerance compared with HVs (587.6 ± 80.2 vs 936 ± 66.2 kcal; P = 0.003). All patients and HVs tolerated the catheters and could finalize the study.

CONCLUSIONS

The measurement of IGP during intragastric ND infusion was well tolerated in children. Nutrient tolerance was reduced in children with FD compared with HVs. In the future, this may be a useful tool to assess GA accommodation and nutrient tolerance in children.

Cyproheptadine: A Potentially Effective Treatment for Functional Gastrointestinal Disorders in Children

Functional gastrointestinal disorders (FGIDs) negatively affect children's quality of life and health care costs. It has been proposed that alteration of gut serotonin leads to gastrointestinal dysmotility, visceral hypersensitivity, altered gastrointestinal secretions, and brain-gut dysfunction. Cyproheptadine, a serotonin antagonist, has been shown to be a potentially effective and safe treatment option in children who meet the clinical criteria for FGIDs. Well-designed multicenter trials with long-term follow-up are needed to further investigate its efficacy. [Pediatr Ann. 2017;46(3):e120-e125.].

Functional Dyspepsia: An Enigma in a Conundrum

As defined by Rome III, there are 4 abdominal pain-related functional gastrointestinal disorders in children: irritable bowel syndrome, functional dyspepsia (FD), abdominal migraine, and functional abdominal pain. Dyspepsia is a constellation of symptoms referable to the gastroduodenal region of the upper gastrointestinal tract. FD refers to dyspeptic symptoms that cannot currently be explained by an organic cause, and affects 25% to 40% of the adult population over a lifetime. In children, this condition results in increased specialist consultations, with reported prevalence between 3% and 27%. The Rome III criteria for pediatric FD include the presence or persistence of recurrent pain or discomfort centered in the upper abdomen, without evidence of organic disease or change in frequency of stools. Symptoms must be chronic, occurring at least weekly and over a period of at least 6 months. The goal of this article is to provide a narrative review of diagnosis and management of the FD in the pediatric population. A comprehensive search of published literature using the PubMed (http://www.ncbi.nlm.nih.gov/pubmed/) database was carried out to identify all articles published in English from 1998 to November 2015, using 3 key terms; "FD," "functional gastrointestinal disorders," and "children."

Childhood functional abdominal pain: mechanisms and management

Chronic abdominal pain is one of the most common clinical syndromes encountered in day to day clinical paediatric practice. Although common, its definition is confusing, predisposing factors are poorly understood and the pathophysiological mechanisms are not clear. The prevailing viewpoint in the pathogenesis involves the inter-relationship between changes in hypersensitivity and altered motility, to which several risk factors have been linked. Making a diagnosis of functional abdominal pain can be a challenge, as it is unclear which further diagnostic tests are necessary to exclude an organic cause. Moreover, large, well-performed, high-quality clinical trials for effective agents are lacking, which undermines evidence-based treatment. This Review summarizes current knowledge regarding the epidemiology, pathophysiology, risk factors and diagnostic work-up of functional abdominal pain. Finally, management options for children with functional abdominal pain are discussed including medications, dietary interventions, probiotics and psychological and complementary therapies, to improve understanding and to maximize the quality of care for children with this condition.

Visceral hypersensitivity and electromechanical dysfunction as therapeutic targets in pediatric functional dyspepsia

Functional gastrointestinal disorders (FGID) are common clinical syndromes diagnosed in the absence of biochemical, structural, or metabolic abnormalities. They account for significant morbidity and health care expenditures and are identifiable across variable age, geography, and culture. Etiology of abdominal pain associated FGIDs, including functional dyspepsia (FD), remains incompletely understood, but growing evidence implicates the importance of visceral hypersensitivity and electromechanical dysfunction. This manuscript explores data supporting the role of visceral hypersensitivity and electromechanical dysfunction in FD, with focus on pediatric data when available, and provides a summary of potential therapeutic targets.

Interprovider variation of celiac disease testing in childhood chronic abdominal pain

Background

To determine within one tertiary care center: 1) the variation between providers in testing for celiac disease in children with chronic abdominal pain; 2) the characteristics of those children who were more likely to be tested, and 3) the prevalence of celiac disease in those evaluated.

Methods

Retrospective review of children with a primary complaint of chronic abdominal pain referred to a tertiary care children’s hospital for pediatric gastroenterology evaluation over a 2-year period was conducted. Children with at least two visits and without an identified organic etiology for the pain were included.

Results

160 children were evaluated by 16 pediatric gastroenterologists and one nurse practitioner. Celiac serologic testing was completed in 63 (39.4%) children. There was no significant variance in the frequency of celiac serologic testing between providers. Child age, gender, body mass index, and baseline gastrointestinal symptoms did not predict whether celiac serologic testing occurred, though Caucasians (P < 0.01) were more likely to be tested. Eighty-two (51.3%) children underwent either serologic testing and/or esophagogastroduodenoscopy. Four (4.9%, 95% CI: 1.6-11.3%) of the 82 tested were diagnosed with celiac disease.

Conclusions

Though interprovider variation for celiac disease testing in children with chronic abdominal pain did not occur, a large number of these children were not evaluated for celiac disease. Children’s race/ethnicity but not their associated gastrointestinal symptoms predicted whether celiac testing was undertaken. In those tested, celiac disease was identified in a higher percentage than that expected in the general population.

Safety and efficacy of cyproheptadine for treating dyspeptic symptoms in children

OBJECTIVE

To present our experience using cyproheptadine, a potent serotonin antagonist used to stimulate appetite, to treat dyspeptic symptoms in children.

STUDY DESIGN

This was a retrospective open-label study conducted to evaluate the safety and efficacy of cyproheptadine in children with refractory upper gastrointestinal symptoms (eg, nausea, early satiety, vomiting, retching after fundoplication, abdominal pain). Response was graded as resolution if symptoms resolved and medication was discontinued, as significant improvement if symptoms resolved with no further interventions, and as failure with any other outcome.

RESULTS

A total of 80 children (65% females) aged <12 years (mean age, 10 years) were included. Response to therapy was reported in 55% of patients. Multivariate analysis revealed better response in children and females (P = .04 and .03, respectively). No associations were found between response to therapy response and gastric emptying, antroduodenal manometry, functional dyspepsia, vomiting, and use of cyproheptadine as first therapy. Early vomiting (occurring within 1 hour after starting a meal) responded better than late vomiting (P = .03), and patients with retching after undergoing Nissen fundoplication had an 86% response rate. Twenty-four patients (30%) complained of side effects, all mild, including somnolence (16%), irritability and behavioral changes (6%), increased appetite and weight gain (5%), and abdominal pain (2.5%), but only 2 of these patients discontinued therapy. Multivariate analysis demonstrated an association between side effects and lack of response to therapy (P = .04), but no associations with age and sex.

CONCLUSION

Cyproheptadine is safe and effective for treating dyspeptic symptoms in children, particularly in young children and those with early vomiting and retching after fundoplication.

Gastric emptying and antral motility parameters in children with functional dyspepsia: association with symptom severity

BACKGROUND AND AIMS

Functional dyspepsia (FD) is an important gastrointestinal problem with obscure etiology. Abnormal gastric motility is suggested as a possible pathophysiological mechanism for symptoms. The main objective of this study was to assess gastric motility in Sri Lankan children with FD.

METHODS

Forty-one children (19 [46.3%] males, age 4-14 years, mean 7.5 years, SD 2.6 years) referred to the Gastroenterology Research Laboratory, Faculty of Medicine, University of Kelaniya, from January 2007 to December 2011, were screened. Those fulfilling Rome III criteria for FD were recruited. None had clinical or laboratory evidence of organic disorders. Twenty healthy children were recruited as controls (eight [40%] males, age 4-14 years, mean 8.4 years, SD 3.0 years). Liquid gastric emptying rate (GE) and antral motility parameters were assessed using an ultrasound-based method.

RESULTS

Average GE (45.6% vs 66.2% in controls), amplitude of antral contractions (58.2% vs 89.0%) and antral motility index (5.1 vs 8.3) were lower and fasting antral area (1.5 cm(2) vs 0.6 cm(2)) was higher in patients with FD (P < 0.01). Frequency of antral contractions (8.8 vs 9.3) did not show a significant difference (P = 0.07). Scores obtained for severity of abdominal pain negatively correlated with GE (r = -0.35, P = 0.025). Children with FD, exposed to stressful events had higher fasting antral area (1.9 cm(2)) than those not exposed to stress (1.0 cm(2)) (P = 0.02).

CONCLUSIONS

GE and antral motility parameters were significantly impaired in children with FD compared with controls. GE negatively correlated with severity of symptoms. This study points to disturbances in gastric motility as an etiological factor for FD.

Assessment of gastric motor function in childhood functional dyspepsia and obesity

BACKGROUND

The aim was to compare gastric emptying rate and nutrient tolerance during a satiety drinking test in children with functional dyspepsia (FD) and obesity and to study the relationship between daily caloric intake and the satiety drinking test.

METHODS

A total of 28 dyspeptic children (22 girls, mean age 12.5 ± 3.1 years) and 15 obese children (five girls, 13.3 ± 1.8 years) were studied. The patients underwent an octanoic acid gastric emptying breath test and a satiety drinking test. Prior to both tests, a dyspepsia questionnaire was filled out to calculate the mean calorie intake.

KEY RESULTS

The most prevalent dyspeptic symptoms were early satiety (96.4%), postprandial fullness (89.2%), and epigastric pain (78.6%), followed by nausea (50%). All dyspeptic and obese children (n = 43) started the satiety drinking test and 41 children completed the test until a score of 5 was reached. The maximum ingested volume in FD was significantly lower than in obesity or in age-matched healthy controls (252 ± 85 vs 479 ± 199 and 359 ± 29 mL respectively, both P < 0.05). As a group, dyspeptic children had significantly slower gastric emptying than obese children (89.7 ± 54.8 min vs 72.5 ± 26.0 min, P = 0.05). Daily calorie intake was significantly higher in obese children than that in dyspeptic children (2325 ± 469 vs 1503 ± 272 cal, P < 0.0001). The endpoint of the satiety drinking test was significantly correlated with body weight or BMI (both R = 0.41, P = 0.04), but not with daily calorie intake, gastric emptying rate or age.

CONCLUSIONS & INFERENCES

The satiety drinking test is a potentially useful non-invasive tool in the investigation of children with FD and obesity.

Recurrent abdominal pain in childhood

BACKGROUND

Chronic, recurrent abdominal pain is common among children and adolescents. It interferes with everyday life, causes absence from school, and leads to frequent medical consultations, often involving burdensome diagnostic testing and protracted attempts at treatment.

METHOD

Selective review of the literature.

RESULTS

Organic causes should be ruled out with a thorough medical history and physical examination and a small number of laboratory tests. The pediatric Rome III criteria include valid diagnostic criteria for functional abdominal pain in childhood. The available data imply that this condition is best treated with cognitive behavioral therapy, rather than with medications or dietary measures.

CONCLUSION

A systematic approach to chronic recurrent abdominal pain in children and adolescents is key to ruling out organic diseases while avoiding unnecessary tests and treatments.

Normal values for the satiety drinking test in healthy children between 5 and 15 years

In adults, a slow caloric drinking test has been proposed as a non-invasive tool to estimate gastric accommodation and to quantify meal-induced symptoms in functional dyspepsia (FD). The same test has been proposed for paediatric FD, but normal values are only available for adolescents and adults. The aim of the study was (i) to establish normal values for the satiety drinking test in young children and (ii) to study the influence of demographic factors. In all, 59 healthy children [27 girls; age range 5-16 years, body mass index (BMI) 17.4 +/- 2.5 kg m(-2)] were studied in the morning after an overnight fast. They drank a liquid nutrient meal (1.5 kcal mL(-1)) from beakers that were filled by a peristaltic pump filled at a rate of 15 mL min(-1) with. For every 5 min, satiety was scored on a graphic rating scale grade 0-5 (1 = threshold, 5 = maximum), until a score of 5 was reached. Values are given as mean +/- SEM and compared by t-test; correlation analysis was performed using Spearman rank test. All children performed the test as indicated except for one 5 years old who stopped prematurely for dislike of the taste. The endpoint was reached at 360 +/- 23 mL (540 +/- 34 kcal), and was age-dependent (Spearman r = 0.28, P = 0.03). No correlation was found between the maximum volume ingested and gender, weight, height or BMI. Age-dependent normal ranges were determined for ages 5-16 at 3-year intervals, and were found to increase with age. We established feasibility of and normal values for a non-invasive satiety drinking test in children with an age range of 5-15 years. This tool can now be used in the assessment of paediatric FD and eating disorders.

Functional gastrointestinal disorders: past and present

BACKGROUND

Chronic abdominal pain is a common complaint in childhood and adolescence. Despite decades of clinical observations and research, it still poses a challenge to pediatric health care professionals. The aim of this review is to highlight the epidemiology of pediatric chronic abdominal pain and to describe the pathogenesis of this disorder, its clinical manifestations, evaluation and therapeutic options.

DATA SOURCES

Articles on chronic abdominal pain in the recent years from PubMed, MEDLINE, and reference textbooks were reviewed.

RESULTS

Chronic abdominal pain, a functional gastrointestinal disorder (FGID), is a multifactorial condition that results from a complex interaction between psychosocial and physiologic factors via the brain-gut axis. A thorough history coupled with a complete physical examination and normal screening studies rule out an organic cause in 95% of the cases. It is highly important for the physician to establish a trusting relationship with the child and parents because successful treatment including modification of physical and psychological stress factors, dietary changes, and drug therapy depends greatly on education, reassurance and active psychological support.

CONCLUSIONS

FGIDs are a cause of great anxiety, distress and morbidity in children as well as adults. As our understanding of these conditions improves, our therapeutic interventions will progress not only to overcome them but also to intervene early in the disease course so as to limit long-term impact.

Antral inflammatory cells, gastric emptying, and electrogastrography in pediatric functional dyspepsia

The aims of the current study were to determine the activation states of antral eosinophils and mast cells and to evaluate the interactions of antral inflammatory cells with gastric emptying and electrogastrography (EGG) in 30 pediatric patients with functional dyspepsia. Eosinophil degranulation was moderate in 42% and extensive in 54% of patients. Mast cell degranulation was > 50% in 81% of patients. Elevated mast cell density was associated with slower one hour gastric emptying and increased preprandial dysrhythmia. Mast cell density correlated with the preprandial percentage tachygastria. CD3+ cell density correlated with the preprandial percentage tachygastria also, but only in patients with increased eosinophil density. In conclusion, antral eosinophils and mast cells are significantly activated in pediatric functional dyspepsia. Mast cell density is associated with delayed gastric emptying and preprandial dysrhythmia, suggesting that there may be an interaction between antral inflammation and gastric electromechanical dysfunction in the pathophysiology of pediatric functional dyspepsia.

Dyspepsia in childhood and adolescence: insights and treatment considerations

Functional dyspepsia (FD) is common in children, with as many as 80% of those being evaluated for chronic abdominal pain reporting symptoms of epigastric discomfort, nausea, or fullness. It is known that patients with persistent complaints have increased comorbidities such as depression and anxiety. The interaction with psychopathologic variables has been found to mediate the association between upper abdominal pain and gastric hypersensitivity. These observations suggest that abnormal central nervous system processing of gastric stimuli may be a relevant pathophysiologic mechanism in FD. Despite increased understanding, no specific therapy has emerged; however, recent nonpharmacological-based options such as hypnosis may be effective. Novel approaches, including dietary manipulation and use of nutraceuticals such as ginger and Iberogast (Medical Futures Inc., Ontario, Canada), may also be considered.