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

If your child has chronic nausea, abdominal pain or constipation and X-rays haven’t revealed a blockage and endoscopies don’t show any problems, they may have a disorder of gut-brain interaction. 

Our brain and gut communicate constantly 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, stomach pain or other symptoms. In other cases, chronic conditions lead to ongoing disruptions of the communication between the gut and brain, causing recurring symptoms.  

Diagnosing some chronic GI conditions, like Crohn's disease or celiac disease, is straightforward. Other GI conditions can be more challenging to identify. A child might complain of belly pain or constipation even though endoscopies or blood tests don't reveal a source.  

John Rosen, M.D., a pediatric gastroenterologist and director of neurogastroenterology and motility (NGM) at Arkansas Children’s Northwest (ACNW) and a professor of pediatric gastroenterology at the University of Arkansas for Medical Sciences specializes in disorders of gut-brain interaction (DGBI).  “There are so many kids who’ve tried the regular laxatives, the toilet-sitting, all the important stuff that works in most situations, but they’re still soiling their pants, and they can’t go to school. It’s a burden for them and their families,” Dr. Rosen said. 

Diagnostic Accuracy 

One reason disorders of gut-brain interaction are difficult to diagnose is that they share symptoms, like indigestion, vomiting or changes in bowel movements, with many other GI conditions.   

Arkansas Children’s added an NGM sub-specialist to improve accuracy in diagnosing disorders of gut-brain interaction using endoluminal functional lumen imaging probe (EndooFLIP) technology and manometry.  

Manometry helps diagnose achalasia, diffuse esophageal spasm and swallowing difficulties in patients with dysphagia. It can also guide treatment decisions, such as the need for surgery for conditions like gastroesophageal reflux disease (GERD). In some cases, insurance requires manometry results before approving surgery. 

EndoFLIP is a minimally invasive procedure that can provide information about the esophagus that barium esophagrams and endoscopies cannot. This information helps diagnose and treat children with difficulty swallowing or chronic esophageal diseases like eosinophilic esophagitis.  

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.  

Common DBGI in pediatric patients include:  

• Cyclic vomiting syndrome 
• Functional constipation (chronic idiopathic constipation) 
• Irritable bowel syndrome  
• No-burp syndrome (retrograde cricopharyngeus dysfunction) 
  
  

DGBI Management 

Treatment plans designed around multidisciplinary care are the most beneficial for DGBI patients. Arkansas Children's facilitates collaboration between primary care providers, gastroenterologists, psychologists and dietitians to provide a combination of medical therapies, dietary interventions and psychological treatments. 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 

NGM specialists at Arkansas Children’s provide:  

• Pneumatic balloon dilation for achalasia 
• EsoFLIP for achalasia, esophageal strictures, eosinophilic esophagitis and dysphagia 
• 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 patients or caregivers can easily respond from the comfort of their home when he says, "Tell me all the details. Let me ask you questions about bowel movements or belly pain. Let's review the studies that your local doctor has done or could do, like X-rays and lab tests. You don't have to come to ACNW or Little Rock for that." 

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 pediatric patients may have achalasia, dysphasia or a tracheoesophageal fistula 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 XXX.