Dyspepsia in Children

Dr. Setia Budi Salekede, Sp. A(K)

 CASE
• A 12 years-old boy presents with a
history of abdominal discomfort of 11
month’s duration.
• The discomfort pain is located in the
right, left, and mid-upper abdomen.
• There is no association of the pain with
activity, position, meals or food type, nor
any with bowel movement
 CASE (cont)
• The abdominal discomfort occurred
more commonly in the morning.
• The pain may last as long as 4 hours.
• He often experiences nausea when he
has the pain and vomits at least once a
week.
• Bowel movement occur once a day and
are not related to pain
 Definition
• Dyspepsia refers to pain or discomfort
centered in the upper abdomen.
• The symptom characteristics of
dyspepsia in children are pain and
discomfort in the upper middle
region of the abdomen.
• Individuals often describe the pain as
occuring around eating, after eating,
or at night.
• the discomfort can be a sensation of
fullness after melas, an early feeling
of having had enough to eat (satiety),
bloating, belching, nausea, retching,
vomiting, regurgitation, anorexia, or
food refusal.
 12
Number of Dyspepsia
10

6 TOTAL
POSITIVE
4

0
PAIN FULLNESS MIXED
TYPE OF DYSPEPSIA

Figure 4. Number of dyspeptic patients with positive result for

SIBO in relation to the dyspepsia type
• Each of these symptoms can be due to
either an organic disease or functional
gastrointestinal disease.
BIOLOGIC PSYCHOLOGIC
FATORS FACTORS

FUNCTIONAL
DYSPEPSIA

SOCIAL
FACTORS
 ORGANIC
• Young age (less than 5 years of age)
• Fever, weight loss, or slowing of growth
• Bile-stained or blood-stained vomitus
• Pain that awakens the child from sleep
• Referred pain to the back, shoulders or
arms
• Pain with urinating
• Blood in the urine
• Side ache (flank pain)
• Inflammation or tears in the anal area
(perianal disease)
• Bloon in the stool
• Abnormal screening laboratory tests
• A family history of inflammatory bowel
disease or peptic ulcer disease
• The list of causes that must be ruled out
before a diagnosis of functional
dyspepsia is made is lengthy and
includes upper gastrointestinal
inflammation; motility disorder;
pancreatic, biliary or urinary disease;
and psychiatric disease
 TYPE OF DYSPEPSIA

PAIN
FULLNESS
MIXED

FIGURE 3. Percentage of the dyspepsia type in relation to the total

of dyspeptic patients
• Previously, functional dyspepsia
was not rigorously defined in
children
• Therefore, the adult criteria
developed in Rome in september
1997 were adopted for children.
• Beginning with the Rome II
consensus meeting in 2000,
functional dyspepsia in children
received its own distinct diagnostic
criteria, which was further modfied
into its current form by the Rome
III consensus in 2006
 DEFINITION
• 1) Persistent or recurrent pain or
discomfort centered in the upper
abdomen,
• 2) No evidence that the
dyspepsia is exclusively relieved
by defecation or associated with
the onset of a change in stool
frequency or stool form
• 3) No evidence that organic
disease is likely to explain the
symptoms.
• The pain or discomfort in the upper
abdomen has to be present at
least once per week for at least
two months prior to diagnosis
• Functional dyspepsia is divided into three
subgroups depending upon the predominant
symptom(s).
• In ulcer-like dyspepsia, the predominant
symptom is pain centered in the upper
abdomen;
• the pain is often relieved by food or
antacid therapy and may wake the child
from sleep
• Dysmotility-like dyspepsia is distinguished
by an unpleasant or troublesome but non-
painful sensation or discomfort centered
in the upper abdomen as the
predominant symptom.
• this sensation may be characterized by or
associated with upper abdominal
fullness, early satiety, bloating or nausea
• Non-specific dyspepsia occurs in
individuals with symptoms that do
not fulfill criteria for either ulcer-like
or dysmotility-like dyspepsia.
 Causes
• There are limited data on the cause and
development of dyspepsia in children, and the
results are similar to those found in adults.
• A motility disorder has been suspected by
some based on studies that show evidence for
irregular gastric electrical rhythm and
delayed emptying of the stomach and
duodenum, or abnormal motility as evidenced
by backwards movement of the stomach and
duodenum.
• A study by Hyman et al.,
demonstrated some of these
abnormalities in 39 of 44 children
and adolescents with functional
upper gastrointestinal symptoms.
• A study by Pineiro Carrero et al.,
also demonstrated that patients
with functional abdominal pain
have more abnormal electrical
activity in the stomach with slow
movement of stomach contents
as compared to healthy controls
• Whether these irregularities cause
dyspeptic symptoms is not clear, but a
slowly emptying stomach, or a backward
flow of food from the duodenum to the
stomach, may be important.
• In addition, these patients also that were
associated with abdominal pain had high-
pressure duodenal contractions during
the study period.
 DIAGNOSIS
• As with many other conditions, a
thorough and detailed history taken by
a physician is the most important
component of the assessment and
often leads to the correct diagnosis.
• The history needs to include dietary,
psychological, and social factors.
• A history may disclose a relationship
between symptoms and food,
activity, or stressors.
• It is often helpful to have the child and
parents maintain a symptom diary
detailing the time, location, intensity
and character of the pain or
discomfort, time and content of the
meals, daily activities, and stool
pattern.
 Diagnostic Tests
• Endoscopy is an examination of the lining of the
esophagus, stomach, and upper part of the small
intestine using a thing flexible tube (endoscope)
with a small video camera on the tip of the scope.
• Ultrasonography is a diagnostic method that
uses sound waves to create representative
images.
• Gastroduodenal manometry is a test that
measures pressure changes that occur within the
stomach and upper intestine.
• Considerable diversity of opinion remains
among physicians regarding the extent of
diagnostic tests to perform in a child who seems
to have a symptom constellation pointing
towards a functional cause of the dyspepsia.
• The diagnostic procedure needs to be
individualized, according to the information
obtained during the history taking and the
physical examination.
• Urine evaluation and blood evaluation to
screen for organic disease are usually
necessary.
• Endoscopy allows the discovery of the
ulcerations or significant inflammation in the
upper gastrointestinal tract.
• If the endoscopy is normal, then it may be
helpful to monitor for acid reflux (back flow
of stomach contents into the esophagus).
• Abdominal ultrasonography does not
appear to be helpful in children
• Upper gastrointestinal x-rays with small
bowel follow-through are useful to exclude
physical causes such as malrotation
[incorrect position of the intestine in the
abdomen], terminal ileitis [Crohn’s
Disease], and other obstructive or
inflammatory lesions.
• Gastroduodenal manometry is a feasible
and useful diagnostic tool in the clinical
investigation of children when symptoms
suggest altered upper gut function
and may provide a basis for a treatment
approach with drugs acting on motility
of the stomach and the small bowel.
 TREATMENT
• The management of dyspepsia
revolves around an organic or
functional cause.
• If an organic cause is found, the
treatment can be specific to the
underlying cause.
• For functional dyspepsia, the aim is
to provide symptomatic relief.
• Reduction or avoidance of spicy,
fatty, or caffeine-containing food
or drink may help if associated
with symptom onset.
• Medications such as
• Prokinetic agents (Domperidone, Metoclopramide,
cisapride) increase gastrointestinal motility],
• H2-blockers [reduce amount of acid produced
in the stomach], and
• Proton pump inhibitor [limit amount of acid
produced], and
• Low dose tricyclic antidepressants [to help reduce
pain] have been used with some success
• It is now clear that ulcer-like
dyspepsia has its basis in altered
gastrointestinal motility and may
respond to propulsive agents to
help control movement
• H2-blocker (Ranitidin) and
prokinetic agents (Domperidone)
are used in children when
continued dyspeptic symptoms
interfere with normal daily
activities and school.
• There remains a proportion of children
who may have behavioral or
psychological base to their complaint.
• For them, treatment that involves
environmental modification, relaxation
techniques, psychotherapy, stress
reduction, hypnotherapy, or biofeedback
have been used with variable success.
• The comparative study of the effectiveness of cimetidine, ranitidine, famotidine, and
omeprazole in treatment of children with dyspepsia.
• Dehghani SM, Imanieh MH, Oboodi R, Haghighat M.
• Abstract
• Background. Functional dyspepsia is a common chronic disorder with non specific upper
abdominal pain or discomfort. Different approaches with anti-secretory, spasmolytic, prokinetic
and anti-inflammatory effects and most preferably reduction of visceral hypersensitivity seem
logical. In this study, we compared the effectiveness of the four most drugs used for treatment of
dyspepsia in children. Methods. 169 patients between 2 to 16 years old that 47.3% was male and
52.7% was female were enrolled in this clinical trial study by the diagnosis of functional
dyspepsia. Then for each patient one of the drugs; Omeprazole, Famotidine, Ranitidine or
Cimetidine was administered, for a period of 4 weeks. Patients were followed after 2 and 6 weeks
from the beginning of the treatment. Results. The distribution of drugs between these patients
were including; 21.9% with Cimetidine, 21.3% with Famotidine, 30.8% with Omeperazole and
26% with Ranitidine that the proportion of patients with all symptoms relief were: 21.6% for
Cimetidine, 44.4% for Famotidine, 53.8% for Omeprazole and 43.2% for Cimetidine (P = .024). In
followups within 2 and 6 weeks after beginning medical therapy, no side effects due to drugs
were seen. Conclusion. If a cure is defined as all symptoms relief after a period of 4 weeks
treatment, our findings showed that Omeperazole are superior to Ranitidine, Famotidine, and
Cimetidine for management of functional dyspepsia.
• ISRN Pediatr. 2011;2011:219287.
• Treatment of non-ulcer dyspepsia: a meta-analysis of placebo-controlled prospective studies.
• Allescher HD, Böckenhoff A, Knapp G, Wienbeck M, Hartung J
• II. Medizinische Klinik und Poliklinik, Technischen Universität München, Germany.
• Scandinavian Journal of Gastroenterology (impact factor : 2.02). 10/2001; 36(9):934-41. source :
PubMed
• Abstract
• Dyspeptic symptoms are commonly reported complaints in clinical practice and are mostly the result of
functional disorders. Empirical treatment with histamine H2-receptor blockers or gastroprokinetics for 2-
4 weeks has frequently been proposed as first line management of these patients. The clinical trials
which support the use of these agents, show a high variation in clinical success rate and benefit of
these treatments.
METHODS:
The available clinical trials were evaluated, pooled where appropriate and subjected to a meta-analysis
with the principal goal to provide valid treatment recommendations for patients with non-ulcer
dyspepsia. In the present meta-analysis 19 studies on gastroprokinetics (cisapride, domperidone) and
10 studies on histamine H2-receptor antagonists (cimetidine, ranitidine) were included.
RESULTS:
Based on these studies, a total of 1540 patients were evaluated for histamine H2-receptor antagonists
(verum n = 786, placebo n = 754) and 1235 patients for gastroprokinetics (verum n = 616, placebo n =
619). The probability for treatment success compared to placebo was 0.2026 (0.1261; 0.2791)
for histamine H2-receptor antagonists and 0.4029 (0.3042; 0.5069) for gastroprokinetics.
 Effect of domperidone therapy on nocturnal dyspeptic symptoms of functional
dyspepsia patients
Chen SL, Ji JR, Xu P, Cao ZJ, Mo JZ, Fang JY, Xiao SD
• Abstract
• AIM:
• To investigate the incidence of nocturnal dyspeptic symptoms in patients with functional dyspepsia (FD) and whether prokinetic drugs
can alleviate them.
• METHODS:
• Eighty-five consecutive Chinese patients with FD were included in this study. One week after single-blinded placebo run-in treatment,
baseline nocturnal intragastric pH, bile reflux and nocturnal dyspeptic symptoms of eligible patients, including epigastric pain or
discomfort, abdominal distention and belching, were investigated with questionnaires. Patients exhibiting nocturnal dyspeptic
symptoms were randomly and double-blindly assigned to domperidone group or placebo group. Nocturnal intragastric pH and
percentage of duodenogastric bile reflux time were determined after treatment.
• RESULTS:
• Of the 85 FD patients, 2 females without nocturnal symptoms, who responded to placebo run-in treatment, were excluded from the
study, 30 (36.1%) exhibited nocturnal dyspeptic symptoms with increased duodenogastric bile reflux time (intragastric bilirubin
absorbance > 0.14) and mean gastric pH (confirming the existence of bile reflux) (P = 0.021, 0.023) at night were included in the
study. Of these 30 patients, 21 (70%) had overt nocturnal duodenogastric bile reflux, which was significantly higher than that of those
without nocturnal symptoms (P = 0.026). The 30 patients were allocated to domperidone group or placebo group (n = 15). The
nocturnal duodenogastric bile reflux and gastric pH were significantly decreased after domperidone treatment (P = 0.015,
0.021). The severity score of nocturnal dyspeptic symptoms was also significantly decreased after domperidone treatment
(P = 0.010, 0.015, 0.026), which was positively correlated with the reduced nocturnal bile reflux or gastric pH (r = 0.736, 0.784,
0.753 or r = 0.679, 0.715, 0.697, P = 0.039, 0.036, 0.037 or P = 0.043, 0.039, 0.040).
• CONCLUSION:
• A subgroup of Chinese FD patients show overt nocturnal dyspeptic symptoms, which may be correlated with the excessive
nocturnal duodenogastric bile reflux. Domperidone therapy can alleviate these symptoms.

World J Gastroenterol. 2010 Feb 7;16(5):613-7.

 Domperidone is more effective than cisapride in children
with diabetic gastroparesis
Franzese A, Borrelli O, Corrado G, Rea P, Di Nardo G, Grandinetti AL, Dito L, Cucchiara
S.
• BACKGROUND:
• Disorders of gastrointestinal motility are commonly detected in patients with insulin-dependent diabetes mellitus and are
associated with significant morbidity. They contribute to poor metabolic control of diabetes.
• AIM:
• To assess the effect of an 8-week course of domperidone or cisapride on gastric electrical activity, gastric emptying time and
dyspeptic symptoms in children with insulin-dependent diabetes mellitus and gastroparesis.
• METHODS:
• Dyspeptic symptoms were assessed by a score system, gastric emptying time was measured by ultrasonography and
gastric electrical activity was obtained by electrogastrography. Fourteen children received domperidone and 14 received
cisapride. The median (range) ages were 11.6 years (5-15 years) and 12 years (6-16.9 years), respectively. Symptom
assessment, ultrasonography and electrogastrography were repeated at the end of the trial. Fasting and fed (180 min after
feeding) glycaemia and haemoglobin A, C (HbA1c) levels were also measured.
• RESULTS:
• At the end of the trial both groups showed a significant decrease in symptomatic score; however, the score was markedly
lower in the domperidone group than in the cisapride group (P < 0.01). Domperidone was significantly more effective than
cisapride in reducing the gastric emptying time (P < 0.05), normalizing gastric electrical activity (P < 0.05) and decreasing
the prevalence of episodes of gastric dysrhythmia (P < 0.01). Domperidone was also more effective than cisapride in
improving diabetic metabolic control. No potentially drug-related adverse effects occurred.
• CONCLUSIONS:
• In children with insulin-dependent diabetes mellitus complicated by dyspeptic symptoms and gastroparesis,
domperidone is superior to cisapride in reversing gastric emptying delay and gastric electrical abnormalities, as
well as in improving dyspeptic symptoms and diabetic metabolic control.
 Conclusion
• Dyspepsia in children is high proporsion
• Diagnosis is not easy
• It is much disturbed for children
• The causes is various from psychologic
to organic
• Ranitidin and Domperidone has an
important role to solve problem
dyspepsia in children