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DOLORE ADDOMINALE RICORRENTE. Annamaria Staiano Dipartimento di Scienze Mediche Traslazionali Università di Napoli “Federico II”, Italia. RECURRENT ABDOMINAL PAIN. In 75% of children in secondary schools at least one episode of AP in previous years In 10-25% the pain is recurrent

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DOLORE ADDOMINALE RICORRENTE

Annamaria Staiano

Dipartimento di Scienze Mediche Traslazionali

Università di Napoli “Federico II”,

Italia


RECURRENT ABDOMINAL PAIN

  • In 75% of children in secondary schools at least one episode of AP in previous years

  • In 10-25% the pain is recurrent

  • Age of onset: 4-15 years, with a peak around 10 yrs

  • Organic cause in only about 10% of them


Quality of Life For Children With Functional

Abdominal Pain: A Comparison Study of Patients’

and Parents’ Perceptions

School absences

Increased psychological distress

Reduced quality of life

Youssef NN et al. Pediatrics 2006; 117: 54-59


Recurrent abdominal pain
RECURRENT ABDOMINAL PAIN

227 children with RAP

Age>5 years

171 (75%)

No Cause

46 (20.3%)

Lactose malabsorption

1 (0.5%)

Celiac disease

9 (4%)

Inflammatory bowel disease

117 (68.4%)

Irritable Bowel syndrome

Hyams, J Pediatr Gastroenterol Nutr, 1995


RECURRENT ABDOMINAL PAIN

FUNCTIONAL GI DISORDERS

  • Functional Dyspepsia

  • Irritable Bowel Syndrome

  • Abdominal Migraine

  • Childhood Functional abdominal pain- Childhood functional abdominal pain syndrome

Gastroenterology 2006; 130: 1527-37


Irritable bowel syndrome ibs diagnostic criteria
IRRITABLE BOWEL SYNDROME (IBS)DIAGNOSTIC CRITERIA

Rasquin A, et al. Gastroenterology 2006;130:1527–1537


Functional dyspepsia fd diagnostic criteria
FUNCTIONAL DYSPEPSIA (FD)DIAGNOSTIC CRITERIA

Rasquin A, et al. Gastroenterology 2006;130:1527–1537


RECURRENT ABDOMINAL PAIN

  • A diagnosis of functional AP should be made in a positive fashion

  • Negative tests do not reassure the patient, but rather reinforce a medical model of disease

  • Minimal diagnostic investigations


Irritable bowel syndrome ibs
IRRITABLE BOWEL SYNDROME (IBS)

Disorders which may mimic IBS:

  • Inflammatory bowel disease

  • Celiac Disease

  • Carbohydrate Malabsorption

  • Infection (e.g. giardia)

  • Intestinal malformation

  • Neoplasias

  • Genito-urinary tract alteration

  • Allergic Bowel Disease


DISEASES ASSOCIATED WITH DYSPEPSIA IN CHILDREN

  • Gastroesophageal Reflux

  • Eosinophilic Esophagitis

  • Gastritis

  • Gastric or Duodenal Ulcer

  • Duodenitis

  • Gall bladder disease

  • Hepatic Disease

  • Pancreatic Disease


RECURRENT ABDOMINAL PAIN

  • Medical History

  • Psychosocial History

  • Physical Examination

  • Limited tests


POST-INFECTIOUS FUNCTIONAL GASTROINTESTINAL DISORDERS IN CHILDREN

  • 36% of exposed children Abdominal Pain

  • 87% Irritable Bowel Syndrome

  • 24% Functional Dyspepsia

  • 56% reported onset of pain following Acute Gastroenteritis (AGE)

    LOOK FOR PRAEVIOUS AGE

Saps M, Staiano A et al. J Pediatr. 2008


Abdominal pain related functional gastrointestinal disorders warning signs
Abdominal Pain-Related Functional Gastrointestinal Disorders CHILDRENWARNING SIGNS

“RED FLAGS”

Rasquin A. et al. Gastroenterology 2006;130:1527–1537


Objective CHILDRENTo compare history and symptoms at initial presentation of patients with

chronic abdominal pain (CAP) and Crohn’s disease (CD).

Study design:Patients with abdominal pain for at least 1 month and no evidence

of organic disease were compared with patients diagnosed with CD.

Results Patients with functional gastrointestinal disorders had more stressors

(P<0.001), were more likely to have a positive family history of irritable bowel

syndrome, reflux, vomiting or constipation (P < .05); Anemia, hematochezia, and

weight loss were most predictive of CD (cumulative sensitivity of 94%).

J Pediatr 2013;162:783-7


Ibs in children psychosocial history
IBS IN CHILDREN: CHILDRENPSYCHOSOCIAL HISTORY

  • Evidence for stressful psychological stimuliMarital-Financial problems

    Death or illnesses

    Family history for IBS, IBD, PUD, Migraine

  • Reinforcement of pain behavior by environmental factors

    Attention at time of pain

    Absence from school on days of pain


CHILDRENFAMILIAL AGGREGATION IN CHILDREN AFFECTED BY FUNCTIONAL GASTROINTESTINAL DISORDERS”

  • Prevalence of FGIDs in

    • the group of parents of children with FGIDs: 64%

    • the group of parents of children without FGIDs: 30.7%

  • Association between the children’s type of GI disorder and their parents’disorder in 35/103 (33.9%)

  • Anxiety was significally higher in the group of children with FGIDs (27.0%, vs 3, 8.3%)

Buonavolontà R. JPGN 2010; 50(5):500-505


CHILDRENFAMILIAL AGGREGATION IN CHILDREN AFFECTED BY FUNCTIONAL GASTROINTESTINAL DISORDERS”

Having a mother with FGID was a stronger predictor (OR=3.5%) of FGID than having a father with FGIDs

Buonavolontà R. JPGN 2010; 50(5):500-505


RECURRENT ABDOMINAL PAIN CHILDREN

PHYSICAL EXAMINATION

  • Abdominal pressure tenderness

  • Chronic constipation ???


  • Occult constipation defined as ‘abdominal pain disappearing with laxative treatment and not reappearing within a 6 month follow up Period was found in 92 patients (46 %) affectedd by RAP.

  • Of these, 18 had considerable relief of pain when treated for a somatic cause but experienced complete relief only after laxative measures;

Eur J Pediatr. 2014 Jan 3. [Epub ahead of print]


  • Sixty-six % (28/42) children with functional dyspepsia disappearing with laxative treatment and not reappearing within a 6 month follow up Period was found in 92 patients (46 %) affectedd by RAP.

    were affected by functional constipation associated

    with delayed gastric emptying

  • Normalization of bowel habit improved gastric

    emptying as well as dyspeptic symptoms

Boccia et al. Clinical Gastroenterol Hepatol 2008


Total gastric emptying time evaluated at entry (T0) and at 3 months of follow-up (T3) in dyspeptic patients with functional constipation (FC yes) who received lactulose and in dyspeptic patients without functional constipation (FC no)

Boccia et al. Clinical Gastroenterol Hepatol 2008


It is important to acquire knowledge about IBS subtypes to design clinical trials that may eventually shed new light on suptype-specific approaches to this condition.

Giannetti E. J Pediatr 2014 Jan 31[Epub ahead of print]


RECURRENT ABDOMINAL PAIN a higher frequency in girls.

LABORATORY TESTS

  • Complete blood count

  • C-reactive protein

  • Erythrocyte sedimentation rate

  • Comprehensive Metabolic Panel

  • Urinalysis

  • Stool studies for bacteria and parasites

  • Breath hydrogen test or trial lactose-free diet

  • Antitransglutaminase antibodies

  • Fecal calprotectin


RECURRENT ABDOMINAL PAIN a higher frequency in girls.

ESR altered in 90% of children affected by IBD

Boyle JT, Pediatr Rev, 1997

Rectal bleeding >ESR, <Hg identify 86% of patients affected by IBD before endoscopy

Khan k et al. Inflamm Bowel Dis, 2002

I level investigations


FECAL CALPROTECTIN a higher frequency in girls.

Patients affected by IBD had high levels of fecalcalprotectin compared with healthy children (p < 0.0001) and children presenting with recurrent abdominal pain (p < 0.0001)

Acta Paediatr. 2002;91(1):45-50.

  • Sensibility and Specificity

  • “Intestinal ESR” for the screening of IBD

Eur J Gastroenterol Hepatol 2002;14 (8):841-5

Conclusions:

Fecal calprotectin could be useful in differentiating the functional recurrent abdominal pain from the organic recurrent abdominal pain

Canani RB, Miele E, Staiano A et al. Dig Liver Dis 2008; 40 (7): 547-53


  • There is no evidence: a higher frequency in girls.

    • On the predictive value of blood tests with or without alarm signs

    • To suggest that the use of US examination of the abdomen and pelvis in the absence of alarm symptoms has a significant yields of organic disease

J Pediatr Gastroenterol Nutr 2005; 40 (3): 245-8

EvidenceQuality C


Value of abdominal sonography in the assessment of children with abdominal pain ap
Value Of Abdominal Sonography In The Assessment Of Children With Abdominal Pain (AP)

  • In children with AP without alarm symptoms: abnormalities in less than 1%

  • In children with AP with alarm symptoms: abnormalities in 11%

J Clin Ultrasound 1998; 26: 397-400


There is little evidence that With Abdominal Pain (AP)

the use of endoscopy with biopsy or

esophageal pH monitoring has a significant yield

of organic disease in the

absence of alarm symptoms

J Pediatr Gastroenterol Nutr 2005; 40 (3): 245-8

EvidenceQuality C


  • Based on the symptoms, endoscopic procedures were considered inappropriate if the Rome criteria had been met and appropriate if they had not been met.

  • Of the 1624 procedures, 26% were considered inappropriate.

  • Inappropriate procedures decreased significantly after publication of the Rome II criteria.

Miele E et al. Aliment Pharmacol Ther 2010; 32:582–590


  • Persistent right upper or right lower quadrant pain predicted a negative diagnostic yield of OGD.

  • As regards colonoscopy, persistent right upper or right lower quadrant pain and gastrointestinal blood loss (haematochezia, occult lower GI bleeding) remained independently associated with an increased diagnostic yield

    The use of the criteria for functional gastrointestinal disorders makes a significant positive impact, they should reduce unnecessary paediatric GI endoscopy.

Miele E et al. Aliment Pharmacol Ther 2010; 32:582–590


Yuk Him Tam et al. JPGN 2011;52: 387–391 predicted a negative diagnostic yield of OGD.


Association between helicobacter pylori and gastrointestinal symptoms in children
ASSOCIATION BETWEEN HELICOBACTER PYLORI AND GASTROINTESTINAL SYMPTOMS IN CHILDREN

Meta-analysis including 14 cross-sectional studies

No association was found between RAP and H pylori infection and conflicting evidence for an association between epigastric pain and H pylori infection

Evidence for an association between unspecified abdominal pain was found, but this finding could not be confirmed in children seen in primary care

Spee LA et al. Pediatrics 2010;125(3):e651-69


Pediatric Patients With Dyspepsia Have Chronic Symptoms, Anxiety, and Lower Quality of Life as Adolescents and Adults

Rippel SW et al. Gastroenterology. 2012 Apr;142(4):754-61

Pediatric patients (ages 8-16 yrs) with dyspeptic symptoms, re-evaluated 5-15 yrs later, both with and without abnormal esophageal histology, had more dyspeptic symptoms, greater functional disability, and poorer health-related quality of life compared with controls, in adolescence and young adulthood

Histology alone is not adequate to discriminate between organic and functional dyspepsia

Anxiety and depression could develop as a consequence of living with chronic dyspeptic symptoms.


Dyspepsia in children and adolescents a prospective study
DYSPEPSIA IN CHILDREN AND ADOLESCENTS: A PROSPECTIVE STUDY Anxiety, and Lower Quality of Life as Adolescents and Adults

127 children with dyspepsia

56 Upper GI Endoscopy

21(38%) 35 (62%)

Mucosal inflammation Normal mucosa

(5HP+)

Functional dyspepsia

Hyams et al. J Pediatr Gastroenterol Nutr 2000 ;30 : 413-418


Dyspepsia in children and adolescents a prospective study1
DYSPEPSIA IN CHILDREN AND ADOLESCENTS: A PROSPECTIVE STUDY Anxiety, and Lower Quality of Life as Adolescents and Adults

SUGGESTIONS:

  • In absence of alarming symptoms short trial with

    antisecretory drugs

  • If persistent symptoms upper GI endoscopy

Hyams et al. J Pediatr Gastroenterol Nutr 2000 ;30 : 413-418


“CHRONIC ABDOMINAL PAIN INCLUDING FUNCTIONAL ABDOMINAL PAIN, IRRITABLE BOWEL SYNDROME AND ABDOMINAL MIGRAINE”

  • Involuntary weight loss

  • Growth retardation

  • Delayed puberty

  • Significant vomiting

  • Significant diarrhea

  • GI blood loss

  • Extra intestinal symptoms

  • Unexplained fever

  • Family history of IBD

  • Consistent RUQ or RLQ abdominal pain

  • Abdominal physical examination

Chronic abdominal pain

History and Physical exam

Presence of alarm signals

Yes

Evaluate further

No

  • CBC with differential

  • ESR

  • CMP

  • Celiac Disease

  • Urinalysis

  • Stool O&P

  • Stool HP antigen/13C UBT

  • Lactose breath test

Fulfills criteria of constipation

Yes

Treat constipation

No

Working diagnosis of pain-related FGIDs

Diagnostic testing

Make subtype diagnosis according to Rome III Criteria

Tests abnormal

  • Pain alone: Call functional abdominal pain

  • Pain + associated symptoms: Call FAPS

  • Pain in upper abdomen: Call Functional Dyspepsia

  • Pain + altered bowel movements: Call IBS

  • Paroxysmal episodes of pain: Call abdomen migraine

Yes

No

Evaluate

further

Initiate

appropriate

treatment

Vlieger AM, Benninga MA. In Walker textbook of Pediatric GI Disease 5; Vol 1: 715-727


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