In this session, two pediatric gastroenterologists walk through how they approach disorders of gut-brain interaction in children and adolescents using real clinical scenarios.

Dr. Paul Hammond and Dr. Charmaine Chai share how they manage functional abdominal pain, nausea, and IBS in practice — including how they approach investigation, navigate uncertainty, and structure conversations with families.

With both ESPGHAN and NASPGHAN now recommending gut-directed hypnotherapy as a first-line treatment for adolescents, the discussion also explores how these recommendations show up in day-to-day clinical decision-making.

What you’ll learn

  • How pediatric gastroenterologists approach functional GI presentations in real-world practice
  • A practical framework for managing functional abdominal pain, nausea, and IBS in children and adolescents
  • When to investigate further — and how to communicate that decision clearly to families
  • How to structure conversations that support both the child and the parent
  • Where gut-brain therapies fit within a pediatric care pathway
  • How current guideline recommendations can be applied in clinical settings
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Download the presentation

Chapters:

‍0:00 – Welcome & speaker introductions

‍1:58 – Case 1: a 6-year-old with acute tummy pain

‍8:33 – When pain becomes chronic: red flags, calprotectin and the DGBI conversation

‍19:55 – Treatment in young children: peppermint and gut-directed hypnotherapy

‍24:19 – Q&A: the grey-zone faecal calprotectin

‍28:14 – Case 2: Christos, 16 — counselling families about DGBI

‍36:13 – IBS-mixed: managing constipation and diarrhoea together

‍43:20 – Case 3: AM, 16, with cramping pain and a family history of IBD

‍47:11 – Gastroparesis, POTS, MCAS and staying in your lane

‍56:00 – Escalation, the MDT, and closing principles

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About the speakers

Dr. Paul Hammond
Pediatric Gastroenterologist at the Women’s and Children’s Hospital in Adelaide, Australia, where he has practiced since 1999. His clinical work spans inflammatory bowel disease, coeliac disease, eosinophilic oesophagitis, food allergies and intolerances, and liver and nutritional disorders. He is actively involved in clinical education and regularly presents at national and international conferences.

Dr. Charmaine Chai
Pediatric Gastroenterologist and Consultant at the Women’s and Children’s Hospital in Adelaide, Australia. She completed advanced training in neurogastroenterology and motility at Great Ormond Street Hospital in London, followed by further training in liver disease and transplantation in Sydney. Her clinical focus includes motility disorders and gut-brain interaction in pediatric patients.

Webinar transcript

Chapter 1: Welcome & speaker introductions

Welcome to the webinar today. Really excited to have everyone here. So as you know the topic for today is beyond the 7 seconds guidelines um pediatric GI decisionmaking and we are very very lucky to have pediatric gastroenterologists Dr. Paul Hammond, Dr. Charmaine Chai with us today to talk through how they manage disorders of gut brain interaction in children and adolescence. and Paul and Charmaine actually work together um at the Women's and Children's Hospital in Adelaide and they're here with us together.

Thanks Amy. Um so I'm not Paul Hammond. I'm Charmaine Shai. Um I'm a pediatric gastroenterenterologist based in Adelaide in South Australia where it's currently 7 a.m. and the sun is rising. Um my background is mostly in eurogastrology motility. I trained over in London for a couple of years and then spent some time trekking around Australia and have been back in Adelaide which is my hometown for a couple of years now.

Paul Hammond. I'm a pediatric gastronurologist. I work at Women's and Children's in Adelaide. Uh trained uh here and in Brisbane and work basically half time in uh the public sector and halfime in private practice for over 20 years. So um nice to be here and nice to um share uh our thoughts with you. We'll be referring to guidelines, the Rome five criteria, which have only recently been released and subsequent Espan and Espan uh guidelines have have followed. But we're really going to be focusing today on uh the practical side of things where we're going to be talking about three cases and uh bouncing off each other, how we might do it, and that won't always be the same necessarily. So, I'll just jump forward. So, first case, basically, GS.

Chapter 2: Case 1: a 6-year-old with acute tummy pain

So, I think this is a really classic tale. So, we've got a six-year-old girl here. She's been brought in, and really this is really more of a primary care setting. She's crying. She's been planning a tummy pain. This isn't booked in because mom called the rooms and basically said, "Oh, it's really, really urgent. You know, she really, really needs to be seen. She's been carried in. What do you want to know on the situation?" Um, yeah. Well, obviously there's a lot more information to to get on board. Um, so we're not saying this is obviously a DGBI lead hypnotherapy straight up. Um, you're worried that there's something acute and something urgent going on and you're uh really wondering what you do in the first instance. Does this person get managed in your primary care office or does this person go somewhere else?

Based on what the limited thing you've said, I would say this patient should go somewhere else. Um, and so when when we when you see this baby, but does she what does she look like? Is she or this child? Is she like she well? Is she unreal?

She's looking a little bit flushed in the cheeks. She's sort of curling up with her mom. She's a she's a little bit pale, but then equally, you know, you've not seen this kid in quite a while. And so you get someone amazingly, you've got a nurse in your clinic. They do some OBS for you, or you whip out the OBS yourself and do them yourself. And she's got a temperature of 37.8. eight. She's a little bit cleat for a six-year-old at 110 beats per minute.

And this is new for her, right? This is This pain is new. This is new. You've met her once before, quite a while ago when she was constipated. Mom booked in. This is really like a last minute add-on to your clinic cuz mom was so distressed. You happened to have a slot. Your secretary said yes. Here they are.

Um, right now to me this sounds like someone's got an acute abdominal pain and uh I think you need to be taking a history examining her and you know I'm is this a pimpitis? I don't know. And I don't think that's something that you think about for a week or two is it? I think it's something that you need to to sort out. So, I mean, is there anything that would worry me that this child has appendicitis or something uh something acute?

So, you know, when she's come into your room, she's pretty destructible. You've got some fun toys on your desk, and she seems to want to reach for them, but she's absolutely refusing to move. So, exactly. We're going to get a further history and a little bit more information about what's going on. She's never had tummy pain. There was really just that episode of constipation. When you ask her exactly where to localize the pan, she just says to you everywhere, which is a really good classic. Fine. When she went to sleep last night, woke up a little bit off and started to complain of tummy pain at breakfast and she's a little bit hot to touch. Parents don't have a thermometer. They're pretty sure it was a fever. I think that's pretty classic story. At least not vomited or done a poo so far today. No one else is sick at home.

Okay. Well, I'm I'm still thinking that this is an acute abdominal pain. Um I um I'm thinking that in in the real world we we see this person. Again, appendicitis always comes to mind. Is it or isn't an appendicitis? And I don't think there's enough here from what you've told me to say that this isn't appendicitis. Obviously, a lot of this stuff, as you know, Charmaine, is a bit of a vibe, as in what you sort of feel at the time. What do you see at the time? Does this person look really sick? Is there something more going on? Is there a test on this child's sick, so there won't be a test at school? But, um, there's a lot of vibe that you take from it. But from this presentation, I'm I'm still thinking, uh, am I going to be sitting on an appendicitis if I don't act on this case right now? And I'm conscious that we've got a really really wide audience and we'll have some pediatric rooms and we'll have some people who see lots of kids but quite probably some people who don't see that many children in their clinic rooms. This kid who really is not wanting to lie down, not wanting to move to the bed. What tips do you have to really sort of try and get that examination basically get them to lie down, get them to cooperate?

Yeah, it's really hard. Obviously distraction is good. You you sort of find whatever treat works um for them. You you you look for fun things around your office. You try to engage with them, get them to talk, find out what they're interested in. You look at their t-shirt. There something there the logo on their t-shirt. There's something on their t-shirt that uh basketball for sport for boys often works. Um yeah. So you you just basically try to engage with them, try to sort of be their friend. And you can do that as much. Some kids you do it as much as you like and at the end of the consultation you've got nowhere. And other times you can engage with them. can get them to smile. You can get them to look. You talk about something when you're feeling their belly. So distraction when feeling their belly is something I always do. And then I usually get them to focus on the pain and I usually see what the examination is like when they're focusing on the pain and when they're distracted. And that can be relevant.

My favorite in the little ones is certainly um I remember when I actually the emergency department here was uh being told you know you go hunting for whatever meal there might have been. So, do you think I can have a feel for what you've eaten for breakfast? This kids unfortunately have not had breakfast, but seeing if you can sort of make it a bit of a game. The other thing I've had to settle for from time to time is literally you've got a screaming 2-year-old, I've literally ended up saying to a parent, can you just give them a squeeze while you're cuddling them and we can just see what happens. Um, but I agree. I think that sometimes it's really useful to distract particularly the teenagers who you straight away you go and you touch their abdomen, they're like, "Ow, ow, and how." I really like to oscultate their abdomen where I tell them I'm gonna have a really good listen and then I pate with stethoscope to see what happens and then I make very pointed glances to a parent if it's really taking some examination with a stethoscope. Anyway, digress and making them I often do look at the parents when you're feeling their belly and when they're distracted and you can feel the the back of their abdomen with no distress and then when you ask them to concentrate on it and you put your hand on their belly and they start wincing and wiggling and carrying on often the parents will look at you and raise their eyebrows and that's often quite meaningful because you really have to engage parents here.

I point out that the child has just absolutely voted onto the bed. So they're telling me that they're a little bit sore. Probably doesn't mean so much when they jumped onto the bed.

Chapter 3: When pain becomes chronic: red flags, calprotectin and the DGBI conversation

Anyway, back to our case. You finally got her to lie down cuz you're an excellent pediatrician. Well done you. You reckon she's a little bit tender on that white Elliot plus appendicitis is the big question. You've packaged her off to the hospital. Yep. A week later get a discharge letter that says blood test normal sound showed me misenteric adonitis. What are your thoughts on misenteritis?

Oh, I didn't know you were going to ask me. Okay. Uh, good question. Does misenteric adenonitis exist? Yeah. Um, I'm not convinced that it does if if I'm honest. I know that um if you've got a viral illness and you got lymph nodes in your neck, axillary, etc., it can be a tiny bit tender. So, sort of makes sense that you can get a little bit of perhaps mild tenderness and tummy pain. Um a lot of the um functional abdominal pain disorders as you know Charmaine are often worse during viral infections when you get a viral infection you get lymphenopathy everywhere including lymphatinopathy in your abdomen. So if you have someone with a pain that's got worse perhaps in the context of the viral infection the ultrasonographer sees lymph nodes and you go oh it's methericadinitis and then that it's included in the letter to you parents clutch to it because it's a physical diagnosis they love that they love something an ultrasound can see a physical diagnosis um I guess the fact that it's basically managed with if you like reassurance and often it goes away It's probably a harmless diagnosis in a sense, but I I'm not necessarily sure that misenteric adinitis is the pathology that it's built up to be. So that's my opinion. What do you think?

Similarly, I I just wonder whether it's really we're placing significance on a radological finding. Yeah. Because basically it's something for us to see rather than actually causing any of the symptoms that the kid might be presenting with at the time. I think it's really it's interesting because I also get a lot of credits where they're just like, "Oh, we were an AD. They got told it's misenteric adonitis, but it's still going. Do you think we should do an the ultrasound to see if it's still there? And I think like no, it's I think it's more of a signifier as to probably an acute infection that might have happened at the time. And that might have tri.

Yeah, I agree. I mean, I I usually frame it in the context of reassurance. So, the ultrasound didn't show appendicitis. Um, often the report says prominent lymph nodes or something really vague like that. And I mean I've never seen uh lymphoma for example abdominal lymphoma diagnosed with an ultan like that but I say these are benign looking lymph nodes and so I I frame it in the context of nothing worrying rather than a positive pathological diagnosis if that makes sense. Yeah. And parents are looking for that. As you know, parents are clapsing on to it and and that comes up on children's probably a sneeze and interrogatenitis 3 years later when an ultrasound says prominent lymph nodes. Um so uh I think it's it's a common thing.

All right. So I don't believe in you've got another late you've got another late stage drop in your clinic and she's back basically. They did book a little bit further in the bunch this time. She is continuing to have tummy pain. and it's happening four times a week. She's just not making to school a lot. When you ask her this pain, she's got a little bit more of a descriptor this time. It's a pushing sensation and it feels like uh feels like almost like a drilling is what she describes. And she points to a better button. She can localize this time. She's looking a little bit more pale and mom said she's just been wiped. She's just really really tired and she's not really wanting to eat much. Where are you going to next? Are you going to be doing some investigations? What's your concept going to look like in this situation?

Um, so firstly, this is a this is a different field to three weeks ago. Um, I mean, she didn't have pendicilus. I sent her into the ED. I knew that she wouldn't have because I've read this case, but uh I still think that was the right thing to do at that time because if she did, that's something you don't want to miss. this this we're now dealing with a sort of a not quite a chronic abdominal pain but a non-accute abdominal uh pain here and you're also dealing with a situation where you know you don't have to uh act immediately you can sit down, think about it, plan, talk to the family. You're clearly going to want more information about what's going on. Um parents are going to want an answer. they're going to want a path pathological diagnosis. And I think it's really important that you don't automatically assume that there isn't one in this situation because I think there could be. And I think you look for things that might indicate organic pathology. You look for the tests that have been done. I don't know Charmaine if this girl has she had her blood test for example, has she had celiac disease curology done? She hasn't. No, I'd be really keen to do that in this um in this setting. I don't know if she's had any diarrhea or not, but is this girl got is this an early onset of inflammatory bowel disease? She's six. It's certainly within the age group we see. It's not typical, but it's within the age group we see. Um, do we need to be keeping that in mind? I don't know that I would necessarily be rushed right now to do a feal calectin with a relatively, if you like, a subacute history, but if this was going for 3 months, that might be something that that I would do. So that's that's how I'm thinking about it and how I'm I'm framing it. Is there something else going on in this girl's life? Is there something else going on in this family's life? So all of those things come out when you've put the abdominal pain. This child needs surgery or something out of the question. You then sort of try to work out exactly what brings this girl to your rooms today.

So investigation. So you mentioned you would think about doing celiac in this situation. And you're potentially not going to pull the trigger on a C protecting just yet just because it's a short history and if you've got gastro as you know your rate can be can be up so you don't want to have a false positive calro but you it's it's in your mindset you're thinking about it. Yeah. What things are going to I suppose what's going to flag for you that potentially you're dealing with a more organic pathology rather than something that's a s DGBI. So you mentioned diarrhea. What else sort of sets up a bit of a hike for you?

Uh obviously things like blood things like uh I mean she's not vomiting. Um is there some form of mechanic obstruction or anything like that? Not obviously the the pain I think as you know pain can be anywhere but if it's more central or generalized or moving around that has a much uh stronger functional feel than and we're trying to get away from the word functional aren't we? um more fast fulfilled than if it's localized to one side of the abdomen or something like that. There's no urary symptoms that you mentioned for example, but these are things that you are so you're really hunting for things that might give you something to look at with with regards to organic pathology. And if you find something, if you're concerned about it, I think you really need to look at that as part of your overall concept uh or uh approach for the case. I think if you um if if you think there there's probably a DGBI but we're checking seriacology but your crap's doing a car protection or something you might frame it in the context of here is what I think is going on however it's really important that we exclude organic pathology so we're going to do this but while we're doing this we're going to think about how we might manage that say yeah I I would say I was going to ask that actually how early do you brought that in basically that you think this might be a disorder of gut brain interaction.

Uh so early I mean I think when people walk out of the first consult with me I like them to um know what I think is going on and I think if this is likely uh if this is likely celiac disease if this is likely inflammatory bowel disease I don't do the whole DGBI talk at that point but I think if this is like DGBI but I just want to rule out other things those other things don't get as much air time. The DGBI gets the air time. Of course, parents are focusing on the other things, but I think you want to make it really clear what you think the most likely diagnosis is.

I find um what are your thoughts on perily pain pointing to a belly button? Oh, that's that's very common in DGBI, but we also do see it in kids with Crohn's. So, that that happens as well. I don't think that can be a differentiating factor but you know reassuring they do it sometimes. Yeah often is but I I think it depends on the context that it happens if if someone's pointing to the belly button a hemoglobin of 65 and a raised car protectant then you don't find that so reassuring even though they're pointing to the belly button. Well, I think in the context of a of a more typical DGBI presentation with reassuring investigations, I'm going this all fits. So, it's you're looking for things that fit with your hypothesis as you go along. Yeah. I have always wondered why kids point to the belly button. And interestingly, I had a couple of kids that would point to their gastrotomy as being a side of pain. And when I worked them up, I would point to nothing. And I just wonder whether it's just like it's an identifier of this is my belly. So, children have an identifier. Anyway, digress. a a point to point something to look at. Um, so you've set her off, done some investigations. She's everything's normal. So you've done a celiac and you did decide to crotch and that was normal. So hooray. It's been another two weeks. They've come back for investigations. She's now feeling sick most days. The family have kept a really diligent food diary. You glass. They've not noticed anything. Um, interestingly on that note, what do you think about a food diary? How often would you ask families to do it?

Um, hardly ever. They will typically tell me that they've done it and they will typically bring it out 12 pages of it and they I I think sometimes families feel that they can give you this and you will comb through it and find something on page nine and go, "Aha, this is the answer." It doesn't happen. I I usually will say to families, tell me what you you've diligently kept this diary, you found any connection because if they haven't found any connection, I'm not going to do that coming through the notes. So, um to be honest, usually for people who have done a free diary, have gone to that effort, they will have found something, cut it out, and not come to see me. So, if here in the room, it's almost always never going to show. That's my feeling. And I've also, you know, the reverse can be true. You have parents who say every time they had milk, they get tummy pain, diarrhea, and flatulence. And I'm wondering if we should pay out lactose because every time we use lactosefree milk, it doesn't happen. And it's like, um, yeah, of course. Yeah. So, yeah, sometimes they just want to hear it from us, I think.

Chapter 4: Treatment in young children: peppermint and gut-directed hypnotherapy

So, just for the sake of time, I'm just going to boo. So I mean I think in this situation anytime someone tells me about a pay attention to my PPR just because I read a paper that said that reflux can certainly cause sensations nausea and basically PPR trial didn't really do anything. You repeated some investigations and sending a new symptom again negative. You cancelled brilliantly though so they are on board with diagnos and accepting well done you. And you've decided to use a little bit of peppermint as your personality. You gave it peppermint tea. I know no real evidence for it, but getting a kid to swallow a capsule of pepper and oil challenging and sometimes I I tend to counselor families. I do suggest peppermint tea because I think it's a nice relaxing ritual. I find bedtime is often a time in which these pain flares sick off. So families really like it as well and they make it a little bit of a family ritual which is nice. You've also recommended gut directed hypnotherapy in this situation with some good effect. So she she's really looking a whole lot better. Mhm. Um, what are your go-tos in this situation? I wrote this case, so those are a few of my go-to duties.

Uh, look, I think you're right. I mean, I think I use GMT as well sometimes, and I agree it's often the ritual. I know that a lot of studies and the there's not been excellent studies in this space, but a lot of the studies that look at this sort of thing have have a high placebo response rate. And I don't care a placebo responseman. I don't care whether it's causing some physiological effect or not. A placebo response was the response and if it's working well I'm going great that's fantastic. So particularly if what you're doing is harmless. A placebo response is fine. So I think peppermint tea is a good example with regards to the um gut directed hypnotherapy. There's a few sites that I websites that I use particularly for a six-year-old. There's one called Imagine Action from Stanford University. Uh, I think that's really good. Uh, it's something that parents can do with the kids and I think that process might be almost as effective in a six-year-old is actually what they're seeing on the screen. Um, the hypnosis for abdominal pain website is another one that I that I often use. um for a six-year-old um things like the Nerv apply Nerv sponsoring this I I think six is young so I wouldn't I wouldn't be doing that in a in a six-year-old I think that's targeted much more towards your your teenager so that's sort of way I would approach it

certainly have made a plea to Nerva to move more into the pediatric sphere so we'll see what happens there um and I think it's a real pick with hypnotherapy in six-year-olds like the six-year-old who can't even sit still in a room who's just tearing up and down like they're never going to sit in the corner and do hypnotherapy. And I will mention to it, but I will also say to apparent I don't think they're going to do it. But sometimes sort of the little more timid kids who are more quietly sitting in New York from Ukraine, they probably are going to do it. And I make it a bit more of a family situation. I had interestingly um a child with autism spectrum disorder who had a lot of success. They would listen to it in the car together on the way to somewhere and it worked brilliantly. And I think that in this though, it's really about the cell and it's really about getting your parent across the line. Yep. Because I think your parent is such a huge if you can get them on board and believe in you, you're there pretty much like you're really threequarters of the way there. You got to get the kid off as well. But if you don't get the parent, you won't get particularly for a six-year-old. Maybe older teenagers are willing to have a different opinion to their parents. But usually the younger kids you you you really do need to get the the parents online. Yeah. Shame unconscious 25 was 26 minutes in. So how did this story end? They didn't they're candid or something.

No, they're all it was not functional abdominal pain otherwise specified because we don't leave that as a title anymore. It is now abdominal pain not otherwise specified in the uh row criteria and she did peppine oil. She absolutely believed everything you said and uh it slowly dissipated and you never saw them ever again. Good. Happy ending for everyone. Happy ending for everyone. So I might say is Annie, is there any are there any questions that have come up or what do we move straight on?

I do have one question for you from Beth. Um so how do you navigate a fecal cal protectin that's between 50 and 120?

Chapter 5: Q&A: the grey-zone faecal calprotectin

Um, it's stated as inconclusive, but it's still not negative for IBD. I'm wondering what your next steps are here, whether it's kids or adults, another test, or do you treat as though it's IBD?

So, so um I tend to repeat um the the practical side of this is that for someone presenting with undiagnosed untreated inflammatory bowel disease in pediatrics, it would be really unusual to get a calectin less than 150 say. So that's really unusual. Nonetheless, it is an abnormal test. I I typically leave it for a couple or a few weeks and I repeat it. Now, very rarely it'll come back as 450. You go on, they've got inflammatory bow disease. That that that rarely happens. I'd have to say much more likely it's going to come back as 40 something and then I'm I'm very reassured. I think Charlene is Yeah. I think in the absence of other red flag symptoms. So if there's no eye deficiency, if someone's gaining weight well and I'm not concerned from that perspective, I don't tend to like if it really is sort of spitting quite well with the disorder of gut bearing interaction and the setup is quite solid for that, then I don't necessarily repeat. I will always frame it every time I do a cow protecting before I even send it, I talk to a patient about what it is. You know, it's neutrfil product. It's white cells in the stool. It can be falsely elevated. a dose of ibuprofen push your cap protection up realistically if it gives you a gastratus and it is a moment in time and I very much have that spiel because you get people coming into your clinic office they're like oh it's 200 and I got told you're really panic and you're like yeah but it could just be that moment I'm still just going to repeat it in the absence of anything else going on and if it continues to be high we'll do something about it

I think the importance of a cow protection is the accuracy of it depends a lot on the pre-est likelihood so can someone who you really think it's got inflatory bowel disease. Um, if the car protectant is normal, you still might go on and do a colonoscopy because it's not a perfect test. It's a screening test with a sensitivity and a specificity equally, excuse me. Um, in someone who has a moderately high calic, say 200, 300 or something. If you really don't think they've got inflammatory bowel disease, it might be very reason to to just repeat it. So if someone you think has got inflammatory bowel disease, they've got a higher cal protection, you go on and you you investigate. If yeah, if if you don't think they've got inflammatory bowel disease, the cal protectant is normal. That's easy. So it's where the cal protectant uh disagrees with your clinical impression that I find is an individual nuance if that makes sense.

It's a hard thing is that I know that I've been to two different conferences in the last year where people have looked at case reports of some LPR 110 that then has Ali Chromes. So I I think that's a really difficult thing to sort of have in the back of my mind as I sort of manage all of these patients that you see lots and lots of patients. I think I probably have started repeating a little bit more after coming across those cases. But I think that ultimately it's just another tool that we have and you've got to look at it in conjunction with everything else. And if you've got someone who's pretty asymptomatic otherwise well you know is there much to be lost by saying well we're going to wait or you know it might present itself. you can always revisit that investigation like if someone develops iron deficiency if someone starts to have you know increasing like issues with weight you can always repeat your capin that's probably the other comment that I would make yeah I think yeah it depends on how worried you are about it um I think the equivalent in celiac disease is a raised glyen antibbody normally I call them but if you're really worried they might have it might be something you repeat you check an IGA that sort of thing um Amy should we move on to a second case Yeah, that sounds great. Thank you.

Chapter 6: Case 2: Christos, 16 — counselling families about DGBI

Cool. So, uh, Charmaine, this is Christos. He's a 16-year-old male who's otherwise well, he's a very good student at his local private school. Uh, he's had nausea for eight months, no vomiting, but when you mention vomiting, he sort of looks away and he becomes decidedly uncomfortable. He's his school attendance uh the past couple of terms is about 70%. does have lower abdominal pain at times which is not bad. You start asking about his stooling habit and uh he sort of switches off and you really get no information. He does have a bit of early satiety but his weight stable. He can sometimes get laded when he stands up uh has some sleep issues sometimes gets gets headaches. Um I move on to uh what the parents are doing. the parents uh are beside themselves uh about this and they're telling you that um you've got to you got to do something about this. They want you to have a look in do a do an endoscopy, do a colonoscopy, do an MRI of his whole body. You've got to find out what's going on. I didn't go to the examination. So this fit healthy looking young man um heightened waiver on the 50th and 25th percentile respectively. He looks really well, mildly tender in the lower abdomen with a bit of firm stool carpable, but basically he's he's a really a really fit uh a really fit kid. So you you've talked to him, you've talked to the family, and then you start, you know, just mentioning how the gut and the brain are connected and both parents who are with him at the time can't even believe that you're going there. Having been to a few GPS who have done the same thing, they they know where this is going. But yeah, what are you doing now? This is in your in your clinic. First first time you met Christos. What a start.

I mean I Okay, so I probably would say that, you know, in terms of workup, I would like a fal cap protection. I kind of tend to do cap protection in most of my patients. I think it's a really it's an easy test. It's a reassuring test and it's a really nice one to help explain, you know, in terms of DGBI versus organic diseases basically. Um, I mean there's a lot going on here. It's it sounds like he's not giving you a whole lot in terms of history basically. Um, I will say school 70% said not terrible given all of the symptoms, but anyway. Um, and I think that certainly when I was doing this history, I would try and focus on Christos and try to build that rapport in terms of these parents and not blame that you're going there. I think obviously they're they're carrying in stigma that potentially someone else has had this diagnosis put in their direction previously or what else is going on.

When I start to broach this, I guess the way that I approach this is I sort of I tend to approach this conversation of okay, let's have a bit of a chat about what's going on. And I start by the way that I start pretty much I've worked out I do it exactly the same way pretty much every single time. The way that I do it is I will Google image search a picture of a GI tract and pull that up on my screen and I say to people do you recognize this until you know what this is and I should just had a proper image instead. I literally pull people every time. And then I go through with the family and the kiddum. I go through literally from mouth all the way down to rectum, the gut, the different roles of it, the different roles of different parts of the gut, what it does in relatively simplistic terms. And then I point out that what a doctor's really good at, we're really really good at identifying problems, the lining of everything. So we're really good at looking for inflammatory issues or and I sort of frame it differently depending on age of child. But then I point out that there are so many other things that the gut has to do. So it's got to move. It's got sensation and there's lots of signalings and it's really really complicated and all of those things can go wrong and then your gut is the other thing that's giving you pain. But it's really good brain that has to give you pain and that's where your gut brain interaction comes in.

That's when they interrupt you and they say you're not telling me he's in all in his head. Are you? You mentioned the brain. All of the GPS we've seen have said it's all in his head and you're telling me it's all in his head. And probably my clarification is I'm not at all sack. It's all in the head. And I would say that disorders of gut brain interaction are much more complicated than that. Disorders of gut brain interaction. What do they really encompass? It's a it's a wide range of diseases. We know that it's contributed by we know that we have alterations in terms of viseral sensitivity. We know that there are genetic factors. We know there are microbiome factors. We know that there are different things in early life that predispose you to disorder gut brain interaction. We know that there is not necessarily a association where stress and anxiety is a precursor to the development of disorder interaction. So, and I think that I usually face that head on and I usually say to people, I'm not at all saying it's in your head and that's not what this is. what this is, it's the combination of things and what's really important is for us to rule out is this a problem of aligning with something and then we go through tests and we talk about you know why is capexin important all of the relatively you know reassuring factors like his weight is stable that's a really really reassuring thing that his gut is doing exactly what it's meant to do I find an alternating bowel habit sometimes in history is a really reassuring thing like if your colon can go from constipation to diarrhea from one day to the eggs, it's probably not inflammation. Like your gut probably isn't healing up in, you know, a 24-hour time spare. And I point that out to parents and they're usually then I'm like, "Oh, yeah, that makes a lot of sense." Which says to us, we're probably dealing with a movement thing. And how does the brain side come into it? Well, really, you know, we know that your brain influences the way your gut move. It it moves. It influences your motility. All of your neurotransmitters come into play. So, they are very, very tied together.

you do you bring in the whole it's not in your head um sort of a discussion with them? Do you wake until parents object and bring it up or I I often get in early and say I want to be really clear about this. This is not in your head. You probably heard that from other people. This is not all in your head. However, what's happening in your head, your thoughts, your experiences do influence what's happening in your gut. But I want to be really clear. this is not all in your head. This is not all anxiety. This is not all that. And often you can feel a weight lift off the child and their parents shoulders when you say that. And then you then you're engaged with them. I think often if you say that then they go, "Okay, well, we're listening now."

Yeah. Sometimes I do a bit of sap in my history taking part for it where like you can feel it in the room, but it's just not going to go down well. And so I'll particularly ask about early life and infancy and PPI use and antibiotic use and profound episodes of gastroentereritis because those are all things that have been recognized risk factors for disorder of gut brain interaction. And I'll point that out and I'll say you've got a setup here. You know there are all of these things that are outside of your control that occurred in life and they have also contributed to why we're here. Um so yeah I tend to not get too many IO fanies when I discuss a DGBI which is particularly nuts. Yeah, I think so. I I think some families will come in and sometimes you you sense that they're almost spoiling for a fight and you you've just got to head that off early before the before it starts and we just often the challenge is is get it in on board and get other family that you would know are really open to the idea of the concept and often say yeah I sort of I figured that myself. So that that can often be be quite good. Um Christos um went away, listened to all the things that you have to say. You did a great job of counseling him, but then nine months later he comes back and he's more

Chapter 7: IBS-mixed: managing constipation and diarrhoea together

got lower tummy pain now and and his his pooing is infrequent. Stools are are very hard. He'd been missing a bit of stool, but more through um pain that gets better when when he does a poo. He's he's had some uh when he's been sort of three or four days about going, parrot would give him a sache of mocoll and sometimes he'll go afterwards, sometimes he wouldn't, but they really delighted that he's not nauseated anymore, but he now got this other problem. How do you what do you do?

I think it's really So I interestingly I I didn't realize that the IBS subclaps hadn't come into Rome five uh into Rome for pediatrics until I got Rome five where it is now in pediatrics. So this child is obviously seen hipping with IBS of a mixed subtype. I will admit I don't calculate the percentages of the time. Every single time I see someone I sort of say, well, you're swinging between both your IBS mix. But I think it's a really useful thing to know because it helps you work out which treatment pathway you're going to go down. IBS mixed, you're going to have a hard time managing your symptoms. um in terms of someone who's swinging between constipation and diarrhea because it is unpredictable and I think in this situation and part of my conversation is going to be around well what is troubling to the you the most and what are we going to target in this situation but to be honest the IBS mix and I'm not just saying this because this is a never talk but genuinely I think that this is really where get gut fit hypnotherapy comes into it because you can't just slow them down you can't just give them and pure again realistically we're going to have to try and untangle or what's underpinning it.

I do realize gut- directed hypnotherapy for that in terms of starting to minimize symptoms. I think a lot of that is about how your expectations around gut directed hypnotherapy. I'm pretty clear. I say this isn't a magic wand. It's not going to fix everything, but I do expect it to really improve things and settle it down. And then I outline to people, do you know in terms of what you're um investing here, it's around about, you know, 10 to 15 minutes a day. I suggest you do you do the reading as well because it's really useful to understand what's going on and but that can be a really I think that I would recommend gut direct hypnotherapy in this situation and then I think getting a feel as to what their response is to that but then also talking through you know I would give it a go have a think about what else is bothering you and then we can have a look at sort of more medication some pharmacological intervention if in six to eight weeks this is not going in the right direction we can look at next steps.

I think that's a good point. I think you also made a good point about the different subtypes of IBS for example and I think the Rome five criteria are really good in as much as they they do differentiate between uh the criteria or the guidelines for clinical practice and the guidelines for research. So I think it's very sensible that in research they have really strict criteria and to enter that research program you have to meet all the criteria and I think in clinical practice you often have someone who virtually meet the criteria but not exactly. You're going to manage that person and I think you know it's not as though people sit in an IBS mixed box and they're all the same. It's a spectrum and you have to sort of put some and some IBS mixed up probably a bit more constipation and diarrhea and so I think you just have to manage personal therapy without without trying to fit them into a into a box. Um conscious of time Amy I wonder if there's any questions that you need Shaman and I to briefly address.

Um just one really quick one um about I guess at the start. So, when you have the the parents that are quite overwhelmed and and the patient coming in that doesn't want to give you much, um, do you ever consider speaking to the the patient or the 16-year-old without the parents in the room? Is that something that you will consider or is that something that has to be driven by the parent?

It's a it's a good question. Um, in my practice, I will I rarely see um teenagers on their own. I I will sometimes see, for example, people with a chronic condition who I've been managing for a long time who I'm transitioning towards adulthood and I think it's really nice when a a 17 and a half year old comes to their appointment on their own. I'm I'm feeling like actually you've done a good job of getting this person ready to to be an adult. But I I think for kids to come in on their own, that's really unusual both in in the hospital practice and and also here sometimes you'll see a teenager for example come in with a grandparent or an uncle or something and they will independently give give the history um etc. And I think that that shows a lot of maturity around the family when that when that happens. I think what you see a lot more is parents who two parents who have canled their work and they've come in and and you see them hovering around with their um 16year-old who wants to be cool and their parents aren't letting them. So I certainly see I'm not going to use the word over parenting but I think I can throw that vibe out there. Yeah, I would suspect in this particular case I probably wouldn't offer it. And I think the reason why is that sometimes there seems to be this impression that parents are worried about what you're going to say when they're not in the room. And I think this case gives a little bit of that impression. It's interesting that certainly it seems like there are moments built in where you know he sort of wits his and grimaces and it's like is he going to give me something more? But I find that I always direct my concert at the kid and sometimes I just they give you nothing and you get nowhere. Um but yeah, it's a useful thing to offer. I have parents who sometimes will offer to do it, which is interesting. Um some of the stuff that is said when parents are out of the room is really really interesting. Um but yeah, useful tool to have. I probably do it more I agree with like transitioning patients to a long term of mine. Um but I don't know if I would do it in this case or if you've seen someone for a third or fourth time and you think there might be something something else going on. But but usually parents don't want that. And and frankly I I ask for all my sort of teenage patients. I always start with uh I need to know why you're here. Who's going to start? Are you going to start? And I invite the child to go the adolescent to go first. And I would say 80 or 90% of the time I go no mom can talk or dad can talk. And that and that immediately puts you in some degree of a framework of where this family is and how this family is. And I find it genuinely reassuring when a teenager say, "No, I can let let me start. I've got this." And I I think that young person is approaching that with a with a maturity and an independent. So that that's always a good sign in my view. Great. Thank you.

Chapter 8: Case 3: AM, 16, with cramping pain and a family history of IBD

All right. Go on to this meaty case, which I'm going to jump to some of the pressure points on. Um, so this is am. So am 16year-old, she's had tummy pain for two months now. It's perumbol and cramping. Maybe it's worse when she eats. It's not really sure. She's missing a lot of school. No fevers, no vomiting, no changes in bowel habit or loss of appetite. Previously, she's had a chronic cough. She's had recurrent headaches. She's had her tease and out, tonslectomy, and ectomy. She's pretty of a she's off a pretty slim build, but healthy BMI promises when with discomfort when you're um have pain in your abdomen and there's no organo megalade. You've decided, you know what? Let's just do a scope anyway. Crack on. The family are pretty worried. They're coma family tree. There's a lot of inflammatory bowel disease. Uh sometimes, actually, now that we really think about it, she's having a bit of non-bloody diarrhea. Will you do a colonoscopy anywhere? You've not done a car yet?

Um almost certainly not is the answer to that. So, definitely I'll do uh a car protection. I'll definitely do a ciac cerology here. Um I think it I think it really depends on the circumstances. Uh but the default answer is no, I won't. And I will uh so when when I'm doing for example a colonoscopy or discussing a colonoscopy, if it's someone who I think's got Cro's disease, he really needs to to have it done. Whilst I do numerically talk about the risk, I I I probably don't focus on it as much as the child who I don't think has a serious pathology where parents are demanding it and that one in a thousand risk but suddenly becomes really really big whereas someone who's probably got Crohn's disease a one in a thousand risk is really really small compared to the disease itself. But I I usually target the way I talk about those tests, parents will come into demanding it. And my my feeling is um that probably of the people who ask for felonoscopies, I reckon probably 10 or 20% get them. Um and typically it's where I'm worried there's something going on. They don't have to ask too much. But what what about you? Do you do a coloss in this case?

No, not if the capra is normal. I usually say I'm going to do a capra while we're waiting for the scope essentially better around a week to come back here and then I'm pretty clear where I say it gives normal mean not done colonoscopy. If it's abnormal I probably would just opportunistically get it done. Um the other thing I would do in this case would be dice though at the time just as a quick mention. I've been one sucrose deficiency as well. Um and I know there's a little bit more evidence about it. So just I think if there's di if there's diarrhea in the mix I think that that helps. I I don't do I do dissects on minority of my cases, but certainly where where diarrhea is a significant factor, I think that's that's really helpful and and useful.

You've decided to do it anyway. You found a bit of lymphoid hyperplasia in the alium and the seeum not particularly useful and a mild non-specific gastritis. And I think I specifically put that in there then because those are things that you see that you then have to explain but ultimately don't really mean anything. I mean there's I think there was a bit of evidence about lymphat hypoplasia and DGBI interestingly in some recollection something that I've read one time but ultimately a reassuring result is what I would say however things have changed she's back for review and she's actually really nauseous and she's starting to vomit effortless only after meals but then she wretches until she's bringing up that really yellow acidy stuff she's also starting to really struggle to pass a batch and she's going four to five days between episode could this be gastrop roperesis. They really want to know. They've been looking at on the internet and gastroparesis is everywhere.

Chapter 9: Gastroparesis, POTS, MCAS and staying in your lane

And the other thing is she wears an Apple Watch. Sometimes her heart rate gets quite high. Should they be thinking about POTS? How would you tackle this? I I feel like we are seeing a lot of this in our clinic. I think everyone is seeing a lot of this in their clinic and and they're complicated. How would you answer that?

Um, so I think you have to address all of the individual concerns um, individually. I think the gastroparesis question is is a really interesting one. What is gastroparesis? That that's the topic of an individual talk and how do you look for it? When do you look for it? But yeah, I think you I think you get nowhere if you immediately rule out all those things. I think you have to describe it in it in and they'll often use the term dish autonomia and and in a sense this is what is happening here. this person's autonomic ner nervous system isn't working properly assuming they haven't got something like sm or something like that and you always have to be conscious of organic pathology even in someone to have a DGBI 6 months ago that they might develop um organic pathology but I think you have to address all of those individual concerns because that's why the family are here and I think until those things are addressed you'll probably go to struggle to get them on board But I think whilst you're addressing them, you need to have some sort of plan to work towards managing the dominant symptoms whilst you're perhaps testing perhaps not. I so

I suppose a bit of a plug for the new there's a new guideline that's coming out or clinical practice guideline that's come out for the gastro gastroenterology society of Australia really looking at gastroparesis and sort of trying to get idiopathic gastroparesis out of the picture. I think the big question that's come across in the neurogastrobology community is that is gastroparesis really an entity or does it sit in a spectrum functional dyslexia? I if I have this come up I have a pretty big discussion about the evidence base which is that there is some really interesting stuff you know gastroparesis how do we diagnose it we do a gastric emptying study gastric emptying studies a moment a time a moment a time solid gastric emptying study is useful liquid gastric emptying studies not um solid gastric emptying studies can be can be sometimes complicated to get and it is it's a day right like it's a moment in time and that's ultimately what you're trying to based treatment around and there's so much about motility of the stomach that we just don't understand. We know it's got all these different rhythms. We know that there is not great correlation between gastric emptying time and symptoms of nausea in particular. And interestingly, I would say that um gastric some of the gastric pacemaker work was really interesting where it looked at improvement in symptoms but there was not necessarily an improvement in your gastric emptying time. So they don't correlate. So really we need to sort of reook at this entire picture of you know is this gastroparesa or this nausea in a functional dispatchic picture. I tend to stay away from it and I tend to not do a gastrokeing study because I think it's just going to get me into trouble basically and the plot situation I tend to basically just say you need to discuss this with someone else and not cardiologist.

Yeah. all kind words but that's the I think that's right and I think I mean I think our role in some extent is staying in our lane of being gastroenterenterologist but obviously psychological factors you sort of have to sort of dip your toe in the water there but not not fully jump in to the same I mean if we look at things like anxiety I'll often mention that you know this might be contributed to the symptoms but I'm not going to be putting patients on antiolytic medications and and things like that. I think um there's certainly a role for sending someone back to the GP and if they do need another subsp specialist or a general pediatrician and I think this case here is a really good case for this person depending on how disabled they are by the symptoms. If if they're not particularly disabled and the family o over Googled, it might be that you can really reassure them and uh that it won't go anywhere. But if this is a child who is becoming somewhat disabled, I think there's a really good role for a general pediatrician who can look at and address all of these individual things and and refer when appropriate.

Gets a little bit worse. So on bird history it's so rumination was where we're really getting into this cancer sort of brain interaction. I find the earlier and you call rumination the better off you are. I would say a really good resource if anyone needs one is I direct everyone do the children's hospital of Philadelphia website for rumination mostly because it's the first well the best resource I found that doesn't say that you need to scope them when you're doing investigations the political diagnosis and I think the sooner they accept diagnosis the much better off you seem to be on the pathway to resolution now this family has had a Facebook support group there's lots of them out there and a lot of people have got similar problems and what they want to know she's a bit bendy could you see hypermobility syndrome. She's always been a bit prone to hay fever. She gets a little bit rashy. What about mass cell activation syndrome and sometimes she gets it at the upper right side of her abdomen. Are you sure there's nothing going to go?

Yeah. So you've you've raised a whole lot of things and I think I've probably addressed a lot of those things by saying I think if you can reassure someone quickly someone who's functionally actually doing reasonably well often you done a service by doing that. I think if someone is doing really badly, I do think you need a general pediatrician or a very good GP who can coordinate and pain the family um in the situation because they're going to go off into a deeper dive into all of this and find more and more things. Um you haven't mentioned vascular compression syndrome. So do you bring that up in your consultation? Probably not. That's another thing sometimes have. Have you sometimes I just call it and I will talk about I say to people you're going to come across vascular compression syndromes and this is my opinion of vascular compression syndromes which is that I don't like looking for them necessarily other than SMA syndrome because when you look at studies around it there are some studies that say that intervention is useful but equally there are other studies that say that you find the same anatomical changes on autopsy findings and asytomatic people so it's just this question of causality I think that comes into play and I I don't I don't intend to go looking for them. That's my Yeah, have a similar um a similar approach. But um yeah, so it's really I've been sorry stay in your lane doing doing your thing, doing what you're good at and trying to uh trying to contain the family, keep them on board. Another question you must um I think just a very comment around the gold.

Oh, the gold. Yeah. So I think uh right out quadrant uh pain and particularly if it relates to eating uh if you haven't had an ultrasound you need an ultrasound if they've got gallstones if they've got you know that that might take you down a certain path. I I suspect you said that because um you know that the Rome five criteria have in pediatric space included billery discomia is a diagnosis. I'm not sure that's the terminology that they use for it but um billary disanesia is commonly uh di or moderate commonly diagnosed in adult practice not commonly in pediatric practice. I've diagnosed a few but but not um not too many. So yeah, I think um yeah, localizing pain to a certain part of the abdomen in my view mandates that you consider structures consistent with such pain as a potential source of the pain and I think it mandates looking into it to a reasonable point depending on on how disabled the person is and how strong the right upper quadrant focus is. I think if it's dominantly right upper quadrant A then you might look a very carefully at it but if explained all over is it sometimes in the right upper quadrant yeah sometimes but also sometimes left lot I think that's less uh indicated to look perhaps look at that in detail my last slide so things have just escalated essentially she's getting more distraught missing lots of school beginning to lose weight they're actually thinking they like to try cheap feeding and I think that she might need some IV toilets what do you think

Uh I think that is a really slippery slope. Um and I

Chapter 10: Escalation, the MDT, and closing principles

well generally I discourage it. Now having said that I think it depends on the circumstance. There are times when that is relevant and is appropriate. But I think if that's the case that's probably someone who requires inpatient management of a multidisciplinary team to look at it in in detail. um I don't think you're heading towards PN but that parental nutrition but that's potentially where these cases can can go as well. So I think we all see these tests. I know our interstate colleagues had cases that are incredibly challenging as we do around this space and I think my view is bringing in lots of people bringing in even colleagues in the same field for another opinion uh about what's going on. I think doing all of that early is is really in the patients and your own best interest.

I think this is really the role of the really good multi-disiplinary team which unfortunately we we don't have. we would really really like one but there is mention of it in if people haven't read it the May gastroenterology edition is basically all about bone 5 and has some really really great articles about sort of gut brain interaction and it makes mention about the importance of a really great noral neuro team for these sorts of patients in particular I think um the St. Vincson's team over in Melbourne have published the mantra study looking at the uh the multi-disiplinary team versus the isolated gastroentermologist. So there are supporting evidence coming out to try and support those business cases to really try and get a multi-d across. I agree these are really really complicated cases and I think the thing that I try and keep in mind when I manage them and try and push across when I'm talking to families is while they're demanding all of these things and asking all of these things one they're asking ultimately they're seeing you for your expertise and opinion not for you to just order tests and order medications and two ultimately you know come back to our cruel which is do no harm. If you think that an intervention or an investigation might lead you down that pathway of harm, don't do it. And have very frank conversations around why you're not doing it. That's probably why. And see, if you're unclear or overure, seek the advice of a colleague. Ask your colleague. I think that makes you feel uh a lot better. Yeah.

Amy, I'm conscious that I'm conscious of time here. Is there any questions that we need to answer or anything else that we need to address?

Well, I think we are pretty good for questions. I think you've covered everything. So, thank you so much for sharing your expertise and your thoughts and opinions on these things because I think it really really helps no matter what type of practitioner you are um to go not to sound cringe but to go beyond the the guidelines and the and the research and actually talk about how things work in real life.

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