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Gastrointestinal (GI) disorders in children are prevalent pediatric conditions that utilize significant health care resources (Guthery, Hutchings, Dean, & Hoff, 2004; Kugathasan et al., 2003). These disorders have a significant impact on a child7#x2019;s sense of physical and emotional well-being (Hyams, 2002; Loonen, Grootenhuis, Last, & Derkx, 2004; Voskuiji et al., 2004; Walker, 1999), and the ripple effects of these disorders extend to family members and caregivers. Pediatric gastrointestinal disorders can cause pain due to the symptoms of the disorder, the diagnostic testing, or the treatment modalities. Embarrassment due to symptoms such as repeated vomiting, fear of choking, excess flatulence, fecal soiling, the urgency to use the bathroom, or the sequelae of the disorder such as having an ostomy or episodes of fecal incontinence, is common and often traumatic for children, especially adolescents. School avoidance can become a chronic problem due to the hesitancy of using the toilets at school.

This chapter provides a historical and theoretical context for a biopsychosocial approach to the pediatric gastrointestinal (GI) disorders. The discussion follows a progression from general mind/body issues to the specific relationship between mind/body issues in pediatric GI disorders. Then pediatric functional GI disorders are examined. Finally, the basis for pediatric GI disorders from a brain-gut axis perspective is discussed.

Inflammatory bowel disease (IBD) is an inflammatory disease of the digestive tract, which includes three distinct diagnoses categories: ulcerative colitis (UC), Crohn’s disease (CD) and indeterminate colitis (IC). IBD is characterized by symptoms of abdominal pain, fatigue, weight loss, diarrhea, cramping, and joint pain. These symptoms often interfere with everyday life and can have long-term effects, such as delayed sexual maturity and growth retardation. In CD, the inflammation extends through the full thickness of the intestinal wall, and this inflammation may affect any part of the GI tract from the mouth to the skin around the anus. In UC, the inflammation is confined to the large intestine, and it is restricted to the inner lining of the colon. Figures 3.1 and 3.2 diagram the different areas of inflammation in CD and UC in children.

The esophagus is a strong, muscular hollow tube, which connects the mouth to the stomach, starting at the cricopharyngeal muscle to a point below the diaphragm where it joins the stomach. The esophagus has two major functions: to propel fluid or food from the mouth into the stomach and to prevent retrograde flow of gastric contents inbetween swallows. These two apparently simple tasks are accomplished by complex mechanisms (Vandenplas & Hassall, 2002). The esophagus is not involved in the absorption, storage, or the digestion of food. The esophagus is closed at the top by the upper esophageal sphincter (UES) and at the lower end by the lower esophageal sphincter (LES). The wall of the esophagus is composed of muscle; the upper third is striated muscle, the lower third is smooth muscle, and the middle portion is composed of a mixture of smooth and striated muscle (Whitehead & Schuster, 1985). These layers of muscle squeeze the food along by a wavelike motion known as peristalsis, which is controlled by the autonomic nervous system.

Rumination is characterized by voluntary regurgitation of stomach contents into the mouth, which are either expectorated or rechewed and reswallowed. The regurgitation is not caused by an associated gastrointestinal condition or other medical disorder. Rumination is a rare disorder that is most commonly seen in infants or persons who are developmentally disabled. It also occurs in children, adolescents, and adults with normal intelligence, albeit much less often. Insufficient awareness of the condition has led to underdiagnosis, with rumination frequently confused with bulimia nervosa, gastroesophageal reflux disease, and upper gastrointestinal motility disorders (Chial, Camilleri, Williams, Litzinger, & Perrault, 2003).When not appropriately diagnosed and treated, rumination can lead to serious complications, including weight loss, malnutrition, dental erosions, halitosis, electrolyte abnormalities, and significant functional disability (O’Brien, Bruce, & Camilleri, 1995).

The term (RAP) has been used and defined in various ways over time. Almost every paper or presentation on RAP, however, begins with a reference to Apley’s criteria (Apley, 1975; Apley & Hale, 1973). According to Apley, RAP is characterized by three or more episodes of abdominal pain that occur over at least 3 months and are severe enough to interfere with activities, such as school attendance and performance, social activities, and participation in sports and extracurricular activities. Clinically, these episodes are characterized by vague abdominal pain that is dull or crampy, is poorly localized or periumbilical, and persists for less than 1 hour (Frazer & Rappaport, 1999). The pain frequently presents with nausea, vomiting, and other signs of autonomic arousal (Apley, 1975).

Irritable bowel syndrome (IBS) is a functional gastrointestinal disorder characterized by chronic or recurrent abdominal pain/discomfort, altered bowel function (urgency, altered stool consistency, altered stool frequency, incomplete evacuation), and bloating/distention. These symptoms are felt to stem from the function of the bowels. They are not explained by identifiable structural or biochemical abnormalities. The two most commonly used symptombased criteria for IBS are the Manning criteria (Manning, Thompson, Heating, & Morris, 1978) and the Rome criteria (Thompson et al., 2000; Thompson et al., 1999). These criteria were originally developed for adults, but have been successfully used with children and adolescents. The Manning criteria were established to differentiate IBS from organic disease in patients attending an outpatient gastroenterology clinic. They have been used for patient selection in epidemiological studies and clinical trials and have served their original purpose well. The Manning criteria include the following: (1) visible abdominal distention, (2) relief of pain with bowel movement, (3) more frequent bowel movements with the onset of pain, (4) loose stools at onset of pain, (5) passage of mucous per rectum, and (6) feeling of incomplete evacuation. The Rome criteria resulted from consensus conferences to define criteria for a broad range of functional gastrointestinal disorders. The most recent version, the Rome II criteria (Rasquin-Weber et al., 1999), have emerged as the gold standard and require that the primary IBS symptoms must be continuous or recurrent for at least 3 months. The abdominal pain or discomfort has two or three features: (1) it is relieved with defecation, (2) associated with a change in frequency of stool, and/or (3) associated with a change in form of stool. No structural or metabolic abnormalities explain the symptoms. According to Rome II criteria, symptoms that cumulatively support the diagnosis of IBS include: abnormal stool frequency (> 3 BMs/day or < 3 BMs/week); abnormal stool form (lumpy/hard or loose/watery stool); abnormal stool passage (straining, urgency, or feeling of incomplete evaluation); passage of mucous; and bloating or feeling of abdominal distention. When appropriate, the Rome II criteria classify IBS as either “diarrhea-predominant” or “constipation-predominant” on the basis of the predominant bowel habit. For some individuals, diarrhea and constipation alternate.

Defecation disorders such as retentive fecal incontinence (RFI) and stool toileting refusal are common childhood problems that require significant health care resources. Estimates report that children with defecation disorders comprise 3% to 10% of all general pediatric visits and 25% to 30% of all pediatric gastroenterology visits (Fishman, Rappaport, Schonwald, & Nurko, 2003; Hatch, 1988; Youssef & DiLorenzo, 2001). These problems can cause pain, discomfort, and anguish for children. Families find these disorders shameful and difficult to manage, and, in addition, they are often a source of conflict between children and parents due to common misconceptions about the etiology of the problem. A unique feature of fecal incontinence is the isolation that children and families experience: they typically report knowing no one else with this problem. Families can avoid such distress, however, as fecal incontinence is a condition that is very amenable to treatment.

Richard, a 16-year-old boy, was referred to me by his pediatric gastroenterologist because of his difficulties related to his Crohn’s disease (CD). His mother reported that Richard’s mood appeared to be depressed, he was often teary, his activity level was low, and he was pessimistic about his future. Because of his embarrassment of having to frequently leave the classroom to use the bathroom, he refused to go to school and started home schooling.