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DOLORI ADDOMINALI:Quando il sintomo è veramente
importante
Annamaria StaianoDipartimento di Scienze Mediche Traslazionali
Sezione di PediatriaUniversità di Napoli “Federico II”, Italia
CLASSIFICAZIONE DEL DOLORE ADDOMINALE
Dolore addominale acuto
Dolore addominale ricorrente/cronico
Dolore addominale acuto:Caratteristiche cliniche
Intensità e durata del dolore
Sintomi associati (vomito, febbre, etc)
Condizioni generali
Esame obiettivo completo con palpazione addomeDolore addominale viscerale, somatoparietale e riflesso
Tsze DS et al Pediatrics 2013;132:e971–e979
Faces Pain Scale - Revised (FPS-R), 2001, International Association for the Study of Pain
Color Analog Scale (CAS)
Differential Diagnosis of Acute Abdominal Pain by Predominant Age
Joon Sung KimPediatr Gastroenterol Hepatol Nutr 2013; 16(4):219-224
Algorithmic approach to the children with acute abdominal pain requiring urgent management
Joon Sung KimPediatr Gastroenterol Hepatol Nutr 2013; 16(4):219-224
305 children aged 4 – 17 years consulting for abdominal pain 89.2% of children were diagnosed with general practice as functional
abdominal pain (GPFAP).
Headaches and bloating were positively associated with GPFAP whereas fever and 3 red flag symptoms were inversely associated.
Additional diagnostic tests were performed in 26.8% of children.
Spee LA et al. Scand J Prim Health Care. 2013 Dec;31(4):197-202.
• Nel 75% dei bambini in età scolare almeno un episodio di dolore addominale negli anni precedenti
• Nel 10-25% il dolore è ricorrente • Età di insorgenza: 4-15 anni, con un
picco intorno ai 10 anni
• Cause organiche in solo il circa 10% di essi
DOLORE ADDOMINALE RICORRENTE
USA13%
Italy10%Italy10%
Prevalence of Functional Abdominal Pain in Children
Prevalence of Functional Abdominal Pain in Children
Finland8%
Finland8%
Germany2.5%
Germany2.5%
United Kingdom
12%
United Kingdom
12%
Norway6%
Norway6%
Sweden13%
Sweden13%
Chitkara DK et al. Am J Gastroenterol 2005; 100:1868Chitkara DK et al. Am J Gastroenterol 2005; 100:1868
• Dispepsia Funzionale
• Sindrome del Colon Irritabile
• Emicrania Addominale
• Dolore addominale funzionale aspecifico
Gastroenterology 2006; 130: 1527-37
DOLORE ADDOMINALE RICORRENTEDisordini Funzionali Gastrointestinali
Rasquin A, et al. Gastroenterology 2006;130:1527–1537
SIDNDROME DEL COLON IRRITABILE: SIDNDROME DEL COLON IRRITABILE: CRITERI DIAGNOSTICICRITERI DIAGNOSTICI
Deve includere tutti I seguenti criteri, soddisfatti almeno una volta a
settimana per almeno due mesi precedenti la diagnosi:
Dolore addominale associato a due o più dei seguenti criteri per
almeno il 25% del tempo
Miglioramento con la defecazione
Insorgenza associata con un cambiamento della frequenza evacuativa
Insorgenza associata con un cambiamento della consistenza delle feci
Nessuna evidenza di condizione infiammatoria, anatomica, metabolica o
neoplastic ache possa spigare i sintomi del soggetto
Rasquin A, et al. Gastroenterology 2006;130:1527–1537
Deve includere tutti I seguenti criteri, soddisfatti almeno una volta a settimana
per almeno due mesi precedent la diagnosi:
Dolore addominale localizzato ai quadranti addominali superiori
Assenza di miglioramento con l’evacuazione o di associazione con un
cambiamento della frequenza evacuativa o della consistenza delle feci
Nessuna evidenza di condizione infiammatoria, anatomica, metabolica o
neoplastic ache possa spigare i sintomi del soggetto
Youssef NN et al. Pediatrics 2006; 117: 54-59
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
Pain Predominant FGIDsPain Predominant FGIDs
Sensitizing medical events:
Inflammation
(infection,
allergies)
Genetic predisposi
tionEarly life events
Visceral hyperalg
esia
Disability
Sensitizing psychosocial events:Secondary
gainsDepression
AnxietyFamily stress
Coping style
DistensionTrauma Stress Motility disorder
P15
00
1010
2020
3030
Gastric suctionGastric suction
Traumascore > 0Traumascore > 0
Asphyxiascore > 0Asphyxiascore > 0
%
of subjects
with FGID
%
of subjects
with FGID
Controls (siblings)
Cases (hospitalized for FGID)
Do Noxious Early Life Events Predispose to FGID?Do Noxious Early Life Events Predispose to FGID?
Anand KJ et al. J Pediatr 2004; 144:449Anand KJ et al. J Pediatr 2004; 144:449
Odds ratio: 2.99; P<0.009Odds ratio: 2.99; P<0.009
Pediatrics
4040
P16
Evidence for Social Learning over Genetics in Twin StudyEvidence for Social Learning over Genetics in Twin Study
Levy RL et al. Gastroenterology 2001;121:799Levy RL et al. Gastroenterology 2001;121:799
Chance of one dizygotic twin having IBS if other does
MZ DZChance of mother of twins having IBS if a twin has IBS
15.2%
6.7%
17.1%
0
5
10
15
20
%
P62
P17
Parent Attention vs. DistractionParent Attention vs. Distraction
Youssef NN 2007©
Questionnaire-Reported GI Symptom Ratings (range 0-20)
Questionnaire-Reported GI Symptom Ratings (range 0-20)
00
55
1010
1515
2020
DistractionDistraction NoInstructionNoInstruction
AttentionAttention
Pain PatientsPain Patients
Well ChildrenWell Children
Pain induced by water-load test
Parents randomized to using distraction or attention in their interaction with children in pain
All mothers felt distraction was inappropriate response to pain
Pain induced by water-load test
Parents randomized to using distraction or attention in their interaction with children in pain
All mothers felt distraction was inappropriate response to pain
Walker LS et al. Pain 2006, 122:43Walker LS et al. Pain 2006, 122:43
Pediatrics
P< 0.01P< 0.01
La diagnosi di dolore addominale funzionale deve essere effettuata in positivo
Test negativi non rassicurano il paziente, ma piuttosto rinforzano il modello medico di malattia
Minime indagini diagnostiche
La diagnosi di dolore addominale funzionale deve essere effettuata in positivo
Test negativi non rassicurano il paziente, ma piuttosto rinforzano il modello medico di malattia
Minime indagini diagnostiche
DOLORE ADDOMINALE RICORRENTE
• Anamnesi/Storia Psicosociale
• Esame obiettivo
• Indagini limitate
DOLORE ADDOMINALE RICORRENTE
• Anamnesi/Storia Psicosociale
DOLORE ADDOMINALE RICORRENTE
Sintomi di allarme Dolore persistente al quadrante superiore destro o inferiore destro Artrite Dolore notturno Malattia perianale Disfagia Vomito persistente Perdita di peso involontaria Decelerazione della crescita lineare Pubertà ritardata Sanguinamento gastrointestinale Diarrea notturna Febbre inspiegabile Storia familiare di MICI, malattia celiaca o Malattia Ulceroso-Peptica
SINDROME DEL COLON IRRITABILE (SCI)SINDROME DEL COLON IRRITABILE (SCI)
Disordini che possono mimare la SCI:
• Malattie Infiammatorie croniche intestinali• Malattia Celiaca• Malassorbimento di Carboidrati• Infezioni (es. giardia)• Malformazioni Intestinali• Neoplasie• Alterazioni del tratto Genito-urinario• Malattie Intestinali Allergiche
MALATTIE ASSOCIATE ALLA DISPEPSIA IN ETA’ PEDIATRICA
• Reflusso Gastroesofageo
• Esofagite Eosinofila
• Gastrite Eosinofilica
• Ulcera Gastrica o Duodenale
• Duodenite
• Malattie della colecisti
• Malattia Epatica
• Malattia Pancreatica
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
• 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
POST-INFECTIOUS FUNCTIONAL POST-INFECTIOUS FUNCTIONAL GASTROINTESTINAL DISORDERS IN GASTROINTESTINAL DISORDERS IN
CHILDRENCHILDREN
Saps M, Staiano A et al. J Pediatr. 2008
IBS IN CHILDREN: IBS IN CHILDREN: PSYCHOSOCIAL HISTORYPSYCHOSOCIAL HISTORY
• Evidence for stressful psychological stimuli Marital-Financial problems
Death or illnessesFamily 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
• 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%)
“FAMILIAL AGGREGATION IN CHILDREN AFFECTED BY FUNCTIONAL GASTROINTESTINAL
DISORDERS”
Buonavolontà R. JPGN 2010; 50(5):500-505
Having a mother with FGID was a stronger predictor (OR=3.5%) of FGID
than having a father with FGIDs
“FAMILIAL AGGREGATION IN CHILDREN AFFECTED BY FUNCTIONAL
GASTROINTESTINAL DISORDERS”
Buonavolontà R. JPGN 2010; 50(5):500-505
ESAME OBIETTIVO
• Abdominal pressure tenderness
• Chronic constipation ???
DOLORE ADDOMINALE RICORRENTE:
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 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
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 164(5):1099-1103.e1
INDAGINI DI LABORATORIO
Emocromo completo con formula Proteina C-reattiva Velocità di eritrosedimentazione Pannello metabolico completo Analisi urine Coprocoltura ed esame parassitologico delle feci Breath test idrogeno o trial con dieta priva di lattosio Anticorpi antitransglutaminasi Calprotectina fecale
DOLORE ADDOMINALE RICORRENTE:
Acta Paediatr. 2002;91(1):45-50.
Patients affected by IBD had high levels of fecal calprotectin compared with healthy children (p < 0.0001) and children presenting with recurrent abdominal pain (p < 0.0001)
Conclusions:
Fecal calprotectin could be useful in differentiating the functional recurrent abdominal pain from the organic recurrent abdominal pain
FECAL CALPROTECTINFECAL CALPROTECTIN
Eur J Gastroenterol Hepatol 2002;14 (8):841-5
Sensibility and Specificity
“Intestinal ESR” for the screening of IBD
Canani RB, Miele E, Staiano A et al. Dig Liver Dis 2008; 40 (7): 547-53
• 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
Evidence
Quality C
J Pediatr Gastroenterol Nutr 2005; 40 (3): 245-8
• In children with AP without alarm symptoms: abnormalities in less than 1%
• In children with AP with alarm symptoms: abnormalities in 11%
Value Of Abdominal Sonography In The Assessment Of Children With Abdominal Pain (AP)
J Clin Ultrasound 2004; 26: 397-400
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
Evidence
Quality 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
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
Diagnostic test Diagnosis/findings
Basic laboratory tests
Complete blood cell count Anemia, thrombocytosis, leukocytosis
Erythrocyte sedimentation rate or C-reactive protein
Systemic inflammation (e.g., inflammatory bowel disease)
Albumin and total protein Nutrition and inflammation
Tissue transglutaminase IgA, total IgA
Celiac disease
Urinalysis and urine culture Hematuria, urinary tract infection
Stool guaiac, Calprotectin Inflammation
Additional laboratory tests/imaging/other testing to consider
Basic metabolic panel, including blood urea nitrogen/creatinine
Electrolyte disturbance, renal insufficiency
Aspartate aminotransferase/alanine aminotransferase, γ-glutamyl transpeptidase
Hepatobiliary inflammation or obstruction
Amylase, lipase Pancreatitis
Stool culture and staining for ova and parasites
Infectious colitis, giardiasis
Breath testing for carbohydrate malabsorption
Lactose or fructose intolerance
Other symptom-guided diagnostic testing: abdominal ultrasound; contrast and other imaging studies; endoscopy/colonoscopy
To be performed only if indicated by history, physicial examinationfindings or screening laboratory tests
Eric Chiou and Samuel Nurko. Therapy. 2011 May 1; 8(3): 315–331.
Approach to diagnostic testing