Who to See If Your Child’s GI Symptoms Won’t Go Away

If your child has chronic nausea, abdominal pain or constipation, they may have a disorder of gut-brain interaction (DGBI) or a gastrointestinal (GI) motility disorder. DGBI and motility disorders are different types of conditions, but they share many of the same symptoms, which can make them difficult to diagnose and treat. Arkansas Children's established a neurogastroenterology and motility (NGM) program that provides personalized therapies and specialized testing for these challenging health issues. 

John Rosen, M.D., a pediatric gastroenterologist specializing in DGBI, directs the Arkansas Children’s NGM program and is a professor of pediatric gastroenterology at the University of Arkansas for Medical Sciences. He understands the frustrations and challenges associated with these GI conditions. 

"There are so many kids who've tried the regular laxatives, the toilet-sitting, all the important things that work in most situations, but they're still pooping their pants, and they can't go to school. It's a burden for them and their families," Dr. Rosen says. 

DGBI  

Our brain and gut constantly communicate about activities like swallowing, digesting, burping and bowel movements. Sometimes, temporary issues, like food poisoning or the norovirus, trigger a breakdown in that communication, leading to vomiting, diarrhea or other symptoms. In other cases, chronic conditions lead to ongoing disruptions of the communication between the gut and brain, causing recurring symptoms like belly pain or constipation. These conditions, or DGBI, can be difficult to diagnose because the digestive tract appears normal on imaging scans or during an endoscopy. Common examples of DGBI include irritable bowel syndrome (IBS), functional constipation and reflux hypersensitivity. Cyclical vomiting syndrome is an example of a rare DGBI, which specialists at Arkansas Children's also treat. Stress or anxiety often amplifies DGBI symptoms, which is one reason for personalized treatments coordinated by a team of pediatric specialists. 

  

DGBI Management 

Disorders of gut-brain interaction are often the result of the interplay between physiological, psychological and environmental factors; therefore, effective therapies include: 

• Addressing sources of stress and anxiety with relaxation training, mindfulness, cognitive behavior therapy and gut-directed hypnotherapy 
• Recommending regular exercise plans and other self-management strategies 
• Preferencing non-opioid medications 
• Regular check-ins and ongoing support from health care providers 
• Targeting gut physiology, microbiota and hypersensitivity to pain in the abdomen 
    

Motility Disorders

While DGBI can be described as a breakdown in communication between the gut and brain, motility disorders affect how the muscles in the digestive system work. Normally, the muscles in the stomach and intestines move food and waste through the body in a smooth, coordinated way. When there is a motility disorder, these muscles don't work correctly, which can cause problems like constipation, diarrhea, bloating or pain. These symptoms can be especially challenging for young children who may not understand what's happening or know how to describe their discomfort. 

There are different types of motility disorders, and they can affect different parts of the digestive system. For example, some children may have problems with how food moves through their stomach, while others might struggle with the intestines or colon. In some cases, the nerves that control the muscles in the digestive tract don't work correctly, which can lead to delayed digestion or food getting "stuck" in the stomach or intestines, causing nausea or pain. 

Arkansas Children’s NGM specialists use tests like manometry and EndoFLIP to determine which muscles are having trouble. 

Manometry is a test that measures how well the digestive system muscles work. During the test, a small, flexible tube is gently inserted into your child's nose or bottom. The tube has sensors that can measure the strength of muscle movements to see if they are too weak, too strong or are behaving abnormally. If the muscles aren't working well, it can cause problems like pain, trouble swallowing or difficulty pooping. 

Manometry results help the Arkansas Children's NGM team diagnose achalasia, Hirschsprung disease, no-burp syndrome (retrograde cricopharyngeal dysfunction) and pediatric intestinal pseudo-obstruction. Manometry results can also provide useful information for treatment decisions. 

EndoFLIP is a minimally invasive procedure done while asleep under anesthesia that can give details about the esophagus that a barium esophagram and endoscopy cannot. These added details help diagnose and treat children with difficulty swallowing or chronic esophageal diseases like eosinophilic esophagitis. 

During the EndoFLIP test, a small, flexible tube with a balloon on the end is gently put into your child's throat and esophagus. As the balloon inflates, your doctor can see how well the muscles can stretch and open when needed. Sensors on the tube measure changes in the size of the esophagus and its stretchability. 

Improving diagnostic accuracy prevents unnecessary treatments, saving patients and their caregivers time and money. Manometry and EndoFLIP are often done at the same time as an endoscopy, so patients aren't required to make multiple trips to the hospital.  

For example, suppose a pre-schooler with autism is refusing food. In that case, an endoscopy can look for inflammation, and EndoFLIP can screen for problems with the muscles in the esophagus while the patient is sedated and comfortable. "We couldn't accomplish that if the patient were awake," Dr. Rosen said.  

Treatments provided by NGM specialists at Arkansas Children’s include:  

• Pneumatic balloon dilation for achalasia
• EsoFLIP for achalasia and esophageal strictures 
• Pyloric and anal Botox for gastroparesis, feeding disorders, functional constipation and Hirschsprung disease 
• Daily enema programs for constipation 
    

Telehealth Champions 

Arkansas has invested in the infrastructure necessary to make telehealth a viable and effective tool. Telehealth is beneficial for diagnosing and managing DGBI because analyzing lab results, consulting with primary care providers and talking with patients can be done remotely, saving patients and caregivers the burden of traveling to a hospital or clinic.  

Dr. Rosen said when he needs to follow-up with patients or caregivers regarding bowel movements or belly pain, they can easily respond from the comfort of their home. "You don't have to drive to Arkansas Children's Northwest or Little Rock for that," he said. If the family desires an in-person visit or it is medically necessary, it can be easily coordinated for follow-up. 

  

A Regional Partner 

The Arkansas Children’s GI team sees itself as one of many partners collaborating to improve pediatric GI health, offering pediatricians consultations and connecting patients to financial support and mental health services for psychology related to behaviors that can improve their medical condition and experience.     

Pediatricians in the region who suspect their patients may have achalasia, Hirschsprung or intestinal pseudo-obstruction can have those diagnoses confirmed and receive consultations on the latest therapies and research. 

  

This article was written by the Arkansas Children’s content team and medically reviewed by John M. Rosen, M.D.