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DOLORE ADDOMINALE RICORRENTE

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

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  1. DOLORE ADDOMINALE RICORRENTE Annamaria Staiano Dipartimento di Scienze Mediche Traslazionali Università di Napoli “Federico II”, Italia

  2. 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

  3. 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

  4. 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

  5. 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

  6. IRRITABLE BOWEL SYNDROME (IBS)DIAGNOSTIC CRITERIA Rasquin A, et al. Gastroenterology 2006;130:1527–1537

  7. FUNCTIONAL DYSPEPSIA (FD)DIAGNOSTIC CRITERIA Rasquin A, et al. Gastroenterology 2006;130:1527–1537

  8. 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

  9. 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

  10. DISEASES ASSOCIATED WITH DYSPEPSIA IN CHILDREN • Gastroesophageal Reflux • Eosinophilic Esophagitis • Gastritis • Gastric or Duodenal Ulcer • Duodenitis • Gall bladder disease • Hepatic Disease • Pancreatic Disease

  11. RECURRENT ABDOMINAL PAIN • Medical History • Psychosocial History • Physical Examination • Limited tests

  12. 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

  13. Abdominal Pain-Related Functional Gastrointestinal DisordersWARNING SIGNS “RED FLAGS” Rasquin A. et al. Gastroenterology 2006;130:1527–1537

  14. Objective To 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

  15. IBS IN CHILDREN: PSYCHOSOCIAL 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

  16. “FAMILIAL 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

  17. “FAMILIAL 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

  18. RECURRENT ABDOMINAL PAIN PHYSICAL EXAMINATION • Abdominal pressure tenderness • Chronic constipation ???

  19. 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]

  20. Sixty-six % (28/42) children with functional dyspepsia 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

  21. 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

  22. Constipation-IBS is the prevalent subtype in children, with a higher frequency in girls. • In boys, diarrhea-IBS is the most common subtype. 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]

  23. RECURRENT ABDOMINAL PAIN 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

  24. RECURRENT ABDOMINAL PAIN 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

  25. FECAL CALPROTECTIN 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

  26. There is no evidence: • 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

  27. 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

  28. There is little evidence that 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

  29. 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

  30. 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

  31. Yuk Him Tam et al. JPGN 2011;52: 387–391

  32. 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

  33. 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.

  34. DYSPEPSIA IN CHILDREN AND ADOLESCENTS: A PROSPECTIVE STUDY 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

  35. DYSPEPSIA IN CHILDREN AND ADOLESCENTS: A PROSPECTIVE STUDY 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

  36. “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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