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.
Differentiating
Many organic diseases can give similar symptoms to IBS. The main diseases that the physician should consider in the differential diagnosis of chronic abdominal pain combined with defecation disorders include:
- Inflammatory bowel disease-IBD: Crohn's disease,colitis ulcerosa)
These are diseases that, like IBS, occur with increasing frequency in our country (this is especially true of Crohn's disease!). They can run an insidious course, mimicking IBS. The suspicion of Crohn 's disease or colitis ul cerosa should be aroused by a finding in a child:
- abnormal somatic development (stunted growth and/or weight gain),
- extra-intestinal symptoms (joint pain, iritis, aphthous mouth, skin lesions),
- anaemia,
- elevated ESR and CRP,
- reduced serum iron concentration,
- blood in stools.
The conclusive test in these situations is colonoscopy. There are serological markers considered to be quite specific for IBD: ANCAs (anti-neutrophil cytoplasmic antibodies ) and ASCAs (against Saccharomyces cerevisiae antigens), but these are only performed as screening tests and cannot replace endoscopic examination with section collection.
- Inflammation or ulceration in the Meckel's diverticulum
It can mimic colitis ulcerosa in its course, causing significant anaemia and stools with an admixture of blood. The history is usually more alarming than in a typical IBS patient. The test usually performed to reveal the presence of a Meckel's diverticulum is abdominal scintigraphy using a radio-luminescent tracer captured by gastric cup cells. The Meckel's diverticulum contains the gastric utricle, hence the scintigrams reveal a second, small tracer uptake point located below the stomach. Unfortunately, the sensitivity of scintigraphy is estimated to be only 60-70% (possibility of false-negative results). In such cases, an exploratory laparoscopy or laparotomy is conclusive.
- Coeliac disease
Genetically determined, persistent gluten intolerance can present with very non-specific and sparse symptoms. Diagnosis in adolescents and even adults is increasingly common. English studies have shown that around 4% of patients initially diagnosed with IBS actually have coeliac disease. The non-specific abdominal symptoms (discomfort, tendency to diarrhoea, bloating) are in such cases the result of villous atrophy of the small intestine.
Celiac disease should be suspected especially in patients with low growth rates, low haemoglobin and iron levels, a tendency to diarrhoea and a family history of autoimmune diseases. Patients with coeliac disease may have coexisting IgA deficiency and chronic skin lesions (Duhring's disease).
Thediagnosis of co eliac disease requires serological tests (anti-endomysial antibodies- EMA, anti-reticulin antibodies- ACR, against tissue transglutaminase- tTG). Positive serological tests must be verified by small bowel biopsy (endoscopically or Crosby capsule). Attention: A cardinal mistake is the "trial" inclusion of a gluten-free diet without performing the above tests. Such a procedure delays the correct diagnosis of coeliac disease and exposes the child to the necessity of three intestinal biopsies, instead of one, conclusive for the diagnosis.
photo: panthermedia
- Hypolactasia/lactose intolerance
Symptoms similar to IBS (bloating, abdominal pain, diarrhoea) occur in children over the age of five who, due to genetic predisposition, have a decrease in the activity of lactase, an enzyme belonging to the enterocyte toothbrush disaccharidases that digest lactose, the primary sugar of milk. The diagnosis of this condition is aided by a history that reveals an increase in complaints after dairy foods. The test that confirms the diagnosis is the hydrogen breath test, i.e. the measurement of the hydrogen concentration in the exhaled air after a test dose of lactose (usually 50 g). Evidence of hypolactasia is a hydrogen concentration of more than 20 ppm 2 hours after lactose administration.
- In addition, the possible existence of the following diseases in the child should be taken into account:
- cystic fibrosis
- food allergies
- acute and chronic pancreatitis
- acute and chronic hepatitis
- cholelithiasis
- kidney stones
Tumours:
- gastrointestinal tract (B-cell lymphoma, VIP-oma),
- ovaries,
- kidney (Wilms tumour),
- neuroblastoma,
- hepatoblastoma.
If the presence of one of these diseases is significantly suspected in a patient, specialised investigations are required. Endoscopic ex aminations (gastroscopy, rectoscopy, colonoscopy) with histopathological evaluation of specimens and imaging examinations (X-ray of the gastrointestinal tract with contrast, Medical US, CT, MR) play a special role here. Some diseases can be detected by specific diagnostic tests, such as the sweat test and genetic tests for cystic fibrosis or alpha-fetoprotein levels for hepatoblastoma.
In most cases, however, children with IBS do not demonstrate any alarming alarm symptoms, suggesting the existence of organic disease. In such situations, the inclusion of a trial of empirical treatment is warranted. There is a very wide choice of pharmacological preparations with different mechanisms of action. The optimal approach in a child with IBS seems to be to try 'targeted treatment', i.e. tailoring the first-line therapy to the most likely pathogenetic mechanism associated with the patient's complaints. This, of course, requires knowledge of the possible aetiopathogenesis of the condition and knowledge of the entire spectrum of therapeutic preparations. Information on this topic will be included in Part 2 of the study.
