Online Health Chat with Dr. Matthew Wyneski
March 21, 2012
“My tummy hurts,” is a cry most parents hear from their kids a lot. Abdominal pain in children is one of the most common reasons for a parent to bring his or her child to the doctor’s office. Evaluation of a “tummy ache” can be a challenge both to the parents and the physician trying to diagnose the problem. In most cases, abdominal pain is not serious and gets better with little or no treatment. Causes for a child’s aching belly can range from trivial to life-threatening, including infections, food poisoning, constipation or acid reflux. However, when it’s recurrent and a specific cause has not been identified, treatment can be a challenge. The chronic pain can affect your child’s ability to have a normal life, including attending school or sporting events.
Our team of gastroenterologists and hepatologists in the Department of Gastroenterology at Cleveland Clinic Children’s Hospital cares for children with problems of the gastrointestinal tract. We take care of children with a variety of gastroenterological conditions involving organs in the digestive system, including the esophagus, stomach, large bowel, small bowel, liver, gallbladder and pancreas. Patient visits to the Pediatric Gastroenterology & Hepatology department number about 8,500 per year. We are also one of the largest U.S. centers for pediatric inflammatory bowel disease.
Matthew J. Wyneski, MD, was raised in Sandusky, Ohio. He went to Boston College for undergraduate education at Boston College (MA) and attended medical school at Northeastern Ohio University College of Medicine. He did his residency in pediatrics at Akron Children's Hospital and then fellowship in pediatric gastroenterology at Cleveland Clinic Children’s Hospital. He joined the staff at Cleveland Clinic Children’s Hospital in 2011.
He has many clinical interests, including Crohn's disease and ulcerative colitis, Celiac disease, Graft vs. Host Disease, gastrointestinal endoscopy/colonoscopy, GI bleeding, acid peptic disease, and general pediatric gastroenterology. To make an appointment with any of our pediatricians or pediatric specialists at Cleveland Clinic Children’s Hospital, please call 216.444.KIDS (5437) or call toll-free 800.223.2273, ext. 5437. You can also visit us online at www.clevelandclinicchildrens.org.
Cleveland_Clinic_Host: Welcome to our Online Health Chat with Cleveland Clinic specialist Dr. Matthew Wyneski. We are thrilled to have him here today for this chat. Let’s begin with some of your questions.
piano_fingers: My young son is constantly complaining that his stomach hurts. He has an appointment next week. When he is crying and it hurts, what can I do to help him? He is 6 and I am not sure what I can give him. We have tried ginger ale, peppermint candy, milk, and other things that have helped in the past but not so much now.
Dr__Wyneski: This is tough - without seeing him or testing him for anything I cannot overly recommend anything. If you notice his stools are different, I would consider fiber (age+5 = 11gm/day - go slowly on increasing). If he has signs of reflux or regurgitation/nausea, using OTC meds such as Pepcid® or Zantac® could also be tried. However without knowing his size or weight, I cannot recommend a dose. Make sure he is well hydrated and maintaining normal daily activity until seen. Unfortunately, he'll have to be seen before anything substantial can be done.
being_funny: What are the causes of abdominal pain in a child?
Dr__Wyneski: Abdominal pain is the most common issue I see in my office. I would say about 95% of the patients I see have one of three things:
- Reflux/acid irritation
- IBS - irritable bowel syndrome
After those three, there are other issues with liver, kidney, pancreas, celiac disease, allergies/allergic conditions, and Crohn’s disease/ulcerative colitis. However, those are all less likely issues.
please3: What are the signs and symptoms of chronic abdominal pain?
Dr__Wyneski: Chronic abdominal pain lasts for several months or longer. There are many causes of abdominal pain. The associated symptoms are the most important factor, along with where the pain is. Symptoms include waking from sleep, weight loss, or a strong family history of a particular GI disease.
hobie1: I have a 9-year-old daughter who has complained of general stomach pain for almost a year now. We have brought her to the doctor two or three times. She has had an x-ray, urine culture, and blood test that came back with no problem. She has possible constipation. We give her Miralax® in water or juice once a day. She is a great fruit eater and drinks lots of liquids. We even took her to therapist to see if this is stress-related. She doesn't have major stressors in her life and the therapist confirmed she is well-adjusted and seems to handle little bumps in the road fine. She tends to get car sick if driving for more than an hour, but that's the only other stomach related issue. She had milk allergy as a newborn and we recently had her allergy-tested. While she was positive for "all things outdoors," she did not have any food allergies at this point. Any other thoughts for follow up that we should consider?
Dr__Wyneski: This can be difficult. If she is gaining weight well with no vomiting, no blood in stool, and a negative workup she would fit more into an irritable bowel syndrome (IBS) category. However, I am not sure exactly what labs were done. Celiac disease is always something we look into, as that can appear as IBS. We'd also usually make sure liver, kidney, pancreas and inflammatory markers were negative. Sometimes we'd consider an ABD ultrasound if any focal pain (to one area) in her abdomen. We'd also usually make sure there is no blood in the stool. If all that was negative, we could consider endoscopy (taking a look inside), but with a negative workup and good growth, the likelihood we would find something would be small. It sounds like she gets fiber in her diet. A goal of 14gm fiber/day, advancing slowly, can help with stooling and IBS. Next thing would be to look at diet and see if there are any associated foods. Lactose or fructose intolerance would be in my differential for what's going on - and those are different than allergies.
Andrea: My 12-year-old daughter has been experiencing continuous abdominal pain that has kept her out of school and dance classes since January. We've been told that we need to see a specialist at Children's Hospital in Pittsburgh, but they cannot give us an appointment until August. Tests from six years ago indicate only functional abdominal pain. What can I do to get her seen earlier?
Dr__Wyneski: If you call 216.444.9000 tomorrow (or can try today), we have a clinic every Wednesday morning where we see new patients. Please try to bring the records that you can.
get_it: How long should one wait before being concerned if a child’s stomach has been hurting? A few days? A week? Longer?
Dr__Wyneski: It's not just abdominal pain that is the main factor. Many kids have abdominal pain, but it’s the other issues: changes in stool, blood in stool, weight loss, Nausea, reflux, vomiting, rashes, joint pain/swelling, fevers and family history all play a role in figuring out the issues. Also, where the pain is at, what it feels like, how long it lasts, and does it wake them from sleep. Typically if someone just has abdominal pain alone for a few days or a few weeks, it's not much to go on, but longer than a few weeks and it would deserve to be seen. Also if there is a big family history of a digestive problem (liver, gallbladder, Crohn’s disease, ulcerative colitis, or celiac) and if the symptoms mimic other family members’, sooner rather than later may be prudent. Abdominal pain with other associated symptoms that cannot be explained is always more concerning that simply abdominal pain alone.
Issues with Newborns:
anthony: When should I ask for a referral to a gastroenterologist from my pediatrician if I am concerned about reflux in my newborn?
Dr__Wyneski: Three main issues I look for with reflux are discomfort, poor weight gain, and signs of aspiration (extreme choking, gagging, turning blue, stopping breathing). The main issue is that if your child isn't obviously improving, it's OK to ask. However, if none of these three issues are present, there is an unlikely chance the children’s gastrointestinal physician may actually need to do anything. Reflux in babies is very common. About 95% of children with reflux will outgrow it by the time they are a year old. The main issue is an incoordination of the muscle between the esophagus and stomach, and that takes time to become better at handling reflux. I have seen babies spit up 30 times per day. As long as they are gaining weight, not aspirating, and have no discomfort, we usually side on just observation.
vj0: My newborn is what you would call a happy spitter, but along with that does not have regular dirty diapers (every few days) and never finishes his bottles. We are going to the specialist next week. Is there anything specific we should ask about? We don’t have a diagnosis yet.
Dr__Wyneski: Growth. If your child is gaining weight well and gaining height appropriately, it makes the likelihood of something serious going on much less likely. However, we need to establish a good growth pattern. As for the stools - is there any pain? Is there any blood? Stooling every several days can be normal if the patient is growing well and not in any pain, has no blood in stools, and is not passing larger/harder stools. As for specific questions for the physician: Making sure the growth chart is good is the #1 priority in my mind. You could ask about potential food allergies or reflux in general. However, if no blood is in the stool, your baby is happy with spitting and is growing well, you simply may have a spitty baby with some slightly altered stooling pattern. This can be normal.
Constipation and Diarrhea
keep_going: My daughter, who is 10, has been battling constipation her whole life. She is taking Miralax® daily now, but it is not really helping. Should we be concerned about something more going on?
Dr__Wyneski: The main cause (about 99% of the time, in my opinion) of constipation is something called functional constipation. This is a cycle of withholding or not completing the evacuation of stool, which then leads to dilation of the colon. This results in the ability to hold on to more stool. When you hold onto stool, your colon keeps working. The job of your colon is to take water out of stool. So, if you don't get all the stool out, the stool becomes harder, bigger, and more difficult to pass. This leads to incomplete evacuation as well as abdominal pain and soiling. They mainstay of treatment is trying to evacuate the stool, and then keeping cleaned out with Miralax® or another stool softener to maintain normal stools. If that has been done and is not helping, the next two things we think of are underactive thyroid (hypothyroidism) or celiac disease. These are less likely causes, but several times per year we find children with those issues who are having constipation. After that, there are much less likely issues such as nerve problems or spinal cord issues. When someone has chronic, non-remitting constipation, many times we will do screening labs for thyroid and celiac. We would also consider anal-rectal manometry (pressure readings of the rectum) to make sure the function of stooling is normal.
jpow717: My 4-year-old son doesn’t have pain all the time, but he has constipation. He suffers from that when it’s time to go. We give him Miralax® every day and our doctor also says to give him Ex-lax®. After he takes it, he can’t control his bowels. He has been like this since birth. Is there anything else we can try?
Dr__Wyneski: This is also very difficult. Miralax® is what we like to try, as it's not absorbed into the bloodstream and there are no issues with dependence. It's usually a matter of finding the right dose to put him on. Also, constipation won't always resolve unless he is completely “cleaned out.” If there is residual stool, that forms a nidus for him to become constipated again. Usually we use Miralax® to soften stools; we then add in fiber - age+5 = 9gm/day (advance slowly) for him; and we also do scheduled sitting. There is a reflex when you eat food/smell food, it stimulated the colon to push out the stool. If you're not doing it already, try getting him to sit on the potty after meals (just 5 minutes) will help evacuate stool to prevent getting backed up again. However, this may be as simple as adjusting the Miralax® dose or splitting the dose to twice a day. Without knowing his size/weight, or his current dose, it's hard to advise you on that. Also, if this is a chronic issue, I would look into celiac/thyroid as causes of constipation - but those are unlikely.
Irritable Bowel Disease, Celiac Disease, and Ulcerative Colitis
kat43: My son is 14 and suffers from IBD. We have been seeing a gastroenterologist, but he does not seem to be getting better. What could we do next?
Dr__Wyneski: If he is not getting better, usually a second look to make sure the initial diagnosis was correct is in order. If confirmed, then looking at therapy would be next. The type of disease (Crohn’s or ulcerative colitis), as well as the location of the disease, play a role in choosing different therapy. Also, if it has been several years since diagnosis, sometimes repeating an endoscopy/colonoscopy may be needed to re-evaluate disease. Also, imaging with a CT scan or MRI may be used to help make an informed decision about changing to a new medication. There are many medications for IBD, and all those factors play a role in choosing the best medicine to treat the disease.
time_out: My daughter has celiac disease and it is really affecting her emotionally. Do you know of any support organizations I can look into? We are local in Cleveland.
Dr__Wyneski: I am checking into that. I know of a group called neohioceliac.com, and have had some people go to their meetings, but I am not sure about the pediatric portion of that. Also there is The Celiac Disease Foundation (www.celiac.org). Also, The Celiac Sprue Association (www.csa.celiacs.org). Here at CCF, we sometimes have patients with a disease speak to other patients with the same disease (same sex, age) talk/call and discuss some issues that they may be having. However, there are confidentiality issues that have to be overcome with that.
jerryr: Do you recommend any alternatives such as probiotics, fish oils, or aloe vera for treating ulcerative colitis?
Dr__Wyneski: I have used probiotics before, as well as fish oil. I have not used aloe vera. I should state I have never used these alone as a single therapy, but only in conjunction with other medications. They seem to help minimally (with other meds), but I have never been able to use them alone to help keep UC under control. So, to answer your question - I have no issue using them with other meds, but I wouldn't overly recommend them as single therapy.
40plus: I have diverticulitis. Should I be concerned my children will get it as well? Is there any testing they can do early to detect the disease?
Dr__Wyneski: Diverticulitis is very uncommon in the pediatric population. I do not know of any lab testing that can be done to detect it, but it can be seen on colonoscopy. I'm sure CT scans could be used, but that is a large amount of radiation. Also barium studies can be used, but they can be very uncomfortable. If your children are asymptomatic and doing well, I wouldn't advise they have a colonoscopy or other testing done. I can reassure you that just because you have it doesn't mean your children will have it. If they would start having severe abdominal pain, diarrhea, and especially blood in the stool, I would advise them to be seen by a GI specialist.
howdo: Please talk about guided imagery as a treatment option. Does it really work?
Dr__Wyneski: That depends on what it is used for. I have had some patients with chronic abdominal pain and constipation use it and it has worked well. The issue is getting the patient to realize that there are factors outside the body playing a role on their physical symptoms. The more somebody understands and realizes that, the more likely (in my opinion) that therapy is going to work.
Hendrix68: My 10-year-old daughter was diagnosed as being lactose intolerant two years ago. Since then, she has been doing really well and we basically stopped the Lactaid® pills. She also was taking Prilosec® for GERD. However, now all of a sudden, her symptoms are coming back with the lactose intolerance. Should I have been continuing the Lactaid® pills as maintenance? Also, she complains about stomach pain and gas almost every day, even when she doesn't have milk products. Should I make an appointment for her for a follow-up or be concerned?
Dr__Wyneski: Over time, lactose intolerance can change. Some people can tolerate a certain amount of lactose in their diet, but over time, that can decrease. She may simply be not able to tolerate the lactose load that she once did. Sometimes it can take time for the issues related to lactose to resolve, hours or days. However, if you feel this is worse, different, or something isn't right, I would side on having her seen again. We like to make sure there is normal growth and no other physical signs of other diseases going on. In the meantime, you could start restricting more lactose from her diet and re-start the lactaid pills. I don't think you did anything wrong, especially since she was doing well. Lactose intolerance does not cause damage to the intestines, but it can cause increased symptoms (bloating, gas, diarrhea, nausea) if the patient is not being treated or is not following the diet.
jbt98: My 4-year-old niece has been diagnosed with an ulcer. Her doctors put her on one medicine that works fine for a while and then the pains come back. At that point, they try a different medicine. They have not yet found one that works continuously. Is this normal? Is there something else they could try? Also, how does a child so young get an ulcer?
Dr__Wyneski: Ulcers in children are unusual. Most common reason would be irritation to the stomach from either increased acid, or maybe recurrent medication (e.g., Motrin®). There is also an infection by a bacteria called H. pylori which can cause ulcers. How was the ulcer diagnosed? The main way is endoscopy (taking a look). If that hasn't been done, I would question the diagnosis. The other situation is that the medicine may have helped the ulcer (if it exists), but maybe there is something else going on. If she has been on multiple medications, and the diagnosis was made with an endoscopy, depending on when the last scope was done, she may warrant another endoscopy to see if the ulcer is still playing a role at all. Common medications we use for ulcers are Prilosec®/Omeprazole; Prevacid®/Lansoprozole, as well as Nexium®/esomeprazole. Sometimes Pepcid® and Zantac® are used. There is also a medicine called Carafate/Sucralfate which is a coating medicine we will use for ulcers.
Cleveland_Clinic_Host: I'm sorry to say that our time with Cleveland Clinic specialist Dr. Matthew Wyneski is now over. Thank you, Dr. Wyneski, for taking the time to answer our questions today about Uncovering the Reasons for Your Child’s Tummy Pain.
To make an appointment with any of our pediatricians or pediatric specialists at Cleveland Clinic Children's Hospital, please call 216.444.KIDS (5437) or call toll-free 800.223.2273, ext. 5437. You can also visit us online at www.clevelandclinicchildrens.org.
A remote second opinion may also be requested from Cleveland Clinic through the secure eCleveland Clinic MyConsult Web site. To request a remote second opinion, visit eclevelandclinic.org/myConsult.
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