DOLORI ADDOMINALI: Quando il sintomo è veramente importante

DOLORI ADDOMINALI: Quando il sintomo è veramente importante Annamaria Staiano Dipartimento di Scienze Mediche Traslazionali Sezione di Pediatria Università 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 addome Dolore addominale viscerale, somatoparietale e riflesso

Faces Pain Scale - Revised (FPS-R), 2001, International Association for the Study of Pain Color Analog Scale (CAS) Tsze DS et al Pediatrics 2013;132:e971 e979

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.

DOLORE ADDOMINALE RICORRENTE 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

Prevalence of Functional Abdominal Pain in Children Norway 6% Sweden 13% Finland 8% USA 13% United Kingdom 12% Italy 10% Germany 2.5% Chitkara DK et al. Am J Gastroenterol 2005; 100:1868

DOLORE ADDOMINALE RICORRENTE Disordini Funzionali Gastrointestinali Dispepsia Funzionale Sindrome del Colon Irritabile Emicrania Addominale Dolore addominale funzionale aspecifico Gastroenterology 2006; 130: 1527-37

SIDNDROME DEL COLON IRRITABILE: CRITERI 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 Rasquin A, et al. Gastroenterology 2006;130:1527 1537

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

Pain Predominant FGIDs Sensitizing medical events: Inflammati on (infection, allergies) Distension Trauma Stress Motility disorder Genetic predispositio n Early life events Visceral hyperalgesi a Disability Sensitizing psychosocial events: Depression Anxiety Family stress Coping style Secondary gains

Pediatrics Do Noxious Early Life Events Predispose to FGID? % of subjects with FGID 40 30 20 Controls (siblings) Cases (hospitalized for FGID) Odds ratio: 2.99; P<0.009 10 0 Gastric suction Trauma score > 0 Asphyxia score > 0 Anand KJ et al. J Pediatr 2004; 144:449 P15

Evidence for Social Learning over Genetics in Twin Study 20 % 15 10 17.1% 15.2% 5 0 6.7% Chance of one dizygotic twin having IBS if other does MZ DZ Chance of mother of twins having IBS if a twin has IBS Levy RL et al. Gastroenterology 2001;121:799 P16 P62

Pediatrics Parent Attention vs. Distraction 20 15 10 Questionnaire-Reported GI Symptom Ratings (range 0-20) Pain Patients Well Children P< 0.01 Pain induced by water-load test Parents randomized to using distraction or attention in their interaction with children in pain 5 0 Distraction No Instruction Attention All mothers felt distraction was inappropriate response to pain Walker LS et al. Pain 2006, 122:43 Youssef NN 2007 P17

DOLORE ADDOMINALE RICORRENTE 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

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) 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

POST-INFECTIOUS FUNCTIONAL GASTROINTESTINAL DISORDERS IN CHILDREN 36% of exposed children 87% Irritable Bowel Syndrome 24% Functional Dyspepsia Abdominal Pain 56% reported onset of pain following Acute Gastroenteritis (AGE) LOOK FOR PRAEVIOUS AGE Saps M, Staiano A et al. J Pediatr. 2008

IBS IN CHILDREN: PSYCHOSOCIAL HISTORY Evidence for stressful psychological stimuli Marital-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

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

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

DOLORE ADDOMINALE RICORRENTE: ESAME OBIETTIVO 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 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

DOLORE ADDOMINALE RICORRENTE: 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

FECAL CALPROTECTIN 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) 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

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

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 2004; 26: 397-400

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

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 Basic laboratory tests Complete blood cell count Erythrocyte sedimentation rate or C-reactive protein Albumin and total protein Tissue transglutaminase IgA, total IgA Urinalysis and urine culture Stool guaiac, Calprotectin Diagnosis/findings Anemia, thrombocytosis, leukocytosis Systemic inflammation (e.g., inflammatory bowel disease) Nutrition and inflammation Celiac disease Hematuria, urinary tract infection Inflammation Additional laboratory tests/imaging/other testing to consider Basic metabolic panel, including blood urea nitrogen/creatinine Aspartate aminotransferase/alanine aminotransferase, γ-glutamyl transpeptidase Amylase, lipase Stool culture and staining for ova and parasites Breath testing for carbohydrate malabsorption Other symptom-guided diagnostic testing: abdominal ultrasound; contrast and other imaging studies; endoscopy/colonoscopy Approach to diagnostic testing Electrolyte disturbance, renal insufficiency Hepatobiliary inflammation or obstruction Pancreatitis Infectious colitis, giardiasis Lactose or fructose intolerance To be performed only if indicated by history, physicial examination findings or screening laboratory tests Eric Chiou and Samuel Nurko. Therapy. 2011 May 1; 8(3): 315 331.