La madre chiede: Come faccio a sapere che non e grave se non faccio esami?

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2 La madre chiede: Come faccio a sapere che non e grave se non faccio esami?

3 ..We should focus on identifying key features or symptoms that characterize functional pain, and promote a positive diagnosis rather than a diagnosis of exclusion.

4 .indeed, the criteria were designed to be used as diagnostic tools

5 Vanner SJ, Depew WT, Paterson et al. Predictive value of the Rome criteria for diagnosing the irritable bowel syndrome.am J Gastroenterol. 1999;94: TIPO DI STUDIO: Studio prospettico /studio retrospettivo OBIETTIVO: Esaminare la predittività dei criteri di Roma e l assenza delle cosi dette red flags (documentata perdita di peso, anomalie all esame obiettivo, sintomi notturni, sangue nelle feci, storia di assunzione di antibiotici, storia familiare di cancro colorettale) nella pratica clinica per la diagnosi di sindrome dell intestino irritabile.

6 RISULTATI: La diagnosi finale dopo 2 anni dalla presentazione dei sintomi mostrava: 93 casi veri positivi 2 casi falsi positivi VPP dei criteri di Roma con l assenza delle red flags era del 98% CONCLUSIONI: lo studio suggerisce che i criteri di Roma (combinati o in assenza di Red flags) hanno un alto valore predittivo per la diagnosi di Sindrome dell intestino irritabile. L applicazione di questi criteri diagnostici ha la potenzialità di modificare il ricorso ad ulteriori

7 243 bambini (4-18 anni): 122 Pain Predominant-FGID Tutti sottoposti a indagini: 92% esami lab; 38.5% Rx addome; 23% Ecografia; 7% CT 33.6% EGDS; 17% colonscopia Costi totali: dollari Costo per paziente: 6104 dollari JPGN 2010

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9 -Upper gastrointestinal endoscopy not mandatory -Warranted in the presence of *dysphagia *persistent symptoms despite the use of acid reducing medications *in those who have recurrent symptoms upon cessation of such medications

10 Il ragazzo dice: Ho diarrea e quando vado in bagno il dolore diminuisce

11 - Symptoms of abdominal pain that meet Rome criteria for IBS -Presence of a normal physical examination and growth curve -Absence of alarm signals -Positive diagnosis -VPN di ecografia per ultima ansa ileale, CPF e ASCA 100%

12 La madre dice Lo so che non perde peso, ma e questo che mi preoccupa

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14 -A complete blood cell count -erythrocyte sedimentation rate or C-reactive protein measurement -urinalysis, and urine culture. - Other biochemical profiles and diagnostic tests can be performed at the discretion of the clinician.

15 Cosa fa la differenza?

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17 This is the largest non-industry sponsored pharmacological clinical trial in abdominal pain associated FGIDs Difficulties found in enrolling patients in trials using medications that have been associated with suicidal risks: 90 vs 528 ((type II error probability 0.72, similar to the initially intended, 0.80) Excellent improvement in the placebo group, the beneficial response of the placebo group in our study was 68% in ITT analysis and 75% in per protocol analysis. Parent's reassurance about the tertiary care's physician's

18 OBJECTIVE The objectives of this study were to (1) compare the cost of medical evaluation for children with functional abdominal pain or irritable bowel syndrome brought to a pediatric gastroenterologist versus children who remained in the care of their pediatrician

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20 AIMS: To demonstrate that functional gastrointestinal disorders (FGIDs) can be diagnosed in a positive fashion and managed by family pediatricians (FPs); to assess the compliance of FPs with a predefined diagnostic/therapeutic protocol for managing FGIDs in order to evaluate efficacy of continuing medical education; to evaluate the success of reassurance by using a biopsychosocial model in comparison to drug treatment in an open-label, nonrandomized study.

21 RESULTS A total of 9291 patients, aged birth to 14 years, were prospectively enrolled; 261 met Rome II criteria and were included in the study. In all cases but 4, diagnosis of FGIDs was confirmed at the end of follow-up (98.4%). Average compliance of FPs was 80%. Among 56 patients treated only with the explanation of symptom and reassurance, 52 (92.8%) have reported success, in comparison with 26 of 35 patients (74.3%) treated with drugs (odds ratio: 4.5 [95% confidence interval: ]).

22 243 bambini (4-18 anni): 122 Pain Predominant-FGID Tutti sottoposti a indagini: 92% esami lab; 38.5% Rx addome; 23% Ecografia; 7% CT 33.6% EGDS; 17% colonscopia Costi totali: dollari Costo per paziente: 6104 dollari

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24 La madre dice E solo un problema di testa Non ha problemi a scuola Noi in famiglia andiamo d accordo Il modello biopsicosociale

25 Pediatr Ann. 2009;38:253 Yacob D, Di Lorenzo C Functional abdominal pain: all roads lead to Rome (criteria) Hopefully not to Hospital

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29 Come e possibile che costi tanto il protocollo diagnostico? Non sono stati applicati i criteri di Roma che dovrebbero far porre in positivo la diagnosi? Vediamo se veramente questi comportano un risparmio? In una rapida carrellata questi criteri tabellatti servono piu per categorizzare i singoli disturbi. Cosa dice la commissione per l approccio diagnostico? In children with abdominal pain related FGIDs, the alarm features, signs, and symptoms listed in Table 2 are generally absent.

30 Psychosocial interventions for recurrent abdominal pain (RAP) and irritable bowel syndrome (IBS) in childhood Angela A Huertas-Ceballos1, Stuart Logan2, Cathy Bennett3, Colin Macarthur4 Cochrane Database Syst Rev 2008:1:CD CBT vs wait list post treatment CBT vs wait list 3-month follow-up

31 Am J Gastroenterol. 2010;105: Cognitive-behavioral therapy for children with functional abdominal pain and their parents decreases pain and other symptoms. Levy RL, Langer SL, Walker LS, et al. Decreases in pain and gastrointestinal symptom severity (as reported by parents) than children in the comparison condition (time x treatment interaction, P<0.01). Also, parents reported greater decreases in solicitous responses to their child's symptoms compared with parents in the comparison condition (time x treatment interaction, P<0.0001).

32 Dietary interventions for recurrent abdominal pain (RAP) and irritable bowel syndrome (IBS) in childhood Angela A Huertas-Ceballos1, Stuart Logan2, Cathy Bennett3, Colin Macarthur4 Cochrane Database Syst Rev 209:1:CD Fibre supplements vs placebo Lactobacillus vs placebo

33 VSL#3 comprises 8 different strains:bifidobacterium breve, B longum, B infantis, Lactobacillus acid-ophilus, L plantarum, L casei, L bulgaris, and Streptococcus thermophilus. Primary endpoint: improvement in the subject s global assessment of relief (SGARC). Secondary endpoints: improvements in abdominal pain/ discomfort, stool pattern, bloating/gassiness, and family assessment of the impact of their child s IBS on the

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35 In IBS + FAP Primary outcome

36 In IBS + FAP Primary outcome

37 NNT: 2.5

38 NNT: 3.8

39 The primary outcome was defined as the reduction of the intensity of FAP, and the secondary outcome was the reduction of the frequency of the symptoms. at both 4 and 8 weeks (P < 0.05

40 Pharmacological interventions for recurrent abdominal pain (RAP) and irritable bowel syndrome (IBS) in childhood Angela A Huertas-Ceballos1, Stuart Logan2, Cathy Bennett3, Colin Macarthur4 Peppermint oil vs placebo Famotidine vs placebo

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42 Aggiornamenti a maggio 2011 A proposito dell endoscopia, premetti che il tipo di pain related FGIDs che potrebbe richiedere esami o trattamento empirico e la dispepsia e che per questa il suggerimento di non rendere obbligatoria l EGDS è derivato dall osservazione della relativa rarita di lesioni ucerative o erosive nei bambini, ma non da studi -inserisci studio sulla resa dell endoscopia di JPGN aprile o maggio 2011 e soprattutto della resa di utilizzare la presenza/assenza dei segnali di allarme (2 DIA: disegno e tabella 3 -Inserisci dia di studio in abstract che effettuare EGDS non è benefico rispetto a non farla -Pensa al fruttosio e alla frutta con rapporto sbilanciato fruttosio/glucosio e inserisci dia da articolo con l informazione del GLT2 che spiega il developmental absorption del fruttosio -Pensa alla colonizzazione batterica intestinale e al ruolo dell antibiotico non dimostrato, almeno fino a quando non si troverà una strategia che riesca a diminuire la SBBO -Aggiorna quando detto nelle pagine gialle di Ventura circa i fattori prognostici che possono influenzare la persistenza di FGIDs in età adulta (2 articoli: 1 disturbi psicosomatici e l altro sui prognostic factors -Rimarca il beneficio del CBT e aggiorna su probiotico

43 JPGN 2011;52: Seventy-five children ages 8 to 18 years with CAP Subjects underwent baseline LBT and completed symptom-based questionnaires. They were then randomized in a 2:1, double-blind fashion to receive a 10-day course of 550mg of rifaximin or placebo 3 times per day (t.i.d.).

44 JPGN 2011;52: Patients were referred to investigate carbohydrate malabsorption as a cause of gastrointestinal symptoms (abdominal pain and diarrhoea). Patients received either 0.5 g/kg body weight of fructose

45 The significant effect of age on fructose malabsorption may represent the normal course of maturation of fructose transport in the developing intestine The proportion of malabsorption on the fructose BHT is also dependent on the dose of fructose given The increasing proportion of incomplete absorption with higher fructose doses agrees with physiological research suggesting that the transport of fructose from the small intestine is a passive process The carbohydrates in juices with a higher proportion of fructose than glucose (pear and apple) and higher levels of sorbitol were less well absorbed The value of a dietary history has been emphasised in

46 JPGN 2011;52: Ask about parental gastrointestinal problems because this is a risk factor for persistence of CAP in children.

47 Di cosa parliamo? Functional gastrointestinal disorders (FGIDs) are defined as a variable combination of chronic or recurrent gastrointestinal symptoms not explained by structural or biochemical abnormalities.

48 We believe that it may even be more cost-effective to perform screening tests of H pylori on male patients The prognostic value of obtaining a negative endoscopy in children with FGIDs (Clin Pediatr 2011): The study does not suggest that a negative endoscopy

49 80 consecutive Chinese children ages 7 to 16 with FD 2 groups: without any alarm features wth alarm features All underwent upper endoscopy Alarm features relevant to dyspepsia: -gastrointestinal blood loss - dysphagia -persistent vomiting, persistent right upper quadrant pain,