Irritablebowel synd rome can occur as early as childhood. The diagnosis and treatment of this condition often causes problems for paediatricians and GPs. The author of this paper summarises the practical principles of managing a child suspected of having irritable bowel syndrome. The first part of the study discusses the typical clinical features of the disease and the principles of differential diagnosis.
Irritable bowel syndrome - introduction
Chronic and recurrent abdominal pain is an increasingly common problem in medical practice. In recent years, there has been an increase in the frequency of these disorders and their occurrence in smaller and smaller children. Analysing the results of detailed examinations carried out in children hospitalised for chronic abdominal pain, it can be hypothesised that in the majority of them abdominal pain is not caused by any serious organic disease.
In modern paediatric practice, the main cause of chronic gastrointestinal complaints is psychosomatic (stress) disorders. Such a condition, called functional abdominal pain, is sometimes classified as a disease of civilisation, as it is clearly associated with a 'western' lifestyle and diet, as well as the ubiquitous stress and family dysfunction that are increasingly common in modern society. Knowledge of the principles of diagnosis and treatment of conditions in this group therefore seems essential for every paediatrician and GP.
Irritable bowel syndrome - definition, description
Patients with abdominal pain unrelated to a serious organic disease generally meet the criteria for the diagnosis of one of two main disease entities: irritable bowel syndrome and functional dyspepsia. Much rarer are, also listed in the functional disease classification, abdominal migraine and aerophagia. This paper will discuss the most common form of functional abdominal pain - irritable bowel syndrome. The diagnosis of irritable bowel syndrome (IBS) can be made in a child:
- of an age that allows a reliable assessment of complaints (usually more than 5 years)
- whose existence of a variety of serious organic conditions that may cause abdominal pain has been at least provisionally excluded
- suffering from chronic or recurrent pain or discomfort located in the abdominal cavity, characterised by at least two of the following three features
- 1. The onset of the complaint is associated with a change in the frequency of bowel movements
- 2. The onset is associated with a change in stool consistency
- 3. Discomfort disappears immediately after defecation
photo panthermedia
Irritable bowel syndrome - clinical picture
The typical clinical picture of IBS is paroxysmal pain, often colicky, lasting from several minutes to a few hours, occurring only during the day, in a child with normal physical development, usually aged over nine years. Between attacks the child feels well. The pain in IBS is usually located in the mid-abdomen and left iliac fossa, accompanied by a tendency to constipation or diarrhoea (vide definition: change in frequency and/or consistency of stools), relief after a bowel movement and the presence of significant amounts of mucus in the stools are typical.
In many patients, periods of constipation and diarrhoea alternate with each other, and an exacerbation of defecation disorders under stress is evident. "Classic" descriptions of adult IBS patients additionally reported symptoms such as weakness, headaches, tachycardia and palpitations, frequent urination with a feeling of incomplete bladder emptying, dry mouth, and pruritic skin. These symptoms are rare in younger children, but may occur in adolescents. Most patients are girls.
They are often hyperactive, or hypersensitive, introverted children, sometimes with a perfectionist nature. Psychological examination may reveal latent family conflicts, traumatisation, anxiety reactions. The intelligence quotient is in the vast majority of cases normal or even above normal.
Depending on which symptoms predominate, three subtypes of IBS are traditionally distinguished:
- Type with predominant diarrhoea
- Type with predominance of constipation
- Type with predominance of bloating and abdominal discomfort
With the typical clinical picture, the diagnosis of IBS is almost certain and, in many cases, there is no need to perform many specialised investigations, although it should be remembered that, according to the current definition, the diagnosis of IBS is a diagnosis by exclusion, i.e. the coexistence of various serious organic diseases should be at least provisionally excluded. Differential diagnosis does not always mean performing laboratory or imaging tests. Often, a well-gathered, well-targeted history and a careful physical examination are just as useful.
