Transcription:
Functional Abdominal Pain, IBS and Auricular Neurostimulation

Andrew Wilner, MD (Host): This is Pediatrics in Practice with Children's Mercy, Kansas City. I'm your host, Dr. Andrew Wilner. My guest today is Dr. Pang Krasaelap, a Pediatric Gastroenterologist in the section of Neuro-Gastroenterology and Motility at Children's Mercy, Kansas City. Welcome Dr. Krasaelap.

Pang Krasaelap, MD (Guest): Hi. Yeah. Thank you Dr. Wilner for the introduction. I'm very happy to be here today.

Host: Well, thanks for joining us. Our topics today are functional abdominal pain, irritable bowel disease, and auricular neurostimulation. I'm a Neurologist. And I can tell this is going to be a fascinating discussion. Dr. Krasaelap, let's begin with the typical characteristics of functional abdominal pain. Could you tell me about a recent patient, for example?

Dr. Krasaelap: Yeah. So first off, I really appreciate the opportunity for me to talk about this because functional abdominal pain is very common and we see this every day and I would say maybe about 10 to 15% of school, age children, they will report episodes of recurrent abdominal pain at some point. And we see this in clinic every day. The term functional, actually means that there is no blockage, there's no inflammation or any kind of infection causing the discomfort. But the pain and discomfort is real. And it's not that they're making it up. It's not that they're faking it. The pain can interrupt school and daily activities. And typically, even though they have a lot of pain and the pain is real, children with functional abdominal pain will continue to have normal growth and overall good health.

Host: So if there's no blockage, how do you make the diagnosis?

Dr. Krasaelap: Yeah. So, before we go into the diagnosis, the main feature of functional abdominal pain is usually stomach pain, right because we call it functional abdominal pain. Sometimes it can be a little bit difficult for kids to really describe what kind of pain they're having. Usually the pain is usually around the belly button. The pattern or location of the pain is not always predictable, but it can be the pain that occurs suddenly, the pain that slowly increases in severity, it can be constant or it can be kind of coming and going. Some children may experience something on top of abdominal pain. They may have bloody nausea vomiting, feeling of fullness after just a few bites, or they may have pain associated with bowel movements.

In terms of diagnosis, functional abdominal pain can be diagnosed in children who have abdominal pain for more than two months or longer. And they would have normal physical exam. And they would have no alarm findings. So, then you may ask, oh, what are alarm findings? Right. Alarm findings may include unintentional weight loss, or poor weight gain in kids. Fever, problem swallowing, painful swallowing, persistent vomiting or having to wake up at night to have a bowel movement, having blood in the bowel movement or having a family member of inflammatory bowel disease or celiac disease. Pretty much otherwise healthy children who repeatedly complain of stomach pain for two months or longer; actually what they have is something called functional abdominal pain.

Host: Now, with the proviso that they don't have any of the other things that you mentioned, what about lab work? Can you make this diagnosis without testing them for, you know, lactose intolerance and doing upper GI and lower GI and all kinds of scopes? Is this just a clinical diagnosis without any of those tests?

Dr. Krasaelap: Yes, totally. IBS is not the there's no, actually, no test to diagnose IBS. I would have to say that in the past, the IBS diagnosis was essentially a diagnosis of exclusion, meaning that the diagnosis of IBS would only be made on only after all the diagnostic testing, rule out other diseases that could possibly cause the symptoms. Those diagnostic testing were often extensive. They can be expensive. It can delay diagnosis and treatment of IBS itself. Until 1990s that a group of specialists from around the world developed something that's called the Rome criteria, which is a symptom based criteria to diagnose functional GI disorder and including IBS into that group. Now we have the Rome IV criteria, which was revised in 2016, and we know that IBS is a condition with very well-defined clinical features with specific diagnostic criteria. We can now make a diagnosis of IBS with more confidence and without unnecessary testing. And with this, the patient will actually get to diagnosis faster and get to that treatment faster as well.

Host: Well, you know, I'm a neurologist and we have a lot of functional neurologic disease, but I don't know of any criteria, like the Rome criteria that would allow me to make the diagnosis without an MRI and an EEG and a lot of testing just to make sure. So, it sounds like the understanding of functional abdominal pain is, has come a long way.

Dr. Krasaelap: Totally. Totally. Yes.

Host: Are there still common misconceptions about abdominal pain and IBS?

Dr. Krasaelap: That's very good question. Like, do we have a couple of hours for this topic?

Host: Sure.

Dr. Krasaelap: Probably not. Right, because there actually quite a lot of misconceptions going around. Um, let me maybe talk about a few major ones. The first misconception that we come across pretty often, is quote unquote "IBS is not a big deal". This can be hurtful and heartbreaking to hear for a lot of patients with severe IBS, right? We know that IBS symptoms can vary from person to person, can be mild to severe. While most people they tend to have mild symptoms they don't even seek care. But some patients, when they have severe IBS, the IBS symptoms can have a lot of impact in their life and they can create a lot of burden, can decrease quality of life, tremendously. IBS patients with bad diarrhea, sometimes they don't even want to leave their home unless we, they know that they have access to the bathroom. Some patients with constipation, they might have intense pain or bloating to the point that they don't want to get out bed or do any activity. Symptoms like this can lead to social isolation, can lead to depression or other mental health illnesses.

So IBS can be a big deal. On to misconception number two. Quote-unquote "IBS is a psychological disorder and IBS is something that's all in your head". We kind of know that IBS is a disorder and it is highly correlated with stress and anxiety. And by highly correlated, I mean the stress and anxiety can trigger IBS. And at the same time, IBS symptoms can also cause stress and anxiety in a lot of patients. When we are in stress, the sympathetic nervous system or the fight or flight response and the stress hormone get activated and all of these can increase hypersensitivity of the gut and change overall GI function. So, bottom line is IBS, stress and anxiety can go hand in hand, but by no mean, I'm not saying that IBS itself is a mental disorder or IBS is the psychological disorder. And IBS is not all in your head. That's the two main misconceptions that we have come across quite a lot.

Host: All right, but it's not yet clear to me what causes IBS. If it's not a cycle, psychological problem, and all the tests are normal and there's no diagnostic test, then what is it?

Dr. Krasaelap: Yeah. So before we get into what actually causing IBS, I think we need to, to learn about brain gut connection. So, Dr. Wilner, let me ask you this, because you are a neurologist, right? How many brains do we have?

Host: Well, I focus on the big one on the top of the body primarily.

Dr. Krasaelap: Yes that's how we believe. Right. But I would say that it's a little bit different in GI world because in GI world, we believe that we have two brains, the brain, and the gut brain. So, the gut brain, or what we call the enteric nervous system, actually contains the largest collection of nerve cells outside of the brain. So, that's why we often talk about oh gut feeling, or we're told to trust our gut when making decision or even try to describe emotions in a gut related term, like, oh I have butterfly stomach or, oh, I just had a gut wrenching experience because the brain gut connection is real and it's not just metaphorical.

Right. There is a real connection there. And I would have to say that the brain and the gut, are like best friends. They talk to each other all the time. They're texting each other. They keep each other in check and they help making sure that things are going well. On the other end, they don't really have Snapchat they don't really have Tik Tok to really get connected, but they actually send signals back and forth through a complex network using hormone system, using immune system and the autonomic nervous system.

And the primary communication is the autonomic nervous system that controls heart rate, controls breathing and digestion. And one of the biggest nerves connecting the gut and the brain is the vagus nerve. The vagus nerve, as we know, is the very long courier nerve that carries a signal between the brain and the gut.

It sends signals from the brain to the gut to control movement of the gut, to what we call peristalsis, controls secretion in the gut, controls certain substances to help GI function and also control blood flow to the gut. And at the same time, the vagus nerve relays important messages from the gut back to the brain and the main messenger involved in this process is serotonin. Serotonin has, it's really cool. It has an important role, not just controlling the gut function, but it's also health regulating our mood as well. And it's very interesting that 90% of body serotonin is produced in the gut and to be more specific, serotonin is produced mainly by our little friendly bacteria in the gut.

So that's why some people, instead of calling the brain gut axis, they started using the term, the brain gut microbiome axis. So now then, so what happened like what's causing IBS and what happened when the axis is dysregulated. Right. So any problem along the brain gut axis or the brain gut microbiome axis, any problems along this axis can cause or trigger symptoms of IBS, such as early live events, stress, anxiety, inflammation, infection, antibiotic use, or combination of the above can also contribute to dysregulation of the brain gut microbiome axis.

Gut hypersensitivity or abnormal movement, abnormal communication of the brain and the gut are responsible for pain or discomfort in IBS. Gut motility, or the movement of the gut will also be affected. But as we know, two little movement of the gut will cause constipation, right? And the other way around too much movement of the gut will cause diarrhea. At the same time, mood can also be affected in IBS patients because as we know the brain and the gut best friends and they are just so connected.

Host: Wow. Thank you for that elucidation. Well, I'm going to treat my gut with a lot more respect now.

Dr. Krasaelap: Totally because the gut is part of your brain, right? So you are a neurologist. So please take the gut as part of your brain.

Host: There we go. Yeah. It's very important. I see that. So what do we do about it? We've got this IBS. How do we treat the brain? Do we treat the stomach? How do we treat it?

Dr. Krasaelap: Yeah. How about both at the same time? Right. But before we go into treatment options, I really like to emphasize the importance of patient doctor relationship. When it comes to treating functional GI disorder, if I feel like communication is the key and we should provide a clear explanation of the disorder and the brain gut axis, the thing that we mentioned before, and also discuss any concerns that they may have.

I feel like the family and patient, they need to know that their complaints and concerns are heard and they are being taken seriously. We, when it comes to pain we need yo acknowledge that the pain is real and it can affect a lot of their lives. And on top of that, I feel like we need to frame the disease in terms of it being a positive diagnosis, rather than a diagnosis of exclusion, I feel all of these would help patient and family to have a clear picture and a better understanding of what they're going through.

Yeah. In terms of treatment, I feel like working as a team will help a long way. They need to be aware that symptoms are often chronic and there will be some good days. There will be some bad days, so don't lose hope yet. And when we try to improve symptoms, they need to know that the treatment itself may not relieve symptoms completely.

And there is no one size fits all when it comes to IBS treatment and we need to kind of work together. Usually, when I have IBS patients, I tend to start with trying to identify the trigger. For some patients, the trigger might be a specific food like spicy food, fatty food, or gas producing food or food that is high in fermentable carbohydrates, or what we call FODMAPs.

In this case, a time limited trial of diet elimination can be considered on a case by case basis. And most of the time we may need help from the dietician. Another common trigger is stress and anxiety that we talked before. Behavioral therapy, such as gut directed, cognitive behavioral therapy, or gut directed hypnotherapy are the main psychological therapies with a lot of evidence proven to be very helpful for a lot of patients with IBS.

So then what else? Probiotics or water soluble fiber can be helpful in a lot of patients. For patients with IBS diarrhea, usually use anti-diarrheal agent like loperimide. Some patients with constipation, they would need laxatives and there are some newer medications that act directly at the specific receptor at the gut level, help modulate the bowel activity and also help with gut hypersensitivity. They are promising, but none of them are approved to be used routinely in kids yet. In terms of pain, we usually use antispasmodics or peppermint as a first-line for treatment of abdominal pain. So, in patients more symptoms like moderate or severe IBS, we often consider using central neuro modulators like anti-depression, anti-anxiety or auricular neurostimulation, which can help the brain gut axis that we mentioned earlier, can help target nerve hypersensitivity in the gut and help modulate gut function and can help anxiety and depression, which are often associated with IBS.

Host: Auricular neurostimulation, auricular neurostimulation. So tell me about that. That sounds a little unusual.

Dr. Krasaelap: Yeah. So, I mentioned it briefly, but thank you for bringing it up. Auricular neurostimulation is a novel and pretty exciting therapy and it just got approved by the FDA in 2017 to be used in adolescents with IBS. The device is placed around the ear, it is kind of look like the hearing aid is generating a low voltage electrical nerve field stimulation around the ear.

And as we know that there are a lot of cranial nerve endings around the ear area, including the vagus nerve. As we mentioned earlier, the vagus nerve is the main nerve communicating between the brain and it gut, right. So this device opposed to go into the cranial nerve endings and modulating the nerve signals from that area. So the device will be placed at the clinic weekly. The patient keeps it on at home for five days and take it off for two days. And the course of treatment depends on clinical response, but at least four weeks.

Host: Well, that's fascinating. I know there is a device called the vagus nerve stimulator that stimulates the vagus nerve directly. And that's used for a very severe depression and also for epilepsy. I'm an Epileptologist. And I'm familiar with the device. Has that been explored as well for this to stimulate the vagus

Dr. Krasaelap: nerve?

Yeah. So from what I heard, the vagus nerve stimulation is a little bit more invasive, right?

Host: Yes.

Dr. Krasaelap: You need to place inside, but this auricular neurostimulation is working pretty much the same way, but you don't have to really cut open or it just placed around the ear and you don't need any surgery. You don't need it's not going to be invasive for the patient.

Host: Yeah. Well, that's a huge advantage. Well, Dr. Krasaelap to wrap up, what would you want other pediatricians to take away from this podcast?

Dr. Krasaelap: So, what I will say when it comes to functional abdominal pain or IBS, I would say that it's not a diagnosis of exclusion anymore. We can use the ROME IV criteria to help guide a diagnosis. Management of this condition is not, the goal is not complete elimination of pain, it's more like a rehab approach with the goal of the children being able to return to normal function.

There is no one size fits all. We need to work as a team with family and patient and tailor treatment to the specific needs of the patient. Most cases can be managed in the primary care setting with a long-term close follow-up, but if children starting to develop alarm findings or abnormal physical exam, they may require referral to pediatric gastroenterologist for further evaluation and management.

Host: Dr. Krasaelap, I want to thank you for enlightening us about IBS and your fascinating work at Children's Mercy, Kansas City.

Dr. Krasaelap: Thank you so much.

Host: To refer your patient or for more information, please visit children'smercy.org to get connected with one of our providers. I'm Dr. Andrew Wilner, and this has been Pediatrics in Practice with Children's Mercy, Kansas City. Please remember to subscribe, rate and review this podcast and all the other Children's Mercy podcasts. Thanks for listening.