Henoch-Schonlein purpura leads to functional gastrointestinal disorders.

BACKGROUND: Pain predominant functional gastrointestinal disorders such as irritable bowel syndrome may develop as sequelae to acute infectious gastroenteritis. Henoch-Schonlein purpura is a vaculitis that causes an inflammatory insult to the intestinal mucosa. OBJECTIVE: To assess whether patients with Henoch-Schonlein purpura are more likely to develop functional gastrointestinal disorders in long-term follow-up than controls. PATIENTS AND METHODS: Families of children diagnosed with Henoch-Schonlein purpura from 2002 to 2009 were contacted at least 6 months after an acute episode. Parents completed a validated questionnaire to diagnose functional gastrointestinal disorders according to Rome III criteria. RESULTS: Thirty-eight patients (mean 9.9 years, range 3-22 years, 19 males) and 38 controls (mean 9.5 years, range 1-24 years, 21 males) were recruited. Of the patients, 81% had abdominal pain with Henoch-Schonlein purpura presentation. Initial abdominal pain had resolved in all cases. At the time of study, 60.5% patients and 2.6% controls had abdominal pain. Children in Henoch-Schonlein purpura group were diagnosed with various functional gastrointestinal disorders: Irritable bowel syndrome in 11%, functional abdominal pain syndrome in 8%, and functional abdominal pain in 2.8%. Steroid usage was associated with higher incidence of abdominal pain (87.5%) at the time of the study as compared to no steroid usage (40.9%), p = 0.0065. CONCLUSIONS: Patients with Henoch-Schonlein purpura are at an increased risk of developing pain predominant functional gastrointestinal disorders. The presence of abdominal pain and use of steroids at presentation of Henoch-Schonlein purpura are associated with higher incidence of pain predominant functional gastrointestinal disorders.

How reliable are the Rome III criteria for the assessment of functional gastrointestinal disorders in children?

OBJECTIVES: Functional gastrointestinal disorders (FGIDs) are common in children. Diagnosis of these conditions is based on the pediatric Rome criteria. In the past, we have shown that there was low inter-rater reliability (IRR) among pediatric gastroenterologists using the Rome II criteria. Since then, a new version of the criteria has been issued. The reliability of the Rome III criteria has not been established. METHODS: A total of 10 pediatric gastroenterologist specialists and 10 pediatric gastroenterology fellows were provided with 20 clinical vignettes and a list of 17 possible diagnoses (all pediatric categories of the Rome criteria plus "none of the above" or "not enough information") and instructed to select one or more diagnosis for each vignette. RESULTS: The average percentage of agreement among the raters was 50% for the pediatric gastroenterologists and 45% for the pediatric gastroenterology fellows. The inter-rater percentage of agreement per clinical case was >50% in only 7 out of 20 (35%) vignettes for the gastroenterologists and only 6 out of 20 (30%) cases for the fellows. The inter-rater percentage of agreement was <25% in 2 out of 20 (10%) vignettes for the gastroenterologists and 4 out of 20 (20%) vignettes for the fellows. The κ coefficient was 0.45 for the specialists (P<0.0001) and 0.39 for the fellows (P<0.0001). In a subanalysis of the groups of pain and constipation-related disorders, the inter-rater percentage of agreement per clinical case ranged between 27 and 100% (mean 57%, κ=0.37, P<0.0001) for the gastroenterologists and between 36 and 80% (mean 52%, κ=0.33, P<0.0001) for the fellows in the constipation subgroup. The inter-rater percentage of agreement per clinical case for the pain subgroup ranged between 22 and 80% (mean 48%, κ=0.36, P<0.0001) for the gastroenterologists and 22 and 62% (mean 39%, κ=0.29, P<0.0001) for the fellows in the pain subgroup. The κ coefficient for specialists with expertise in FGIDs was 0.37 (P<0.0001) and for those with expertise in other gastroenterology conditions was 0.53 (P<0.0001). CONCLUSIONS: The IRR among pediatric gastroenterologists and fellows was found to be fair to moderate for the Rome III criteria. Only slight to fair agreement between raters existed for important subcategories of pain and constipation. The results from our current study are almost similar to that of the IRR study done for the Rome II criteria. This indicates the need for further refinement of the Rome criteria to make them more encompassing and user friendly.

A million-dollar work-up for abdominal pain: is it worth it?

BACKGROUND AND AIM: Pain-predominant-functional gastrointestinal disorders (PP-FGIDs) are common. The diagnosis is clinical and there are no biological markers to characterize these conditions. Despite limited evidence, investigations are commonly performed. The aim of the study was to investigate diagnostic practices, yield, and costs in children with PP-FGIDs. PATIENTS AND METHODS: Charts of all of the children older than 4 years diagnosed as having abdominal pain were reviewed. Results and costs of diagnostic investigations were analyzed. RESULTS: Of 243 children with abdominal pain, 122 (50.2%) had PP-FGIDs (79 girls, mean age 12.7 years). All of the children underwent diagnostic work-up. Complete blood cell count was done in 91.8% of patients. None had elevated white blood cells, platelets, and low albumin. Six had either elevated erythrocyte sedimentation rate or C-reactive protein, but none had elevation of both; 4 of these 6 cases underwent endoscopies with normal results in 3 cases; Helicobacter pylori was found in 1 case. One child had elevated tissue transglutaminase 1 only antibodies with normal endoscopy. Amylase, lipase, direct bilirubin, stool cultures, and ova or parasites were always normal. One child had intermittent elevation of aspartate aminotransferase and alanine transaminase. There were no significant abnormalities in urinalysis or electrolytes. Abdominal x-rays were done in 38.5%, showing only retained stools in 13% of these patients. Abdominal ultrasound and computed tomography scan were done in 23.7% and 9% of cases, respectively, but were of no clinical value; 33.6% patients had esophagogastroduodenoscopy (9.7% abnormal: Helicobacter pylori, chemical gastritis, esophagitis) and 17.2% had colonoscopy (9.5% abnormal: rare fork crypts, lymphoid hyperplasia). Total costs: $744,726. Average cost per patient: $6104.30. CONCLUSIONS: In children with PP-FGIDs, investigations are common, costs are substantial, and yield is minimal.

Recurrent headaches in children: an epidemiological survey of two middle schools in inner city Chicago.

OBJECTIVES: The aim of this study was to longitudinally evaluate the epidemiological characteristics of headaches in a school-based, community setting and to determine the impact of headache symptoms on the health of children. METHODS: After institutional review board approval, a prospective cohort study was conducted at two Chicago public schools for a period of 6 months. Members of the research team surveyed both schools weekly for headache and other pain symptoms. The students rated each pain symptom on a 5-point scale from 0 ("not at all") to 4 ("a whole lot"). Demographic information was collected at the time of enrollment, and all participants were asked to complete age-appropriate and validated pediatric surveys to assess the severity of concurrent somatic complaints, anxiety symptoms, functional limitations, and quality of life issues. RESULTS: Of the participating children, 89.5% reported at least one headache during the study period. Females experienced more frequent headaches compared with males (P < 0.05). Children reporting headaches had a significantly increased risk of experiencing other troubling somatic symptoms (P < 0.05). Headache severity showed a moderate correlation with increased feelings of anxiety, functional disability, and a diminished quality of life (P < 0.05). CONCLUSIONS: School-aged children commonly experience headaches. Children experiencing headaches are more likely to report other somatic symptoms, feelings of anxiety, functional limitations, and quality of life impairments.