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
Sweden
Norway 13%
6%
Finland
8%
United
Kingdom
12%
USA
13%
Chitkara DK et al. Am J Gastroenterol 2005; 100:1868
Germany
2.5%
Italy
10%
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 Distension Trauma Stress Motility
on
disorder
(infection,
allergies)
Genetic
Visceral
predispositio
hyperalgesi
narly life events
a
E
Sensitizing psychosocial events:
Depression Family Coping Secondary
Anxiety stress style
gains
Disability
Pediatrics
Do Noxious Early Life Events Predispose to
FGID?
40
Controls (siblings)
Cases (hospitalized for FGID)
30
%
of subjects
with FGID
Odds ratio: 2.99;
P<0.009
20
10
0
Gastric
suction
Anand KJ et al. J Pediatr 2004; 144:449
Trauma
score > 0
Asphyxia
score > 0
P15
Evidence for Social Learning over
Genetics in Twin Study
20
15
15.2%
%
17.1%
10
5
6.7%
0
Chance of one
dizygotic twin
having IBS if other
does
Levy RL et al. Gastroenterology 2001;121:799
MZ
DZ
Chance of mother of
twins having IBS if a
twin has IBS
P16
P62
Pediatrics
Parent Attention vs. Distraction
Questionnaire-Reported
GI Symptom Ratings (range 0-20)
20
P< 0.01
Pain Patients
15
Well Children
 Pain induced by water-load
test
 Parents randomized to using
distraction or attention in
their
interaction
with
children in pain
10
 All mothers felt distraction
was inappropriate response
to pain
5
0
Distraction No
Instruction
Walker LS et al. Pain 2006, 122:43
Youssef NN 2007©
Attention
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
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
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
publication of the Rome II criteria.
significantly
Miele E et al. Aliment Pharmacol Ther 2010; 32:582–590
after
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
Approach to diagnostic testing
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 examination
findings or screening laboratory tests
Eric Chiou and Samuel Nurko. Therapy. 2011 May 1; 8(3): 315–331.