As a physician, you have probably seen many cases of diarrhea and abdominal pain. When you see patients with these symptoms, you are faced with a number of questions and decisions:

• Is it a self-limited infection or a reaction to something the child has eaten; a problem that will resolve itself with time?
• Could it be irritable bowel syndrome (IBS), a condition where treatment can help to reduce discomfort?
• Could the symptoms be indicators of inflammatory bowel disease (IBD), a chronic inflammatory condition that can lead to serious health problems if left untreated?
• Should you send the child home to wait it out? Should you order blood and stool tests? At what point should you refer the child to a GI specialist?

In this article, GI specialists at Children’s Hospital of Philadelphia (CHOP), in collaboration with a CHOP pediatrician, offer advice on what to look for when making these assessments, what lab tests to order when the symptoms warrant, and when to make a referral to a specialist.

What to look for and what questions to ask?

As the child’s physician, you are in a unique position to notice changes in the child and to find out from the parent and the child what is going on.

Questions to ask

If the child is suffering from diarrhea:

• How long has the patient had diarrhea? Is the diarrhea constant or does it come and go?
  • Diarrhea for five days or longer, or intermittent diarrhea for three weeks or longer may be an indicator of IBS or IBD.
• Is there anything unusual or alarming about the stool?
  • Bloody stool, nocturnal bowel movements and tenesmus may be indicators of IBD. Bowel movement urgency may be an indicator of IBD or IBS.

If the child is suffering from abdominal pain:

• How long has the pain been present? Has the pain been constant or does it come and go?
  • Abdominal pain for five days or longer, or intermittent pain for three weeks or longer may be an indicator of IBS or IBD, and may require further investigation.
• How does the child describe or indicate the pain?
• Does it occur during the day? At night?
• Does it interfere with the child’s sleep or daily activities?
• Does it occur before or after meals? After eating certain types of food?
• Is pain related to, worsened by, or relieved by having a bowel movement?
  • Answers to these questions help determine the severity of the problem and may help in making a diagnosis.

Physical examination

• Plot the child’s weight and height on a growth chart.
  • Weight loss, lack of weight gain, and/or decline in linear growth velocity are red flags in pediatrics. These changes warrant further investigation into nutritional status and may be signs of IBD. Typically, children with IBS have normal weight gain and growth.
• Perform a perianal examination.
  • Skin tags in the anal area, particularly if multiple, inflamed and/or in positions other than 6 or 12 o’clock, may be a sign of IBD.
  • A fistula surrounding the anus, with or without drainage, may be a sign of IBD.
  • Signs of abscess in the anal area, including tenderness, swelling, erythema, induration or fluctuance, may be an indication of IBD.
• Extra-intestinal manifestations of IBD
  • There are several extra-intestinal manifestations of IBD which can be identified on physical exam, including oral ulcers, arthritis, erythema nodosum and uveitis. It is important to recognize that oral ulcers, in particular, can be seen commonly in healthy children.
• A normal physical exam does not preclude a diagnosis of IBD.

Laboratory tests

When a diagnosis of IBD is being considered, additional laboratory blood and stool tests are suggested (though not essential) as the next step before referring a patient to a GI specialist for diagnosis. The results of the tests listed below should be included with the referral to a specialist.

Blood tests

Complete blood cell count with differential (CBC) — abnormalities could include leukocytosis, anemia, thrombocytosis

Comprehensive metabolic panel (CMP) — used to detect hypoalbuminemia, which is very common in Crohn’s disease

Elevation of erythrocyte sedimentation rate (ESR)*

Elevation of C-reactive protein (CRP)*

* It is important to remember that up 20 percent of children with IBD have normal CRP and/or ESR; therefore, normal inflammatory markers should not preclude referral to a GI specialist if the history is otherwise concerning (Mack, Langton, Markowitz, et al 2007).

Note that blood test options often include IBD serology panels. While these panels seem attractive, GI specialists do not recommend these or find them helpful when included as part of a referral. There is not enough data to support using IBD serologic testing for screening evaluation of suspected IBD.

Tests for other antibodies such as ANA (antinuclear) are also unnecessary to GI specialists in screening for IBD or IBS. Only include these if there is another clinical reason for their consideration.

Stool studies

• Clostridium difficile
• General bacterial stool culture (which should include Salmonella, Shigella, E. coli, Yersinia and Campylobacter)
• Optional: stool viral panel, ova and parasites, Cryptosporidium
• Stool calprotectin. Clinically, the concentration of calprotectin in feces is used as a non-invasive measure of neutrophilic infiltrate in the bowel mucosa, and thus intestinal inflammation.
  • There is not a universally agreed upon cutoff value for normal and abnormal. However, a recent meta-analysis identified a cut point of between 200-300 mcg/g as optimal to distinguish the presence or absence of endoscopically detectable mucosal inflammation (Henderson, Casey, Lawrence, et al 2012).
  • Fecal calprotectin is usually covered by insurance with a diagnosis code of diarrhea when it is ordered with the purpose of determining which children with gastrointestinal symptoms or growth failure require further investigation.

Referring a patient to a GI specialist

If the patient’s symptoms and the examination indicate the possibility of IBD or IBS and the stool studies do not identify a treatable or self-limited infection that makes sense clinically, you should make a referral to a GI specialist.

IBD can sometimes be difficult to diagnose. Patients with IBD can have a normal laboratory evaluation. If the patient has had diarrhea or abdominal pain for an extended period, and the stool test results rule out infection as the cause, a referral to a GI specialist is warranted. A referral is also appropriate if other indications of IBD are present, such as bloody stool, extra-intestinal signs or symptoms, or growth failure.

IBS can also be difficult to diagnose. Patients with IBS will often have negative stool studies, normal laboratory evaluation and appropriate growth – but ongoing GI symptoms and may benefit from evaluation with a GI specialist.

For patients with both IBD and IBS, a GI specialist can collaborate with dieticians and GI-focused pediatric psychologists to address the nutritional and behavioral aspects of managing the disease.

Communicating with the GI specialist

Share the information from the physical examination with the specialist, along with the results of the laboratory and stool tests listed above and all relevant information from the patient’s history and family history. Copies of growth charts are also very useful.

Communicating with the patient

When making a referral to a GI specialist for a possible diagnosis of IBD, explain to the family that the specialist may need to do additional tests. Let them know that blood and stool tests are useful in detecting indicators of IBD and in ruling out other possible causes of the child’s symptoms. However, to obtain a firm diagnosis of IBD, which is required before starting treatment, a GI specialist will generally need to perform an endoscopy and colonoscopy with biopsies. The specialist may also order an imaging study of the small intestines.

Referring a patient to Children’s Hospital of Philadelphia

For short-term symptoms, or while the patient is awaiting an appointment with a specialist, you should continue to provide supportive care.

The general scheduling number for outpatient pediatric GI appointments at CHOP is 215-590-3630. To schedule an appointment in the CHOP IBD Center, please call 215-590-7423. For more urgent clinical guidance, physicians can call the provider priority line: 1-800-TRY-CHOP to reach a CHOP physician in the appropriate specialty directly to discuss a case.

Sources

Henderson P, Casey A, Lawrence SJ, et al. The diagnostic accuracy of fecal calprotectin during the investigation of suspected pediatric inflammatory bowel disease. Am J Gastroenterol. 2012;107(6):941-949

Mack DR, Langton C, Markowitz J, et al. Laboratory values for children with newly diagnosed inflammatory bowel disease. Pediatrics. 2007;119(6):1113-1119

Contributed by: Elizabeth Clabby Maxwell, MD, MS; Lindsey G. Albenberg, DO; and Jane Nathanson, MD