An 11-year-old boy was evaluated for a two-year history of daily, intermittent abdominal pain in a multidisciplinary abdominal pain clinic
By Amanda A. Drews, Kim Tennissen, Craig A. Friesen, and Jennifer Verrill Schurman
Tyler, an 11-year-old boy, was evaluated for a two-year history of daily, intermittent abdominal pain in a multidisciplinary abdominal pain clinic. In addition to abdominal pain, Tyler complained of nausea, bloating, and the sensation of feeling full quickly during meals. He also reported problems with sleep onset and sleep-wake transition. His medical history was positive for asthma, seasonal allergies, and a prior diagnosis of ADHD. At the time of his evaluation, Tyler was being homeschooled and missing extracurricular and social activities several times per week due to abdominal pain. Tyler previously was evaluated by a gastroenterologist and a naturopathic practitioner, with extensive laboratory testing plus an upper and lower endoscopy. He was tried on multiple medications and followed a restricted diet with no significant symptom relief. Review of Tyler’s previous work up revealed normal lab findings, but increased eosinophilic inflammatory cell counts on his endoscopy biopsies.
The collection of conditions known as pediatric functional gastrointestinal disorders (FGIDs) is best understood using a biopsychosocial framework. This model asserts that chronic abdominal pain in childhood is not the result of a single causal factor, but of a complex interplay among biological (e.g., inflammation, dysmotility, visceral hyperalgesia), psychological (e.g., anxiety, depression, sleep), and social (e.g., interactions with peers, teachers, parents) factors (Drossman, 2006). Further, each of these factors, on its own or in combination with another of the factors, has the potential to affect the duration, intensity, and frequency of pain episodes (Schurman & Friesen, 2006). As such, an integrated, multidisciplinary approach that addresses all relevant factors simultaneously has the potential to enhance clinical outcomes, thereby limiting long-term disability, and yield health care savings within this patient population (Schurman, Wu, Grayson, & Friesen, 2010).
In this case, Tyler’s evaluation and initial treatment took place over a period of approximately four months. At the onset, we recommended numerous specific interventions that addressed presumed biological, psychological, and social factors thought to be impacting his abdominal pain and other symptoms. A few of the treatment components considered pivotal in Tyler’s treatment are discussed below.
Tyler was diagnosed with functional dyspepsia using the symptombased Rome III criteria. He was prescribed Gastrocrom (cromolyn sodium) 400mg four times daily to address the identified inflammatory component of his abdominal pain. Gastrocrom belongs to a class of medications termed mast cell stabilizers. Mast cells are normal body cells that release substances (e.g., histamines) that are needed for normal body defense and healing. When too many of these cells are present, however, they release an excess of these substances which can lead to gastrointestinal symptoms, as well as itching and flushing. When used for treating gastrointestinal symptoms associated with eosinophilic inflammation, Gastrocrom is administered orally and works topically in the lining of the gastrointestinal tract. The lining is coated with medication, thereby limiting the release of histamines thought to contribute to gut and skin problems. Gastrocrom, while generally effective, must be timed with meals and can take up to eight weeks to reach full effect.
Tyler was referred to a BCIA (Biofeedback Certification International Alliance) certified biofeedback practitioner near his home. Biofeedback training is a technique wherein patients receive in vivo visual and/or auditory feedback about the physical state of their bodies as a measure of sympathetic nervous system arousal. Paired with relaxation training, biofeedback-assisted relaxation training (BART) provides patients with concrete skills (e.g., deep breathing, progressive muscle relaxation, visualization/ imagery) that are thought to decrease nervous system arousal, thereby alleviating physical symptoms. Tyler attended sessions three times per week initially and practiced the skills several times per day at home. Over the next six months, session frequency was tapered to monthly visits.
Tyler and his family utilized a structured plan for graduated school reentry. Approaching the return to school in a graduated fashion has two primary advantages, namely reintegrating patients into the academic and social activities of school while, at the same time, providing them with the necessary support to succeed (Walker, 2004). This balance of demands and support is vitally important, as stress can exacerbate abdominal pain and have an overall negative effect on the recovery process. Given that Tyler was being homeschooled completely at the time of initial evaluation, he started by attending one consistent class period daily and gradually added time to his in-school schedule as his stamina increased. During the process of reentry, Tyler also received instruction from a homebound teacher in the classes he was not yet attending. As specific classes gradually were added to his in-school schedule, support for these classes was dropped from homebound and the amount of homebound instruction was reduced. Communication with school staff during this process decreased barriers to return and ensured that appropriate school supports were in place, such as taking breaks for biofeedback practice and using the restroom, as needed.
After about one month of treatment, Tyler reported that BART was extremely helpful to him in terms of helping to manage his pain. At his next visit, four months later, Tyler was having abdominal pain only about once per week. His appetite, energy, and headaches also were improved. Within approximately eight weeks of beginning graduated school reentry, Tyler was attending school full time.
Important to convey is the fact that Tyler’s recovery was not perfectly linear, nor has it ended. Eosinophilic inflammation within the GI tract is especially sensitive to viral illnesses, seasonal allergies, and stress. As a result, Tyler evidenced temporary symptom flares at predictable times during his treatment. Shortly after the start of school, for example, Tyler had an exacerbation of his abdominal pain. He complained of daily pain with episodes lasting up to one hour. We learned that Tyler had a viral infection just prior to the worsening of his GI symptoms and was experiencing “severe allergies” according to his PCP. These factors, in combination with a recent transition to full time school attendance, may have contributed to this temporary resurgence in Tyler’s symptoms. While certainly disappointing for Tyler and his family, these set backs provide important clues to families and providers for preventing, or at least managing, flares when they do occur. Proper hand washing to reduce transmission of viruses, aggressive treatment of seasonal allergies, and advance planning to reduce stress could be helpful in reducing the odds of a temporary increase in GI inflammation. Continued availability of the treatment team to assess symptom improvement, day-to-day functioning, and ongoing implementation of the treatment plan also may be important in early intervention during later flares.
Tyler’s case is one that highlights the clear benefits of assessing and treating childhood chronic abdominal pain from a truly biopsychosocial perspective. Simultaneously intervening with known biological factors while providing coping skills and environmental supports to encourage functioning offers the greatest likelihood of positive treatment outcomes and decreased disability.
- Drossman, D.A. (2006). The functional gastrointestinal disorders and the Rome III process. Gastroenterology, 130, 1377-1390.
- Schurman, J.V., & Friesen, C.A. (2006). Chronic abdominal pain in children: An update. Missouri Medicine, 103, 66-71.
- Schurman, J.V., Wu, Y.P, Grayson, P., & Friesen, C.A. (2010). A pilot study to asses the efficacy of biofeedback-assisted relaxation training as an adjunct treatment for pediatric functional dyspepsia associated with duodenal eosinophilia. Journal of Pediatric Psychology, 35(8), 837-847.
- Walker, L.S. (2004). Helping the child with recurrent abdominal pain return to school. Pediatric Annals, 33(2), 128-136.