Abdominal Pain Associated with Eosinophilia

Overview

Gastrointestinal eosinophilia (GE) is an inflammatory condition that causes irritation

to the lining of the stomach and/or intestines. GE is not life-threatening and is
treatable with a variety of medications and other treatments.

The cause of GE is not known. In some patients, there may be a food allergy or a
reaction to a food or food additive. However, an elimination or hypoallergenic diet,
by itself, is not often effective in managing this condition. GE may also be triggered
(or worsened) by viral infections, seasonal and environmental allergies, and stress.

Once GE is activated, two types of white blood cells, mast cells and eosinophils,
begin releasing chemicals (such as histamine) that contribute to inflammation. This
inflammation results in a number of symptoms. The severity of symptoms varies
greatly from time-to-time and from person-to-person. Treatments are aimed at
decreasing the inflammation, decreasing the amount of chemicals released, and/or
blocking the effects of these chemicals once released.

Depending on the severity of the condition, children c an present with any of the
following GI problems:
 growth failure  black tarry stools
 weight loss  diarrhea
 anemia  constipation
 vomiting  abdominal pain

Other general symptoms which may be associated with the condition include:
 flushing  shortness of breath
 itching  chest pain
 dizziness  fatigue
 fainting

Headaches, lethargy and leg or arm pain can occur in about 60-70% of children with
GE and may or may not be related to the condition.

Diagnosis

Diagnosis of GE is confirmed with biopsies (pinhead-sized pieces of tissue removed

from the lining of the stomach and small intestines) which are taken during an EGD
(esophagogastroduodenoscopy) or colonoscopy. These biopsies are reviewed and
evaluated for an increased number of eosinophils.

It is our experience at Children’s Mercy Hospital & Clinics, that 60-70% of patients
do not have recurrences once symptoms are treated effectively. The remaining
patients typically have milder and shorter duration of recurrences following
treatment. Viral infection, seasonal and environmental allergies, and stress can
cause the symptoms to be worse or cause a recurrence of sympt oms.
Medications

Montelukast (Singulair) is a medication that lessens inflammation. This medication is

also used in the same way for the airway inflammation in asthma. It takes about
two weeks for this medication to have a significant effect on the GI symptoms.
Although it is uncommon to have side effects with this medication, there have been
reports of behavioral and mood changes. Please contact us if you notice these
changes in your child.

Ranitidine (Zantac) blocks the action of histamine on the stomach and greatly
decreases the amount of acid produced by the stomach. This medication can heal
ulcers, decrease irritation in the stomach lining and decrease abdominal pain. It is
uncommon to have any side effects with this medication.

Hydroxyzine (Atarax) is an antihistamine. Once histamine is released from mast

cells, this medication can keep the histamine from causing the previously listed
symptoms. The major side effect of this medication is exces sive sleepiness, which
often goes away after a few days.

Budesonide (Entocort) is a corticosteroid. It mainly works locally in the GI tract, like

putting hydrocortisone on a skin rash. We do not typically see the side effects found
with regular steroids, such as prednisone, when we give a short course of this
medication.

Cromolyn Sodium (Gastrocrom) is a medication which “coats” mast cells and keeps
them from releasing chemicals. It is effective and safe, but slow acting. It takes 2
to 3 weeks after starting on a dose before an improvement in symptoms may be
seen. Several adjustments may have to be made before the effective dose is
reached. It is given four times per day (30 minutes before meals and at bedtime).

More specific side effects for the medications above will be discussed with your
provider when the medications are initiated for treatment. If you have any questions
about side effects please feel free to call the clinic to discuss your concerns.

Non-Medication Treatments

Biofeedback-assisted relaxation training (BART) with a certified biofeedback

practitioner may be recommended to help children learn to reduce physical stress,
improve coping with mental stress, enhance pain management skills, improve sleep,
and reduce GI symptoms.

Cognitive-behavioral therapy (CBT) with a licensed psychologist may be

recommended to help children modify their thoughts and behaviors in response to
pain, anxiety, and/or stress.

Modification of the home and/or school environments often is recommended as part

of the treatment package to support improved coping, increased daily functioning,
and decreased GI symptoms.
For all children, we recommend:

Continuation or return to normal daily routine, including school, chores, and other
activities. These daily activities are important in keeping children connected with
their peers, maintaining a high level of distraction, minimizing focus on illness, and
reducing potential secondary gain issues. Further, absence from school can increase
academic demands. All of these issues further increase stress and make pain
episodes more likely to occur in the future.

Parent encouragement of positive coping with pain and/or stress. It is important for
parents to be aware of their own behavior when not feeling well and to make an
effort to model positive coping skills. Further, parents must be aware of how they
respond to a child’s illness. Parents can be most helpful to children when they can
stay calm, maintain consistent daily expectations, remind c hildren what pain
management strategies might be helpful, and then notice/reward children for trying
to engage in positive coping behavior.

Other Possible Treatment Recommendations:

 Promotion of sleep quality through consistent sleep routine/schedule and

good sleep hygiene.
 Sleep evaluation/study to examine and address more significant sleep
disturbance.
 Physical therapy and/or consultation with an exercise physiologist to aid in
return to normal activity level or sports participation.
 Therapeutic massage to reduce physical tension and stress.
 Psychoeducational testing to assess for possible unidentified learning
difficulties that may be creating stress at school.
 Individual therapy to address more broad emotional and/or behavioral issues.
 Family therapy to address significant stress within the home environment.
 Acupuncture (the placement of very small needles at specific pain points) to
reduce pain and nausea, as well as to promote healing.

Follow Up

During initial treatment, patients seen in the Abdominal Pain Clinic (APC) will be
scheduled for approximately monthly follow up visits with one of our highly-trained
advanced nurse practitioners under the ongoing direction of Dr. Friesen, Dr.
Colombo, and Dr. Schurman. Periodically throughout follow up, you also will have
contact with Dr. Amanda Deacy, a licensed psychologist, for ongoing support and
coaching.

Additional follow up will be provided, as needed, by our dedicated nursing staff

through phone contact at (816) 983-6975. Phone contact is usually requested on at
least a biweekly basis throughout treatment, until your child is doing well.

Once your child has been symptom-free for 2-3 months, we will begin to wean
medications. At that time, the frequency of follow up visits and phone calls to the
APC will decrease. However, your child should continue with other recommended
treatments (e.g., BART, CBT, etc.) as directed by those providers to ensure
maximum benefit in the short - and long-term.