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DOLORI ADDOMINALI: Quando il sintomo è veramente importante Annamaria Staiano Dipartimento di Scienze Mediche Traslazionali Sezione di Pediatria Università.

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Presentazione sul tema: "DOLORI ADDOMINALI: Quando il sintomo è veramente importante Annamaria Staiano Dipartimento di Scienze Mediche Traslazionali Sezione di Pediatria Università."— Transcript della presentazione:

1 DOLORI ADDOMINALI: Quando il sintomo è veramente importante Annamaria Staiano Dipartimento di Scienze Mediche Traslazionali Sezione di Pediatria Università di Napoli “Federico II”, Italia

2 CLASSIFICAZIONE DEL DOLORE ADDOMINALE  Dolore addominale acuto  Dolore addominale ricorrente/cronico

3 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

4 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)

5 Differential Diagnosis of Acute Abdominal Pain by Predominant Age Joon Sung KimPediatr Gastroenterol Hepatol Nutr 2013; 16(4):

6 Algorithmic approach to the children with acute abdominal pain requiring urgent management Joon Sung KimPediatr Gastroenterol Hepatol Nutr 2013; 16(4):

7  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 Dec;31(4):

8 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

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

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

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

12 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

13 Youssef NN et al. Pediatrics 2006; 117: 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

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

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

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

17 P17 Parent Attention vs. Distraction Youssef NN 2007© Questionnaire-Reported GI Symptom Ratings (range 0-20) Distraction No Instruction No Instruction Attention Pain Patients Well 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, 122:43 Pediatrics P< 0.01

18  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

19 Anamnesi/Storia Psicosociale Esame obiettivo Indagini limitate DOLORE ADDOMINALE RICORRENTE

20 Anamnesi/Storia Psicosociale DOLORE ADDOMINALE RICORRENTE

21 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

22 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

23 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

24 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

25 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 GASTROINTESTINAL DISORDERS IN CHILDREN Saps M, Staiano A et al. J Pediatr. 2008

26 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

27 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):

28 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):

29 ESAME OBIETTIVO Abdominal pressure tenderness Chronic constipation ??? DOLORE ADDOMINALE RICORRENTE:

30  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 Jan 3. [Epub ahead of print]

31 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

32  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 (5): e1

33 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:

34 Acta Paediatr. 2002;91(1): Patients affected by IBD had high levels of fecal calprotectin compared with healthy children (p < ) and children presenting with recurrent abdominal pain (p < ) Conclusions: Fecal calprotectin could be useful in differentiating the functional recurrent abdominal pain from the organic recurrent abdominal pain FECAL 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):

35 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

36 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:

37 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): Evidence Quality C

38 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

39 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

40 Diagnostic testDiagnosis/findings Basic laboratory tests Complete blood cell countAnemia, thrombocytosis, leukocytosis Erythrocyte sedimentation rate or C-reactive protein Systemic inflammation (e.g., inflammatory bowel disease) Albumin and total proteinNutrition and inflammation Tissue transglutaminase IgA, total IgACeliac disease Urinalysis and urine cultureHematuria, urinary tract infection Stool guaiac, CalprotectinInflammation 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, lipasePancreatitis Stool culture and staining for ova and parasitesInfectious colitis, giardiasis Breath testing for carbohydrate malabsorptionLactose 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 examination findings or screening laboratory tests Eric Chiou and Samuel Nurko. Therapy May 1; 8(3): 315–331. Approach to diagnostic testing

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