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There is no uniformly successful treatment or cure for functional bowel disorders. Once the diagnosis has been made, it is essential to emphasize the benign aspects of the history, physical examination and laboratory tests in order effectively to reassure the patient and the family of their significance. Initial treatment of functional pain is based on reassurance and establishing an effective physician-patient-family relationship. Alleviating symptoms is one of the main goals of caring for patients with functional bowel disorders, but a rational management of these disorders is often challenging, owing to the lack of objective diagnostic criteria and unclear pathogenesis. As a consequence, there are no specific, universally effective therapies.115


It is of great importance to assure the family and the patient that the physician believes that the symptoms are 'real' and that an organic or progressive disease is not present. An extensive explanation of the nature of the disorder should be given, discussing the problem as a common diagnosis and not just an exclusion of an organic disease. A comprehensive but easily understandable description of the nature of this group of disorders should be attempted. Comparisons with other common and benign entities such as headaches or muscle cramps may help. The family and the patient should be encouraged to ask questions and share their concerns, which should be addressed in depth to avoid fears and misconceptions.

The main goal of the therapy is to re-establish a normal daily life for the patient and the family. The family should be discouraged from reinforcing the symptoms by allowing the child to miss school and leisure activities. Patients with perceived low self-worth and academic competence may find the relief of responsibility as a benefit of the pain experience;116 meanwhile, patients with adequate perception of their self-worth may find it discouraging. Fordyce and others have suggested that positive attention from others may serve as a secondary gain, transforming the painful experience into a rewarded activity that in turn could reinforce symptoms, leading to further disabil-ity.117,118 However, negative attention to pain in children with low self-esteem has been associated with increased pain behavior, possibly by creating affective distress that may further contribute to somatic symptoms.116 Thus, the parents' attitude towards the pain experience should be balanced, showing support and understanding, but being aware that excessive attention to the painful experience and missing activities may allow some patients (especially those with low self-worth) to develop a sick role, perpetuating the symptoms.

Behavior alternative to assuming the sick role should be encouraged and rewarded. Patients should be encouraged to discuss perceived triggering factors. Psychosocial stressors at home or school should be addressed. At school, strict toilet times or issues relating to social embarrassment to attend the restrooms should be discussed. It is often useful to communicate with the school nurse or teacher in order to address these issues.

Owing to the high index of symptomatic success with reassurance, medications are not necessary for every patient with functional abdominal pain. Drug therapy should be recommended only for patients with symptoms interfering with satisfactory quality of life.


A detailed dietary history may identify factors that patients may feel as aggravating or provoking the symptoms. Food intolerance was perceived as a problem by 20% in an unselected UK population who responded to a questionnaire, but with controlled challenge the prevalence was slightly higher than 1%.119 Food-induced symptoms are common reports among IBS patients, with 20-65% attributing their symptoms to adverse food reac-tions.120,121 In a study of 200 IBS patients,120 the effect of an exclusion diet was evaluated, with a symptomatic improvement in almost 50% of patients, indicating that a significant proportion of IBS patients could benefit from therapeutic dietary manipulation. However, such intervention is still controversial because the observed response rate replicates the average placebo response rate in IBS trials.40 Within IBS patients the subgroup of patients with diarrhea-predominant symptoms seems to benefit the most by a trial of exclusion diet. Among those with abdominal pain with or without diarrhea, lactose, or excessive fructose or sorbitol intake may induce symptoms. The avoidance of gas-forming foods such as legumes, complex carbohydrates, lactose and fructose may provide symptomatic relief in some patients.

High-fiber diets have long been used in adult IBS patients but the data in children are still preliminary and accomplishing a substantial increase in fiber consumption may be difficult.122,123 As fibers decrease the whole-gut transit time, fiber-enriched diets may be more useful in the subgroup of patients with constipation.124,125 Fiber may also decrease intraluminal pressures, reducing wall tension and pain.126 In committed families wishing to increase dietary fibers, the change should be attempted gradually, as the excess of undigested carbohydrates in the colon results in fermentation with consequent increase of gas, aggravating IBS symptoms.127 Frequently, non-pharmacological strategies alone fail to bring complete relief to IBS patients, necessitating pharmacotherapy (Table 14.4).


Patients with severe constipation may find relief by combining fiber with a laxative. It is our preference to use polyethylene glycol or a senna derivative, but other laxatives may be used according to the practitioner's preference. Lactulose should be avoided, as the increase of gas production derived from its use may trigger pain.

Anticholinergic and antidiarrheal medications

Some patients with diarrhea seem to benefit from an antidiarrheal preparation such as loperamide or diphenoxylate. Studies in adults6 and anecdotal experience seem to demonstrate that some patients find relief by using anticholinergics such as hyoscyamine,128 dicyclomine or others that may modify intestinal tone and motility. These agents are best used on a sporadic basis, whenever the symptoms are present much like analgesics are used for headaches. When giving medications for pain, the high placebo response rate should be considered, as several preparations may work in the short term, only to relapse after a variable period of time.129

Tricyclic antidepressants

An additional option for treating chronic abdominal pain is the use of tricyclic antidepressants (TCA). TCA are used at smaller doses (0.2-0.4 mg/kg per day, 5-50mg/day) than needed for treatment of clinical depression. The analgesic effects of TCA and other antidepressants are independent of their effects on depression, and this information should be shared with the family and the patient. The beneficial effect of the TCA starts

Table 14.4 Drugs approved for treatment of IBS and scientific evidence

USA Canada

Scientific evidence












Peppermint oil








yes (restricted)


Source: physicians' desk reference 2001 (USA) Compendium of Pharmaceuticals and Specialties (Canada)

3-7 days after the beginning of the treatment, while it takes 2-3 weeks for the onset of the anti-depressant effects.130 Relief of chronic pain with the use of antidepressants has been documented in the absence of any measurable antidepressant response, both in depressed patients131 and in patients without clinical depression. In addition to its action on noradrenergic and serotoninergic receptors, the TCA have antimuscarinic and antihistamine effects. Thus, these agents are especially effective in diarrhea-predominant patients132 and those with disturbed sleep, when slowing intestinal transit and the side-effects of sleepiness may be of therapeutic value. The medication is best administered at bedtime. Other side-effects such as undesirable weight gain and the possibility of cardiac arrhythmias, although rare at such low doses, demand caution when prescribing these drugs. Electrocardiogram (EKG) monitoring can be performed at the practitioner's discretion. Amitriptyline, although probably more effective, has greater sedative and anticholinergic effects than imipramine.133 It is recommended that the medication be started at low doses, increasing the dose progressively as needed to achieve a full dose in weeks.134 Other antidepressant drugs, such as selective serotonin reuptake inhibitors (SSRIs) are also being used in the relief of chronic pain.135

Selective serotonin re-uptake inhibitors

SSRIs, such as paroxetine, fluoxetine, or sertraline, also seem to have therapeutic value in relieving symptoms in adult patients with functional bowel disorders.128 SSRIs have become the most frequently prescribed antidepressant medications, owing to their favorable side-effect profile.136 Despite the growing popularity of SSRIs, there are few controlled studies of their efficacy in managing chronic pain syndromes. The effects of TCAs and SSRIs in the GI tract are different, with the TCAs slowing intestinal transit and SSRIs increasing motility in the small intestine.39,137 Thus, a patient in whom the main symptom is constipation may benefit most from an initial trial of an SSRI, whereas a patient with increased bowel frequency may benefit from an antidepressant with anticholinergic properties. Recent reviews concluded that, although SSRIs may be effective, in most circumstances TCAs should remain the first-line antidepressant agents for chronic pain.131

Serotonin receptor antagonists

There has been much recent interest in clinical gastrointestinal pharmacology focused on 5-HT3 and 5-HT4 receptors. Such receptors have been shown to be involved in diverse sensory and motor regulatory processes in the GI tract. The 5-HT3 receptor has a role in modulating colonic motility and visceral pain, increasing the threshold for sensation and discomfort, slowing colonic transit and improving stool consistency.138 A number of selective 5-HT3 antagonists have been developed including ondansetron, granisetron, tropisetron renzapride and zacopride. Ondansetron was the first 5-HT3 to be evaluated for its effects on the gut. It demonstrated some benefits in diarrhea-predominant IBS, but no improvement in abdominal pain. Similarly, no reduction in pain was seen with granisetron. This modest efficacy led to the search for a 5-HT3 with greater potency. Alosetron, a newer 5-HT3 receptor antagonist, has greater potency than ondansetron, and good bioavaila-bility.139 Treatment with alosetron has led to significant relief of abdominal pain and discomfort in women with diarrhea-predominant IBS. Though generally safe, its use has been associated with severe constipation and ischemic colitis. It is currently available in the USA as part of a limited access program.

5-HT4 agonists such as tegaserod and prucalo-pride, have been developed for patients with IBS and constipation. Tegaserod has demonstrated efficacy in the short-term relief of abdominal pain and discomfort in adult women with constipation-predominant IBS140 and is commercially available for this indication. Adverse events, particularly loose stools, are compatible with an exaggerated pharmacological response to tegaserod and are most common during the first 2 days of therapy.

Alternative and complementary therapy

Despite the interventions described above, some patients will continue to experience symptoms, suggesting that current treatments that target the predominant symptom are only partially effective, presumably because they do not resolve the underlying cause of functional bowel disorder.6 The large number of patients in whom these therapies fail has prompted an interest in alternative therapies such as diet supplements, probiotics and ancient therapeutic modalities such as Chinese medicine.

Peppermint oil (Mentha piperita), which is commonly found in many over-the-counter preparations for IBS, has long been recognized as a spasmolytic agent that relaxes GI smooth muscle, relieving pain. Placebo-controlled studies have shown an overall improvement in IBS patients who used peppermint oil.141,142 A double-blind clinical trial in Chinese medicine demonstrated that herbal therapy was effective in the management of symptoms related to IBS.143 Natural and herbal medications are not without adverse effects, and patients should not take these products without medical supervision. A variety of other herbal preparations have been studied with different methodologies, resulting in mixed results. More well-designed, controlled trials must be performed to identify other complementary therapies, with validation of the safety and efficacy of their use.73

Another alternative therapeutic strategy for patients with significant pain is to use hypnotherapy or psychotherapy.144-146 Hypnotherapy has been shown to be effective in the treatment not only of gastrointestinal symptoms but also of urological, sexual and psychological symptoms that are often associated features of IBS in adults.147 Effective psychological treatments include cognitive-behavioral interventions, dynamic or interpersonal psychotherapy and stress management. In a review of published psychological trials, Talley et al found methodological problems in all the studies, concluding that the efficacy of psychological treatment for IBS could not yet be established.148

Despite the fact that alterations of enteric flora may play a role in IBS, convincing evidence for a pathogenic role of bacterial overgrowth or for a beneficial effect of probiotic therapy is still scant. A review of the therapeutic role of probiotics concluded that further studies are needed to identify particular subgroups of patients with IBS who could benefit from their use.149 More recently, however, a very encouraging randomized, doubleblind and placebo-controlled study in adults with diarrhea-predominant IBS showed efficacy for the probiotic preparation 'VSL#3'.150 These findings will of course have to be reproduced in children.

In chronic cases of refractory pain, referral to specialized treatment centers for an interdisciplinary pain management approach may be the most efficient method of treating disability.

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