Medicine

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Abdominal pain predominant functional gastrointestinal diseases in children and adolescents: prevalence, symptomatology and association with emotional stress
(Sri Lanka Medical Association, 2011) Devanarayana, N.M.; Mettananda, S.; Rajindrajith, S.
INTRODUCTION AND OBJECTIVES: To assess the prevalence of abdominal pain predominant functional gastrointestinal diseases (FGD) in Sri Lankan children, their symptomatology, and predisposing factors. METHODS: A cross sectional survey was conducted among a randomly selected group of 10-16 year olds, in 8 randomly selected schools, in 4 provinces in Sri Lanka. A validated, self-administered questionnaire was distributed in an examination setting. Research assistants were present while filling the questionnaire and explanations were given. FGD Were Diagnosed using Rome III criteria. RESULTS: A total of 2180 questionnaires were distributed and 2163 (99.2%) were included in the analysis [1189 (55%) males, mean age 13.4 years, SD 1.8 years]. Seventeen incompletely filled questionnaires were excluded. Two hundred and seventy (12.5%) had at least one abdominal pain predominant FGD. Irritable bowel syndrome (IBS) was seen in 107 (4.9%), functional dyspepsia (FD) in 54 (2.5%), functional abdominal pain in 96 (4.4%) and abdominal migraine (AM) in 21 (1.0%) (2 had AM and FD, 6 had AM and IBS). Extraintestinal somatic symptoms (headache, limb pain, sleeping difficulty) were more common among affected children (p<0.05). Abdominal pain predominant FGD were significantly higher in girls and those exposed to stressful events (p<0.05). Prevalence negatively correlated with age. CONCLUSION: Abdominal pain predominant FGD were a significant health problem in Sri Lankan children affecting 12.5%. IBS was the commonest FGD diagnosed. Abdominal pain predominant FGD were higher in girls and those exposed to emotional stress. Prevalence of FGD decreased with age. Somatic symptoms were more frequent in affected children.
Abdominal pain predominant functional gastrointestinal disorders in adolescent Nigerians
(Lippincott Williams and Wilkins, 2016) Udoh, E.; Devanarayana, N.M.; Rajindrajith, S.; Meremikwu, M.; Benninga, M.A.
AIMS: To determine the prevalence, pattern and predisposing factors of abdominal painpredominant functional gastrointestinal disorders (AP-FGIDs) in adolescent Nigerians. METHODS: A cross sectional study was conducted in two states in the southern part of Nigeria in June 2014. Adolescents aged 10 - 18 years were recruited from 11 secondary schools using a stratified random sampling technique. A validated self-administered questionnaire on Rome III criteria for diagnosing AP-FGIDs and its determinants were filled by the participants in a class room setting. RESULTS: A total of 874 participants filled the questionnaire. Of this, 818 (93.4%) filled it properly and were included in the final analysis. The mean age of participants was 14.6 ± 2.0 years with 409 (50.0%) being males. AP-FGIDs were present in 81 (9.9%) participants. Among them, 46 (5.6%) had irritable bowel syndrome (IBS), 21 (2.6%) functional abdominal pain, 15 (1.8%) abdominalmigraine while 3 (0.4%) had functional dyspepsia. The difference in AP-FGIDs between adolescents residing in rural and urban areas was not statistically significant (P = 0.22). AP-FGDs was significantly associated with frequent punishment at school (P = 0.03), Intestinal and extra-intestinal symptoms occurred more frequently in those with AP-FGIDs. loss of appetite (56.8% vs. 38.4% in controls), nausea (51.6% vs. 30.0%), headache (76.5% vs. 65.0%), photophobia (56.8% vs. 34.6%) and light-headedness (50.6% vs. 32.6%). Nausea was the only symptom independently associated with AP-FGIDs (p = 0.015). Multiple regression analysis showed no significant association between stressful life events and FGIDs. (P < 0.05). CONCLUSIONS: AP-FGIDs are a significant health problem in Nigerian adolescents. In addition to the intestinal symptoms, most of the affected children had other them also had extra-intestinal symptoms. None of the stressful life events evaluated was significantly associated with FGIDs. Frequent punishment in schools was significantly associated with the condition.
Assessment of gastric emptying and antral motility in different types of abdominal pain related functional gastrointestinal diseases: a paediatric study
(BMJ Publishing, 2010) Devanarayana, N.M.; Rajindrajith, S.
INTRODUCTION: Functional gastrointestinal disorders (FGD) are common among paediatric population. Abdominal pain related FGD are the most common subgroup found, of which irritable bowel syndrome is the most common. The exact mechanism of pain remains unclear in FGD. Visceral hypersensitivity and altered gastrointestinal motility are considered possible causes for abdominal pain and discomfort found in these children. METHODS: The main aim of this study was to evaluate the gastric emptying and antral motility in children and adolescents with abdominal pain related FGD. Hundred and fifty-five children referred to the Gastroenterology Research Laboratory who fulfilled Rome III criteria for abdominal pain related FGD (60 (38.5%) males, 4–14 years, mean 8.1 years, SD 2.6 years) and 20 healthy children without gastrointestinal symptoms (8 (40%) males, 4–15 years, mean 8.9 years, SD 2.7 years) were recruited. None had clinical or laboratory evidence of organic diseases. All subjects underwent ultrasonographic assessment of liquid gastric emptying rate (GE) and antral motility, using a previously reported method. RESULTS: Gastric motility parameters of children with FGD and controls are presented in the table. GE negatively correlated with the scores obtained for severity of symptoms in functional dyspepsia (FD) (r=−0.67, p<0.001) and functional abdominal pain (FAP) (r=−0.38, p<0.001), but not in irritable bowel syndrome (IBS) (r=−0.16, p=0.29). CONCLUSIONS: GE and antral mortality parameters were significantly impaired in children with all types of abdominal pain related FGD. GE negatively correlated with symptoms in FD and FAP. Mortality parameters were not significantly different between subtypes of IBS.
Association between functional abdominal pain disorders and asthma in adolescents: A cross-sectional study
(Baishideng Publishing Group, 2018) Kumari, M.V.; Devanarayana, N.M.; Amarasiri, L.; Rajindrajith, S.
AIM: To find the association between asthma and different types of functional abdominal pain disorders (FAPDs) among teenagers. METHOD : A cross-sectional study was conducted among 13 to 15-year-old children from six randomly selected schools in Anuradhapura district of Sri Lanka. Data were collected using translated and validated self-administered questionnaires (Rome III questionnaire, International Study on Asthma and Allergies in Childhood questionnaire, and Pediatric Quality of Life Inventory 4.0) and administered under an examination setting after obtaining parental consent and assent. RESULTS: Of the 1101 children included in the analysis, 157 (14.3%) had asthma and 101 (9.2%) had at least one FAPDs. Of children with asthma, 19.1% had at least one type of FAPDs. Prevalence rates of functional abdominal pain (FAP)(8.9% vs 3.3% in non-asthmatics), functional dyspepsia (FD) (2.5% vs 0.7%), and abdominal migraine (AM) (3.2% vs 0.4%) were higher in those with asthma (P < 0.05, multiple logistic regression analysis), but not in those with irritable bowel syndrome (4.5% vs 3.1%, P = 0.2). Severe abdominal pain (10.8% vs 4.6%), bloating (16.6% vs 9.6%), nausea (6.4% vs 2.9%), and anorexia (24.2% vs 16.2%) were more prevalent among asthmatics (P < 0.05). Lower gastrointestinal symptoms did not show a significant difference. Scores obtained for health related quality of life (HRQoL) were lower in those with asthma and FAPDs (P < 0.05, unpaired t-test). CONCLUSION: Asthma is associated with three different types of FAPDs, namely, FD, AM, and FAP. HRQoL is significantly impaired in teenagers with asthma and FAPDs.
Autonomic functions and gastric motility in children with functional abdominal pain disorders
(WJG Press, 2019) Karunanayake, A.; Rajindrajith, S.; de Silva, H.A.; Gunawardena, S.; Devanarayana, N.M.
BACKGROUND: Abdominal pain-predominant functional gastrointestinal disorders (AP-FGIDs) are the most common cause of recurrent abdominal pain in children. Despite its high prevalence, the underlying pathophysiology of this condition is poorly understood. AIM: To assess the role of gastric dysmotility and autonomic nervous system dysfunction in the pathophysiology of AP-FGIDs. METHODS: One hundred children, fulfilling Rome III criteria for AP-FGIDs, and 50 healthy controls, aged 5 to 12 years, were recruited after obtaining parental consent. All patients were investigated for underlying organic disorders. Gastric motility and cardiovascular autonomic functions were assessed using validated non-invasive techniques. RESULTS:The main gastric motility parameters assessed (gastric emptying rate [45.7 vs 59.6 in controls], amplitude [48.7 vs 58.2], frequency of antral contractions [8.3 vs 9.4], and antral motility index [4.1 vs 6.4]) were significantly lower in children with AP-FGIDs (P < 0.05). The post-prandial antral dilatation at 1 min after the test meal significantly correlated with the severity of abdominal pain (P < 0.05). Assessment of autonomic functions in AP-FGID patients showed neither a significant difference compared to the control group, nor a correlation with gastric motility abnormalities (P > 0.05). The duration of pain episodes negatively correlated with the parasympathetic tone (maladaptive parasympathetic tone) (P < 0.05).CONCLUSION: Children with AP-FGIDs have abnormal gastric motility but normal cardiovascular autonomic functions. There is no relationship between abnormal gastric motility and autonomic functions. The pathogenesis of AP-FGIDs is not related to cardiovascular autonomic dysfunction.
Causes for recurrent abdominal pain in children and adolescents: a classification according to rome ii criteria
(Sri Lanka College of Paediatricians, 2007) Devanarayana, N.M.; de Silva, D.G.H.; de Silva, H.J.
BACKGROUND: Recurrent abdominal pain (RAP) among children and adolescents is defined as "at least three bouts of abdominal pain, severe enough to affect activities, over a period of not less than 3 months". RAP has multifactorial aetiology with many affected children having no evidence of organic pathology. The ROME II criteria for 'childhood functional gastrointestinal disorders' classify non-organic RAP into five main categories: functional dyspepsia (FD), irritable bowel syndrome (IBS), abdominal migraine, aerophagia and functional abdominal pain. OBJECTIVES: To identify the causes of RAP in Sri Lankan children. To classify non-organic RAP using ROME II criteria. DESIGN, SETTING AND METHOD: The children identified as having RAP during a school survey were recruited and screened for organic diseases using history, examination, stool microscopy and culture, full blood count, erythrocyte sedimentation rate and abdominal radiograph. Other investigations, performed based on clinical evidence, included serum amylase, renal and liver function tests, abdominal ultrasound and gastrointestinal endoscopy. RAP was defined according to Apley criteria. Children without clinical or laboratory evidence of organic diseases were classified using ROME II criteria. RESULTS: Fifty five children with RAP were investigated [25(45.5%) males, aged 5-15 years {mean 8.1 years, SD3.1 years)]. Thirteen (23.6%) had organic RAP (constipation 7, urinary tract infection 2, urinary calculi 1, gastro-oesophageal reflux I, antral gastritis and duodenitis I, and intestinal amoebiasis 1) and 42 (76.4%) had no organic disease. Thirty three (60%) could be classified according to ROME II criteria [functional abdominal pain 13, IBS 9, FD 9, abdominal migraine l,aerophagia I]. Nine (16.4%) did not fall into any of the above categories. CONCLUSIONS: The majority (60%) of children with RAP had functional bowel disease, which can be classified using ROME II criteria. • Organic pathology accounted for symptoms in less than 25% of patients.
Childhood functional abdominal pain: mechanisms and management
(Nature Pub. Group, 2015) Korterink, J.; Devanarayana, N.M.; Rajindrajith, S.; Vlieger, A.; Benninga, M.A.
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.
A Core outcome set for clinical trials in pediatric functional abdominal pain disorders.
(Mosby, 2020) Zeevenhooven, J.; Rexwinkel, R.; Van Berge Henegouwen, V.W.A.; Krishnan, U.; Vandenplas, Y.; Strisciuglio, C.; Staiano, A.; Devanarayana, N.M.; Rajindrajith, S.; Benninga, M.A.; Tabbers, M.M.; Consensus Group on Outcome Measures Made in Pediatric Enteral Nutrition Clinical Trials Working Group
OBJECTIVE: To ensure consistency and reduce outcome measure reporting heterogeneity in clinical trials on pediatric functional abdominal pain disorders (FAPDs), a core outcome set (COS) was developed for pediatric FAPD trials. STUDY DESIGN: A mixed-method 2-round Delphi technique was used and key stakeholders, including healthcare professionals (HCPs), patients with FAPD, and their parents were invited to participate. In the first round, key stakeholders identified outcomes of importance through an open-ended questionnaire. Outcomes mentioned by ≥10% of the participants were included in a shortlist. In the second round, this shortlist was rated and prioritized. During a consensus meeting with an expert panel, the final COS was defined. RESULTS: The first round was completed by 152 of 210 (72%) HCPs, 103 (100%) parents, and 50 of 54 (93%) patients. A total of 104 from 167 (62%) HCPs, 102 (100%) parents, and 53 (100%) patients completed round 2. Pain intensity, pain frequency, quality of life, school attendance, anxiety/depression, adequate relief, defecation pattern (disease specific, irritable bowel syndrome), and adverse events were included in the final COS for FAPDs. CONCLUSION: A set of 8 core outcomes has been identified that should minimally be measured in pediatric FAPD trials. Implementation of the use of this COS will increase comparison between studies and, therefore, improve management of children with FAPDs.
Delayed gastric emptying rates and impaired antral motility in children fulfilling ROME III criteria for functional abdominal pain
(Lippincott Williams & Wilkins, 2011) Devanarayana, N.M.; Rajindrajith, S.; Rathnamalala, N.; Samaraweera, S.; Benninga, M.A.
BACKGROUND: Abdominal pain is a common paediatric disorder affecting approximately 10% of children worldwide. The majority of affected children has no identifiable organic cause for their symptoms and considered to have functional gastrointestinal disorders (FGD). Gastric sensory motor dysfunctions have been implicated in the pathophysiology of FGD such as functional dyspepsia and irritable bowel syndrome. However, very little is known regarding gastric motility in children with functional abdominal pain (FAP), whose predominant symptom is abdominal pain. AIM: We hypothesized that abnormal gastric emptying and impaired antral motility are possible underlying mechanisms of symptoms in children with FAP. METHODS: All children referred to the Gastroenterology Research Laboratory, Faculty of Medicine, University of Kelaniya from 1st January 2006 to 31st December 2010 were screened and those fulfilling Rome III criteria for FAP were recruited. All patients were screened for organic disorders using history, examination and basic investigations (urine microscopy and culture, stool microscopy, C-reactive protein, full blood count and liver and renal function tests). An age and sex compatible group of healthy children were selected as controls. Liquid gastric emptying rate (GER) and antral motility (frequency of antral contractions, amplitude of antral contractions and antral motility index) were assessed using a previously reported ultrasound method. Results: A total of 102 children with FAP [37 (36.3%) males, 4–14 years, mean 7.8 years, SD 2.7 years] and 20 healthy controls [8 (40%) males, 4–14 years, mean 8.4 years, SD 3.0 years] were recruited. Average GER (42.1% vs. 66.2% in controls), amplitude of antral contractions (56.5% vs. 89%), frequency of contractions per 3 min (8.5 vs. 9.3) and antral motility index (4.9 vs. 8.3) were significantly lower in patients with FAP compared to controls ( p<0.01). Fasting antral area was higher in patients (1.4 vs. 0.6, p<0.0001). GER negatively correlated with the scores obtained for severity of abdominal pain (r= -0.29, p=0.004). CONCLUSIONS: Gastric emptying and antral motility parameters were significantly impaired in patients with FAP and GER negatively correlated with symptom severity. These findings highlight the possible role of gastrointestinal motility abnormalities in the pathophysiology of childhood FAP
Effects of body mass index on gastric motility in children with abdominal pain-predominant functional gastrointestinal disorders
(The Physiological Society of Sri Lanka, 2015) Karunanayake, A.; Devanarayana, N.M.; Rajindrajith, S.
INTRODUCTION: Objective of this study was to assess the effects of body mass index (BM1) on gastric motility abnormalities in children with abdominal pain-predominant FGIDs (AP- FGIDs). METHODS: Gastric motility parameters of 100 children with AP-FGIDs (39.0% boys, mean age 8.0 years [SD +or -2.1years] and 50 healthy controls (30% boys, mean age 8.6 years [SD +or -1.9 years]) were assessed by previously validated ultrasound method. AP-FGIDs were diagnosed using Rome III criteria. Fifty four had functional abdominal pain, 23 had irritable bowel syndromes, 9 had functional dyspepsia, 8 had abdominal migraine and 6 had more than one AP-FGID. RESULTS: Patients with AP-FGIDs had significantly lower gastric emptying rate (44.9% vs. 59.5% in controls, p<0.0001), frequency of antral contractions (8-3 vs. 9.4, p<0.000l), amplitude of antral contraction (48.6% vs. 58.1%, p<0.000l) and antral motility index (MI) (4.0 vs. 6.4, p=0.001). Fasting antral size (FA) and antral area at Iminute (AA1) and antral area at I5 minutes (AA15) after ingestion of the liquid test meal were not significantly different. BMI of children with AP-FGIDs and controls were respectively 15.2 and 15.6 (p=0.42). The correlations between BMI and AA1 (r=0.29, p=0.007), AA15 (r=0.32, p=0.003) and MI (r=0.22, p=0.038) in children with AP-FGIDs were significant. Patients with BMI <15Kg/m2 had a lower FA (1.5cm2 vs. 2.1cm2, p=0.03), AA1 (8.9 cm2 vs. 10.7 cm2, p=0.003) and AA15 (4.6 cm2 vs. 5.8 cm2, p= 0.01) than patients with BMI >15Kg/m2. CONCLUSION: BMI has an impact on certain gastric motility parameters in children with AP-FGIDs.
Effects of body mass index on gastric motility in children with abdominal pain-predominant functional gastrointestinal disorders.
(Lippincott Williams & Wilkins, 2015) Karunanayake, A.; Devanarayana, N.M.; Rajindrajith, S.
INTRODUCTION: There is evidence that overweight children have a higher prevalence of functional gastrointestinal disorders (FGIDs) than normal-weight children. Objective of this study was to assess the effects of body mass index (BMI) on gastric motility abnormalities in children with abdominal pain-predominant FGIDs (AP-FGIDs). METHODS: Gastric motility parameters of 100 children with AP-FGIDs (61(61%) girls, mean age 8.0 years [SD 2.1years] and 50 healthy controls (30 (30%) boys, mean age 8.6 years [SD 1.9 years]) were assessed at the Gastroenterology Research Laboratory of Faculty of Medicine, University of Kelaniya, Sri Lanka, using a previously validated ultrasound method. AP-FGIDs were diagnosed using Rome III criteria. Fifty-four had functional abdominal pain, 23 had irritable bowel syndromes, 9 had functional dyspepsia, 8 had abdominal migraine and 6 had more than one AP-FGID. RESULTS: Patients with AP-FGIDs had significantly lower gastric emptying rate (44.9% vs. 59.5% in controls, p < 0.0001), frequency of antral contractions (8.29 vs. 9.44, p < 0.0001), amplitude of antral contraction (48.6% vs. 58.1%, p < 0.0001) and antral motility index (4.0 vs. 6.4, p = 0.001). Fasting antral size (FA) and antral area at 1minute (AA1) and antral area at 15 minutes (AA15) after ingestion of the liquid test meal were not significantly different. BMI of children with AP-FGIDs and controls were respectively 15.2 and 15.6 (p = 0.42). The correlations between BMI and AA1 (r = 0.29, p = 0.007), AA15 (r = 0.32, p = 0.003) and MI (r = 0.22, p = 0.038) in children with AP-FGIDs were significant. Patients with BMI <15Kg/m2 had a lower FA (1.5cm2 vs. 2.1cm2, p = 0.03), AA1 (8.9 cm2 vs. 10.7 cm2, p = 0.003) and AA15 (4.6 cm2 vs. 5.8 cm2, p = 0.01) than patients with BMI >15Kg/m2. CONCLUSIONS: BMI has an impact on certain gastric motility parameters in children with AP-FGIDs. However, it does not contribute to abnormalities seen in main gastric motility parameters such as gastric emptying.
Epidemiological and pathophysiological aspects of abdominal pain predominant functional gastrointestinal disorders in children and adolescents: a Sri Lankan perspective
(Author Publication, 2015) Devanarayana, N.M.
SUMMARY Abdominal pain is the second common painful health problem in children, only second to headache. Abdominal pain can be acute or recurrent in origin. Chronic abdominal pain is a misnomer since episodes of abdominal pain in children are distinct and separated by periods of well being. Numerous organic disorders lead to recurrent abdominal pain (RAP). However, in Sri Lanka, and also in developed countries, common causes for RAP are functional gastrointestinal disorders (FGIDs) such as irritable bowel syndrome (IBS), functional abdominal pain (FAP), functional dyspepsia (FD), and constipation. John Apley, the British pediatrician is the first person to study abdominal pain among children. He gave the initial definition for RAP. Apley’s criteria has been used frequently to diagnose non-organic RAP in children until Rome criteria for abdominal pain predominant functional gastrointestinal disorders (AP-FGIDs) are released. Main AP-FGIDs recognized by Rome III definition are IBS, FD, abdominal migraine (AM) and FAP. Childhood FGIDs are a worldwide health problem. With growing population trends and increasing predisposing factors such as psychological stress and obesity, it can be predictable that the incidence of FGIDs will increase further and become a significant healthcare problem. Although FGIDs are not life threatening, research shows that children suffering from FGIDs tend to have a lower quality of life than their healthy peers and frequently miss school. In addition many FGIDs such as constipation and IBS has high healthcare expenditure and are becoming a major challenge on already overstretched healthcare budgets. Chapter 1 of this thesis introduces these key aspects of FGIDs in children including definitions, global epidemiology and burden of the disease. Chapter 2 of this thesis gives a detailed account on possible underlying pathophysiological mechanisms for AP-FGIDs and available treatment modalities. In the currently accepted biopsychosocial model, the interplay of genetic, physiological, psychological and immunological factors are considered to give rise to FGIDs in children. The prevailing viewpoint is that the pathogenesis of func¬tional pain syndromes involves the inter-relationship between changes in visceral sensation, so-called visceral hyperalgesia or hypersensitivity, and altered gastrointestinal motility. Potential targets for pharmacological and nonpharma¬cological therapy are arising from this model. To date, high-quality efficacy studies of treatment in pediatric AP FGIDs are scarce. Available evidence indicates benefi¬cial effects of hypnotherapy and combined behavior therapy. Evidence for diets low in fermentable oligosaccharides, disaccharides, monosaccharaides and polyols (FODMAP) and probiotics is promising, as well as for drug treatment such as peppermint oil, cyprohep¬tadine or famotidine, but well-designed trials with long-term follow-up are needed to confirm these preliminary results. Chapter 3 describes the prevalence and risk factors for development of AP-FGIDs in Sri Lanka. AP-FGIDs are seen in 12.5% of Sri Lankan children ages 10 to 16 years. IBS is the most common AP-FGID diagnosed, followed by FAP and FD. AP-FGIDs are significantly higher in girls compared with boys. There is a negative correlation between the age and prevalence of AP-FGIDs, with highest prevalence observed in children aged 10 years. Intestinal-related symptoms and extraintestinal symptoms are more frequent in affected children, compared with controls. Exposure to home- and school-related stressful life events are significantly associated with AP-FGIDs. The distribution of IBS subtypes in 10-16 year olds, their symptom characteristics, and bowel habits are described in details in chapter 4 of this thesis. Constipation predominant IBS (IBS-C), diarrhea predominant IBS (IBS-D) and mixed IBS (IBS-M) have almost equal distribution while untyped IBS (IBS-U) has a relatively lower prevalence. IBS is more frequent in girls than in boys. Several intestinal-related and extraintestinal symptoms are significantly associated with all four subtypes of IBS, indicating higher occurrence of somatization among affected children. Asia is the home for over 50% of the world’s childhood population. In addition, most of Asian countries are going through a rapid change in socio-economic status and their cultural foundations are constantly being challenged by globalization. In that light, we believed that studying epidemiological patterns of IBS in Asian children in a systematic way will provide a greater perspective for understanding the burden of IBS, its epidemiological distribution, and patterns of subtypes in this continent. Chapter 5 is a systematic review and meta-analysis which has demonstrated that a sizeable population of young Asians have IBS. The prevalence of IBS varies widely depending on the country, diagnostic criteria, and age of the participants. It is more common among girls compared to boys. There is a significant difference in the prevalence of sub-types in different studies. This systematic review concluded that further studies using pediatric criteria for IBS are needed to understand the true prevalence, especially in other parts of the Asia with large populations. It is believed that exposure to abuse as a child may subsequently result in abdominal pain. However, only a handful of studies have evaluated the impact of abuse on AP-FGIDs in children and none in teenagers. Results of a study conducted to assess this association between exposure to child abuse and AP-FGIDs in teenagers is presented as Chapter 6. The prevalence of AP-FGIDs is significantly higher in teenagers who have been exposed to physical, sexual, and emotional abuse. In addition, scores obtained for severity of bowel symptoms were significantly higher in teenagers with AP-FGIDs exposed to abuse than those not exposed to such events. Chapter 7 describes the health related quality of life (HRQoL) and healthcare consultation in Sri Lankan teenagers aged 13 to 18 years with AP-FGIDs. Children with AP-FGIDs have significantly lower HRQoL scores for physical, emotional, social and school functioning. Approximately 28% of affected children have sought medical advice for their symptoms during previous 3 months. The main symptoms associated with healthcare consultation were abdominal bloating and vomiting. The HRQoL was an important determinant of healthcare consultation, more than the severity of individual symptoms. Chapter 8, chapter 9, chapter 10 and chapter 11, using a simple, safe and non-invasive ultrasound method, we have shown a significant delay in gastric emptying and impairment in antral motility in children who fulfil Rome III criteria for all 4 main types of AP-FGIDs, namely FAP, IBS, FD and AM. Furthermore, there is a significant negative relationship between delayed gastric emptying and severity of symptoms in children with FAP, FD and AM. Furthermore, children with IBS who were exposed to recent stressful life events had a significantly lower gastric emptying rate compared to those not exposed to such events, suggesting the possibility of altered brain-gut interactions. In this light, our findings suggest that delayed gastric emptying and impaired antral motility play a role in the pathogenesis of AP-FGIDs. CONCLUSIONS This thesis clearly shows that AP-FGIDs are common among Sri Lankan children, especially those exposed to psychological factors such as school and home related stressful events and abuse. The commonest AP-FGID type is IBS of which IBS-D, IBS-C and IBS-M have almost equal prevalence. Affected children have a poor HRQoL in physical, emotional, social and school functioning domains. Only approximately a quarter of children with this troublesome symptom have received healthcare. Affected children have significant abnormalities in their gastric motility functions, and in some, the abnormal motility correlates with the severity of symptoms.
Epidemiology of functional abdominal pain disorders and functional defecation disorders in adolescents in Curacao.
(Raven Press., 2020) Zeevenhooven, J.; van der Heijden, S.; Devanarayana, N.M.; Rajindrajith, S.; Benninga, M.A.
OBJECTIVES: Functional abdominal pain disorders (FAPDs) and functional defecation disorders (FDDs) are common in children and adolescents, but prevalence rates from the Caribbean are lacking. Therefore, our aim was to determine the prevalence of FAPDs and FDDs in adolescents in Curacao and to assess the influence of psychosocial factors on the prevalence of FAPDs and FDDs. METHODS: The prevalence of FAPDs and FDDs in children and adolescents living in Curacao, ages 11 to 18 years, was assessed using the Rome IV Questionnaire on Pediatric Gastrointestinal Disorders (RIV-QPGD). FAPDs and FDDs were diagnosed according to the Rome IV criteria. Sociodemographic characteristics, somatic symptoms, early adverse life events, stressful life events, and physical and emotional abuse were evaluated as associated factors. RESULTS: Out of 946 questionnaires distributed, 783 were included for further analysis. The mean age of adolescents was 14.7 years (±1.6) with 61.7% being girls. A total of 266 adolescents (34%, 95% confidence interval [CI] 30.7-37.5) met Rome IV criteria for at least 1 FAPD or FDD. Twenty-nine adolescents (3.7%) qualified for 2 functional gastrointestinal disorders. Functional constipation (18.6%) and irritable bowel syndrome (12.3%) were the most prevalent disorders. After multivariate logistic regression analyses, dizziness (odds ratio [OR] 1.84, 95% CI 1.28-2.64) was significantly associated with having a FAPD or FDD. CONCLUSIONS: FAPDs and FDDs are common in adolescents in Curacao. Dizziness is associated with the presence of a FAPD or FDD.
Epidemiology of functional abdominal pain disorders and functional defecation disorders in adolescents in Curacao. [Letter to the editor]
(Raven Press., 2020) Zeevenhooven, J.; van der Heijden, S.; Devanarayana, N.M.; Rajindrajith, S.; Benninga, M.A.
This is response to the article (J. Pediatr. Gastroenterol. Nutr. . 2020;70(4):e71-e76.) by same authors.
Functional abdominal pain in children and adolescents: association with impaired gastric motility
(Sri Lanka College of Paediatricians, 2009) Devanarayana, N.M.; Dharmawansa, R.; Rajindrajith, S.
INTRODUCTION: Chronic abdominal pain is a common paediatric problem affecting nearly 10% of school aged children. The majority of them have functional gastrointestinal diseases including functional abdominal pain (FAP). In them, the exact mechanism of pain remains unclear. Periumbilical pain, characteristic of this condition, appears to be of visceral origin, probably originating in the gastrointestinal tract. Gastrointestinal motility disturbances are reported in children with irritable bowel syndrome and functional dyspepsia, but are not properly studied in those with FAP. OBJECTIVES: To evaluate gastric emptying and antral motility in children and adolescents with FAP, DESIGN, SETTING AND METHOD: Sixty six children with FAP [24 (36.4%) males, 4-14 years, mean 8.2 years, SD 2.7 years] referred to the Gastroenterology Research Laboratory for gastric motility studies and 20 healthy children without evidence of gastrointestinal diseases [8 (40%) males, 4-15 years, mean 8.9 years, SD 2.7 years] were evaluated. FAP was diagnosed using Rome III criteria. None had clinical or laboratory evidence of organic diseases except for one control who was positive for Helicobacter pylori stool antigen test. All subjects underwent ultrasonographic assessment of liquid gastric emptying rate (GE) and antral motility, using a previously reported method. RESULTS: Average gastric emptying rate (42.7% vs. 66.2%), amplitude of antral contractions (60.6% vs. 89%), frequency of contractions per 3 minutes (8.5 vs. 9.3) and antral motility index (5.2 vs. 8.3) were significantly lower in patients with FAP compared to controls (p<0.01). Fasting antral area was higher in patients (1.2 vs. 0.6, p<0.01). The gastric emptying rate had a significant negative correlation with the scores obtained for severity of abdominal pain (r=-0.42, p<0.005). CONCLUSIONS: Gastric emptying rate and antral motility parameters are significantly impaired in patients with functional abdominal pain. Gastric emptying rate had negative correlation with the severity of abdominal pain.
Gastrointestinal disorders in children admitted to a tertiary care paediatric unit in Sri Lanka
(Wiley Blackwell Scientific Publications, 2008) Devanarayana, N.M.; Adikari, A.M.D.B.; Sanjeewa, P.A.B.; Rajindrajith, S.
OBJECTIVES : Gastrointestinal diseases, including diarrhoea and abdominal pain, are common presenting complains in children admitted to hospitals. In those with abdominal pain, non-specific abdominal pain is the commonest diagnosis at discharge. This study evaluated the gastrointestinal disorders in children admitted to a tertiary care general paediatric unit in Sri Lanka. METHODS: Records of all neonates, infants and children admitted to University paediatric unit in North Colombo Teaching Hospital, Ragama, Sri Lanka, during 12 month period from 01/10/2006 to 30/09/2007, were evaluated. Demographic information, details regarding the symptoms, exam nation findings, investigations, treatments and diagnosis at discharge were analysed retrospectively. RESULTS: Of the 5202 patients admitted during the study period, 167 (3.2%) had gastrointestinal disorders [90 (54.9%) were males, mean age 6.3 years, SD 2.5 years, range 2–13 years]. Common presenting complains were diarrhoea [79 (47.3%)], abdominal pain [62 (37.1%)], constipation [10 (6%)] and vomiting [8 (4.8%)]. Most common discharge diagnosis was acute gastroenteritis (AGE) [57 (45.5%)]. Of 62 children presented with abdominal pain, only 23 (36.1%) had exact diagnosis at the discharge (AGE 13, gastritis 3, constipation 4, gastro-oesophageal reflux 1, typhoid fever 1, functional abdominal pain 1). CONCLUSIONS: Diarrhoea and abdominal pain accounted for more than 80% of hospital admissions due to gastrointestinal disorders. Nearly two third of patients admitted due to abdominal pain had no diagnosis at discharge. Even though, Rome III criteria are widely available, only one patient was diagnosed as having functional gastrointestinal disorder.
Helicobacter pylori infection in children
(Medknow Publications, 2009) Rajindrajith, S.; Devanarayana, N.M.; de Silva, H.J.
Helicobacter pylori infection is a common problem in pediatric practice, and its acquisition is related with poor socioeconomic conditions. Although the organism is thought to be responsible for many diseases, only a handful of them have a direct causal relationship. At present, only a small number of children with well-defined clinical syndromes are benefited from testing and treatment. The treatment should include at least two antibiotics with a proton pump inhibitor.
Helicobacter pylori infection in children
(Sri Lanka College of Paediatricians, 2009) Rajindrajith, S.; Devanarayana, N.M.; de Silva, H.J.
No Abstract Available
Oro-caecal transit in Sri Lankan children and adolescents with functional recurrent abdominal pain
(Wiley Blackwell Scientific Publications, 2008) Devanarayana, N.M.; de Silva, D.G.H.; de Silva, H.J.
INTRODUCTION: Recurrent abdominal pain (RAP) is a common paediatric problem. The majority of the affected have no organic pathology. Gastrointestinal motility abnormalities are considered as a possible cause for their symptoms. This study evaluated oro-caecal transit in children and adolescents with functional RAP. METHODS: Thirty one children with functional RAP and 20 healthy children from the same geographical area underwent oro-caecal transit time measurement by lactulose (0.25 g/kg in 10% solution) breath hydrogen test. None had evidence of organic disease, except for one control who had a positive Helicobacter pylori stool antigen test. RESULTS: Oro-caecal transit times could be calculated in 30 patients [10 (33.3%) males, mean age 7.2 years, SD 2.4 years, 12 functional abdominal pain, 8 irritable bowel syndrome, 8 functional dyspepsia, 1 abdominal migraine, 1 non-specific abdominal pain according to Rome III criteria] and 19 controls [10 (52.6%) males, mean age 9 years, SD 2.7 years]. One patient (3%) and 1 control (5%) were non-responders. Oro-caecal transit time was significantly prolonged in patients (median 90 min, range 45–150 min) compared to controls (median 75 min, range 30–105 min) (p = 0.0045). Oro-caecal transit time did not correlate with scores obtained for severity of abdominal pain (r = 0.176, p = 0.354) and had no association with exposure to recent stressful life events (p > 0.05). CONCLUSIONS: Oro-caecal transit time was delayed in children and adolescents with functional RAP. The future studies are needed to confirm the role of delayed oro-caecal transit in generation of symptoms, and to evaluate the therapeutic value of drugs that normalize small intestinal transit.
Personality assessment in children with abdominal pain predominant functional gastrointestinal diseases
(Wiley Blackwell Scientific Publications, 2012) Ranasinghe, N.; Rajindrajith, S.; Devanarayana, N.M.; Warnakulasuriya, T.; Nishanthini, S.; Perera, M.S.
BACKGROUND AND AIMS: Chronic abdominal pain is a commonly associated with psychological problems. This study aimed to evaluate the personality traits in teenagers with abdominal pain predominant functional gastrointestinal diseases (AP-FGD). METHODS: Data regarding gastrointestinal symptoms, and personality assessment were collected from teenagers aged 13–18 years from 5 randomly selected schools in Ampare district of Sri Lanka. AP-FGD were diagnosed using Rome III criteria. Translated and validated personality assessment questionnaire (PAQ) was used to assess the total personality maladjustment score and personality domains; namely hostility and aggression, dependency, lack of self esteem, lack of self adequacy, emotional instability, emotional unresponsiveness, and negative world view. RESULTS AND DISCUSSION: A total of 1697 children were recruited [males 778 (45.9%), mean age 15.1 years and SD 1.66 years]. AP-FGD were seen in 202 (11.9%) teenagers. They were compared with 1051 normal children. When the cutoff value for Sri Lankan children (89) was used, 66.3% of with AP-FGD and 42.5% controls had PAQ scores within that of psychological maladjustment (p < 0.001). When the international normative value of 105 was used, these percentages were 27.2% and 11.2% respectively (p < 0.0001). Subgroup analysis revealed similar differences in all 4 subtypes of AP-FGD compared to controls (p < 0.05). Children with AP-FGD had significant higher mean scores for all personality domains compared to controls except for dependence (p < 0.05). Children with irritable bowel syndrome and abdominal migraine also showed similar results (p < 0.05). Apart from dependency and emotional instability children with functional dyspepsia were noted to have higher mean scores for all other personality domains (p < 0.05). In addition, children with functional abdominal pain had signifi cantly higher mean scores for all personality domains except dependency and negative world view (p < 0.05). CONCLUSIONS: Psychological maladjustment is significantly more common in all four subtypes of AP-FGD.