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Gastrointestinal Disorders, Developmental Aspects Of

Pediatric gastroenterologists are trained in the medical model to identify, assess, and treat organic disease. Organic disease is generally accepted as having identifiable tissue changes in the form of inflammatory, infectious, or structural abnormality. Yet it is not uncommon for gastroenterologists to encounter patients with functional gastrointestinal symptoms (medically unexplained gastrointestinal symptoms). According to Wilhelmsen (2002), nearly half the patients in a gastroenterologist's office are diagnosed as having a functional disorder without any biological markers or endoscopic findings.

Medically unexplained physical symptoms are common in children and adolescents (Garralda, 1996). Functional abdominal pain, recurrent abdominal pain, and functional constipation constitute the majority of cases referred to the pediatric gastroenterologist. Many of these children and adolescents do not have organic disease. At the present time, patients with psychological, developmental, and social attendant illness are inadequately served through conventional medical management. Pediatric gastroenterologists must recognize how children's developmental aspects and their mind-body interrelatedness jointly contribute to functional disorders.

Definition

In functional gastrointestinal disorders, the symptoms cannot be traced to any lesion or change of structure. Functional gastrointestinal disorders are complex and heterogeneous, and thus are difficult to describe. A variety of diagnostic labels are used to describe patients with unexplained gastrointestinal symptoms. Medically, such symptoms are more often labeled as nonorganic or idiopathic disorders.

A number of disorders for medically unexplained physical symptoms are given in the Diagnostic and Statistical Manual of Mental Disorders, 4th edition (DSM-IV; American Psychiatric Association, 1994). While it is common for children to report physical symptoms without any physical cause, diagnosis and classification of children under the existing DSM-IV criteria is difficult. The existing categories were established for adults, and children do not experience all symptoms to meet the diagnostic threshold. These categories include somatoform disorder, conversion disorder, somatization disorder, body dysmorphic disorder, hypochondriasis, pain disorder, malingering, and undifferentiated somatoform disorder.

Munchausen Syndromes

Factitious disorders, synonymous with Munchausen syndrome, is a form of self-abuse; it is the intentional production or falsification of symptoms to fabricate an illness. The primary purpose in inducing illness is to take on the sick role for attention without any other external incentives. This is an understudied condition in children and adolescents. Many pediatric gastroenterologists are unaware that children and adolescents can intentionally falsify gastrointestinal illness. As such, medically unexplained gastrointestinal symptoms may often be overlooked or misclassified as a somatization disorder.

Factitious illness by proxy, synonymous with Munchausen syndrome by proxy, is a form of child abuse. It happens when a parent or caregiver consciously and intentionally induces or falsifies illness in a child. Unlike external abuse, falsifying and inducing illness using the gastrointestinal system is much easier to accomplish and more difficult to detect. A healthy suspicion, deep concern, and dogged determination of a gastroenterologist are required to confront and follow through with the diagnosis and referral to appropriate agencies. Appropriate diagnosis should not be limited by the physician's concern for risk avoidance.

Epidemiology

Functional disorders are still the most common disorders seen in gastrointestinal practices. Studies show patients with unexplained symptom complex to be as high as 50% to 80%. The 1980–1981 National Ambulatory Medical Care survey determined that as many as 72% of the 90,000 visits to physicians receiving a psychiatric diagnosis had one or more physical symptoms (Cypress, 1984). Somatic complaints are twice as common in children and adolescents with depression (McCauley, Carlson, & Calderon, 1991). Abdominal pain is the most frequent cause for pediatric gastroenterology consultation, with almost one third of patients with no identifiable etiology for their symptoms. Thirty-two percent of overall health is explained by four main stress variables: abuse history, lifetime traumas, turmoil in childhood family, and recent stressful life events (Leserman, Li, Hu, & Drossman, 1998).

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