Overview
Definition:
Functional dyspepsia (FD) is characterized by persistent or recurrent upper abdominal pain or discomfort, without evidence of structural disease, occurring after meals or related to meals
Gastroesophageal reflux disease (GERD) is a chronic condition where stomach acid or bile irritates the food pipe lining, leading to symptoms like heartburn and regurgitation
In children, GERD can present with a broader range of symptoms beyond typical adult GERD
Differentiating these is crucial for appropriate management in school-age children.
Epidemiology:
Functional dyspepsia is a common functional gastrointestinal disorder in children and adolescents, with prevalence rates varying widely (reported from 10% to 30% in some studies) and often overlapping with other functional GI disorders
GERD is also highly prevalent in children, with estimates ranging from 10% to 20% for symptomatic GERD and higher for physiological reflux
School-age children represent a significant demographic experiencing both conditions.
Clinical Significance:
Accurate differentiation between FD and GERD in school-age children is vital for effective treatment and to avoid unnecessary investigations or prolonged medicalization
Misdiagnosis can lead to suboptimal care, impacting the child's quality of life, school attendance, and nutritional status
Understanding the distinct pathophysiologies and diagnostic approaches is essential for pediatric residents preparing for DNB and NEET SS examinations.
Clinical Presentation
Symptoms:
Functional Dyspepsia: Epigastric pain or burning
Postprandial fullness or early satiety
Bloating
Nausea
Upper abdominal discomfort
Absence of significant heartburn or regurgitation as the predominant symptom
GERD: Heartburn
Regurgitation of gastric contents
Esophagitis symptoms (dysphagia, odynophagia)
In infants and younger children, GERD may present atypically with irritability, poor feeding, vomiting, failure to thrive, coughing, wheezing, or apnea
School-age children typically present with more classic symptoms but may also have atypical manifestations.
Signs:
Physical examination in both conditions is often normal
Tenderness on epigastric palpation may be present in FD
Signs of malnutrition or anemia may suggest more severe or complicated GERD, though less common in school-age children with typical presentations
Examination should focus on ruling out red flags such as weight loss, chronic vomiting, hematemesis, dysphagia, or palpable masses.
Diagnostic Criteria:
Rome IV criteria for Functional Dyspepsia (in children): Criteria include bothersome upper abdominal pain or discomfort occurring on average at least twice per week for at least two months, with symptom onset for at least two months prior to diagnosis
Symptoms must include either postprandial fullness or early satiety, or epigastric burning or epigastric pain
Criteria also specify the absence of evidence of structural disease that explains the symptoms
For GERD, diagnosis is often clinical but may be supported by investigations like pH monitoring or endoscopy if symptoms are persistent or severe.
Diagnostic Approach
History Taking:
Detailed history is paramount
Inquire about symptom character, frequency, duration, triggers (food, posture, time of day)
Ask about associated symptoms like nausea, vomiting, abdominal pain, changes in bowel habits, weight loss, fever
Assess impact on daily activities, school attendance, and sleep
Red flags: dysphagia, odynophagia, vomiting of blood or bile, unintentional weight loss, chronic cough, stridor, hoarseness, significant abdominal tenderness, or family history of GI malignancy.
Physical Examination:
Perform a thorough abdominal examination, checking for tenderness (epigastric, diffuse), organomegaly, masses, and ascites
Assess for signs of dehydration or malnutrition
Evaluate vital signs
A systematic examination may help rule out other causes of abdominal pain.
Investigations:
For suspected Functional Dyspepsia: Upper GI endoscopy with biopsies is often reserved for children with alarm symptoms or persistent symptoms unresponsive to empiric therapy, to rule out peptic ulcer disease, esophagitis, or celiac disease
Helicobacter pylori testing (stool antigen or breath test) may be considered if there is a suspicion for H
pylori-related dyspepsia
For suspected GERD: In school-age children with typical symptoms and no alarm features, empiric trial of acid suppression therapy may be sufficient
If symptoms are persistent, severe, or atypical, upper GI endoscopy, 24-hour esophageal pH monitoring, or impedance monitoring may be indicated to confirm diagnosis and assess severity.
Differential Diagnosis:
Conditions to consider include peptic ulcer disease, H
pylori infection, gastroesophageal reflux disease (GERD), eosinophilic esophagitis, celiac disease, irritable bowel syndrome (IBS), functional abdominal pain, gallbladder disease, pancreatitis, intestinal parasites, and anxiety-related somatic symptoms
Distinguishing features for FD include the absence of alarm symptoms and a primary focus on upper abdominal discomfort or pain related to eating
GERD is primarily distinguished by heartburn and regurgitation, although atypical symptoms can overlap.
Management
Initial Management:
For suspected Functional Dyspepsia: Lifestyle modifications including dietary adjustments (avoiding trigger foods like fatty or spicy foods, caffeine, carbonated drinks), regular meal patterns, and stress management techniques
For suspected GERD: Lifestyle modifications including avoiding trigger foods, smaller more frequent meals, upright posture after meals, and elevating the head of the bed if nocturnal symptoms are present.
Medical Management:
Functional Dyspepsia: Proton pump inhibitors (PPIs) may be used empirically for a trial of 4-8 weeks, especially if epigastric burning is a prominent symptom
Prokinetics (e.g., domperidone, though use is restricted in some regions) or low-dose tricyclic antidepressants (TCAs) may be considered for refractory symptoms under specialist guidance
GERD: PPIs are the mainstay of medical therapy
Doses are weight-based and adjusted based on response
Examples include Omeprazole (0.5-1 mg/kg/day divided BID, max 40 mg/day) or Pantoprazole (0.5-1 mg/kg/day divided BID, max 40 mg/day)
H2 receptor antagonists may be used for milder symptoms
Antacids can provide short-term relief.
Surgical Management:
Surgical management (e.g., Nissen fundoplication) is rarely indicated for functional dyspepsia
For GERD, surgery is generally reserved for severe, refractory cases with complications such as strictures or Barrett's esophagus, or in the presence of a significant hiatal hernia, after failure of medical management
This is very uncommon in school-age children without specific indications.
Supportive Care:
Psychological support and reassurance are crucial for both conditions, given their functional nature and impact on quality of life
Education of the child and family about the condition, management plan, and expected outcomes is vital
Nutritional assessment and support may be needed if there are concerns about growth or development, particularly with severe GERD.
Complications
Early Complications:
For FD: Chronic discomfort, anxiety, and impact on social and academic life
For GERD: Esophagitis, erosions, bleeding (rare in school-age), aspiration pneumonia (more common in infants but possible), laryngitis, and sinusitis.
Late Complications:
For FD: Persistence of symptoms leading to chronic pain syndromes and functional impairments
For GERD: Strictures, Barrett's esophagus (very rare in children but a long-term risk with chronic untreated esophagitis), dental erosion
In severe, untreated cases, failure to thrive can be a late complication, though less common in school-age children.
Prevention Strategies:
For FD: Education on trigger avoidance and stress management
For GERD: Consistent adherence to lifestyle modifications and medical therapy, regular follow-up, and prompt management of escalating symptoms to prevent esophagitis and its sequelae.
Prognosis
Factors Affecting Prognosis:
For FD: Factors include the presence of comorbid functional GI disorders, psychological distress, and effectiveness of lifestyle modifications and empiric therapy
For GERD: Severity of reflux, presence of esophagitis, adherence to treatment, and underlying anatomical or motility disorders can influence prognosis
Early diagnosis and appropriate management generally lead to a good prognosis for both.
Outcomes:
Most children with functional dyspepsia experience symptom improvement with lifestyle changes and empiric therapy, though relapses can occur
GERD in children is often outgrown in adolescence, but a significant proportion may have persistent symptoms into adulthood
Long-term outcomes depend on the severity and management of the condition.
Follow Up:
Regular follow-up with a pediatrician or pediatric gastroenterologist is recommended, especially for children with persistent or severe symptoms, or those on long-term medication
Follow-up should focus on symptom assessment, medication adherence, monitoring for side effects, and reassessment of the diagnostic approach if symptoms do not improve.
Key Points
Exam Focus:
DNB/NEET SS examiners often test the ability to differentiate common pediatric GI complaints
Recognize that in school-age children, FD and GERD share symptoms but have distinct primary features
Rome IV criteria for FD are important
Empiric PPI trials are common for suspected GERD and sometimes for FD.
Clinical Pearls:
Always consider red flags (weight loss, dysphagia, etc.) to exclude organic pathology
A careful history focusing on symptom triggers and impact on daily life is key
Remember that atypical GERD presentations are more common in younger children but can persist
Reassurance and a strong doctor-patient relationship are crucial for managing functional disorders.
Common Mistakes:
Over-investigating for FD when symptoms are mild and without alarm features
Assuming all upper abdominal pain in children is GERD without considering FD
Not adequately exploring lifestyle and psychological factors
Inappropriate or prolonged use of PPIs without reassessment
Failing to recognize red flags and delaying appropriate workup for serious organic conditions.