1. DOLORE ADDOMINALE RICORRENTE
Annamaria Staiano
Dipartimento di Scienze Mediche Traslazionali
Università di Napoli “Federico II”,
Italia

2. RECURRENT ABDOMINAL PAIN
In 75% of children in secondary schools at least one episode of AP in previous years
In 10-25% the pain is recurrent
Age of onset: 4-15 years, with a peak around 10 yrs
Organic cause in only about 10% of them

3. 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

4. RECURRENT ABDOMINAL PAIN
Functional disorders
Functional abdominal pain
Functional abdominal pain syndrome
Irritable bowel syndrome
Abdominal migraine
Aerophagia
Genitourinary tract
Urinary tract infection
Hydronephrosis
Urolithiasis
Dysmenorrhea
Pelvic inflammatory disease
GI tract
Gastroesophageal reflux disease
Helicobacter pylori gastritis
Peptic ulcer
Esophagitis
Lactose intolerance
Celiac disease
Parasitic infection (Giardia, Blastocystis hominis)
Inflammatory bowel disease
Meckel diverticulum
Malrotation with intermittent volvulus
Chronic appendicitis
Miscellaneous causes
Gilbert’s syndrome
Familial Mediterranean fever
Malignancies
Sickle cell crisis
Lead poisoning
Vasculitis (especially Henoch Schonlein Purpura)
Angioneurotic edema
Acute intermittent porphyria
Galbladder, liver and pancreas
Cholelithiasis
Choledochal cyst
Hepatitis
Liver abcess
Recurrent pancreatitis

5. RECURRENT ABDOMINAL PAIN
227 children with RAP
Age>5 years
171 (75%)
No Cause
46 (20.3%)
Lactose malabsorption
1 (0.5%)
Celiac disease
9 (4%)
Inflammatory bowel disease
117 (68.4%)
Irritable Bowel syndrome
Hyams, J Pediatr Gastroenterol Nutr, 1995

6. RECURRENT ABDOMINAL PAIN
FUNCTIONAL GI DISORDERS
Functional Dyspepsia
Irritable Bowel Syndrome
Abdominal Migraine
Childhood Functional abdominal pain - Childhood functional abdominal pain syndrome
Gastroenterology 2006; 130:

7. IRRITABLE BOWEL SYNDROME (IBS) DIAGNOSTIC CRITERIA
Rasquin A, et al. Gastroenterology 2006;130:1527–1537

8. FUNCTIONAL DYSPEPSIA (FD) DIAGNOSTIC CRITERIA
Rasquin A, et al. Gastroenterology 2006;130:1527–1537

9. RECURRENT ABDOMINAL PAIN
A diagnosis of functional AP should be made in a positive fashion
Negative tests do not reassure the patient, but rather reinforce a medical model of disease
Minimal diagnostic investigations

10. IRRITABLE BOWEL SYNDROME (IBS)
Disorders which may mimic IBS:
Inflammatory bowel disease
Celiac Disease
Carbohydrate Malabsorption
Infection (e.g. giardia)
Intestinal malformation
Neoplasias
Genito-urinary tract alteration
Allergic Bowel Disease

11. DISEASES ASSOCIATED WITH DYSPEPSIA IN CHILDREN
Gastroesophageal Reflux
Eosinophilic Esophagitis
Gastritis
Gastric or Duodenal Ulcer
Duodenitis
Gall bladder disease
Hepatic Disease
Pancreatic Disease 11

12. RECURRENT ABDOMINAL PAIN
Medical History
Psychosocial History
Physical Examination
Limited tests

13. 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

14. Abdominal Pain-Related Functional Gastrointestinal Disorders WARNING SIGNS
“RED FLAGS”
Rasquin A. et al. Gastroenterology 2006;130:1527–1537

15. 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

16. 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

17. the group of parents of children with FGIDs: 64%
“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):

18. “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):

19. RECURRENT ABDOMINAL PAIN
PHYSICAL EXAMINATION
Abdominal pressure tenderness
Chronic constipation ???

20. 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]

21. 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

22. Total gastric emptying time evaluated at entry (T0) and at 3 months of follow-up (T3) in dyspeptic patients with functional constipation (FC yes) who received lactulose and in dyspeptic patients without functional constipation (FC no)
Boccia et al. Clinical Gastroenterol Hepatol 2008

23. In boys, diarrhea-IBS is the most common subtype.
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 Jan 31[Epub ahead of print]

24. RECURRENT ABDOMINAL PAIN
LABORATORY TESTS
Complete blood count
C-reactive protein
Erythrocyte sedimentation rate
Comprehensive Metabolic Panel
Urinalysis
Stool studies for bacteria and parasites
Breath hydrogen test or trial lactose-free diet
Antitransglutaminase antibodies
Fecal calprotectin

25. RECURRENT ABDOMINAL PAIN
ESR altered in 90% of children affected by IBD
Boyle JT, Pediatr Rev, 1997
Rectal bleeding >ESR, <Hg identify 86% of patients affected by IBD before endoscopy
Khan k et al. Inflamm Bowel Dis, 2002
I level investigations

26. Sensibility and Specificity “Intestinal ESR” for the screening of IBD
FECAL CALPROTECTIN
Patients affected by IBD had high levels of fecal calprotectin compared with healthy children (p < ) and children presenting with recurrent abdominal pain (p < )
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):

27. On the predictive value of blood tests with or without alarm signs
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
Evidence Quality C

28. In children with AP with alarm symptoms: abnormalities in 11%
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 1998; 26:

29. 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
Evidence Quality C

30. Of the 1624 procedures, 26% were considered inappropriate.
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

31. Persistent right upper or right lower quadrant pain predicted a negative diagnostic yield of OGD.
As regards colonoscopy, persistent right upper or right lower quadrant pain and gastrointestinal blood loss (haematochezia, occult lower GI bleeding) remained independently associated with an increased diagnostic yield
The use of the criteria for functional gastrointestinal disorders makes a significant positive impact, they should reduce unnecessary paediatric GI endoscopy.
Miele E et al. Aliment Pharmacol Ther 2010; 32:582–590

32. Yuk Him Tam et al. JPGN 2011;52: 387–391

33. Meta-analysis including 14 cross-sectional studies
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

34. Pediatric Patients With Dyspepsia Have Chronic Symptoms, Anxiety, and Lower Quality of Life as Adolescents and Adults 
Pediatric patients (ages 8-16 yrs) with dyspeptic symptoms, re-evaluated 5-15 yrs later, both with and without abnormal esophageal histology, had more dyspeptic symptoms, greater functional disability, and poorer health-related quality of life compared with controls, in adolescence and young adulthood
Histology alone is not adequate to discriminate between organic and functional dyspepsia
Anxiety and depression could develop as a consequence of living with chronic dyspeptic symptoms.
Rippel SW et al. Gastroenterology Apr;142(4):754-61

35. DYSPEPSIA IN CHILDREN AND ADOLESCENTS: A PROSPECTIVE STUDY
127 children with dyspepsia
56 Upper GI Endoscopy
21(38%) (62%)
Mucosal inflammation Normal mucosa
(5HP+)
Functional dyspepsia
Hyams et al. J Pediatr Gastroenterol Nutr 2000 ;30 :

36. DYSPEPSIA IN CHILDREN AND ADOLESCENTS: A PROSPECTIVE STUDY
SUGGESTIONS:
In absence of alarming symptoms short trial with
antisecretory drugs
If persistent symptoms upper GI endoscopy
Hyams et al. J Pediatr Gastroenterol Nutr 2000 ;30 :

37. Chronic abdominal pain
“CHRONIC ABDOMINAL PAIN INCLUDING FUNCTIONAL ABDOMINAL PAIN, IRRITABLE BOWEL SYNDROME AND ABDOMINAL MIGRAINE”
Involuntary weight loss
Growth retardation
Delayed puberty
Significant vomiting
Significant diarrhea
GI blood loss
Extra intestinal symptoms
Unexplained fever
Family history of IBD
Consistent RUQ or RLQ abdominal pain
Abdominal physical examination
Chronic abdominal pain
History and Physical exam
Presence of alarm signals
Yes
Evaluate further No
CBC with differential
ESR
CMP
Celiac Disease
Urinalysis
Stool O&P
Stool HP antigen/13C UBT
Lactose breath test
Fulfills criteria of constipation
Yes
Treat constipation No
Working diagnosis of pain-related FGIDs
Diagnostic testing
Make subtype diagnosis according to Rome III Criteria
Tests abnormal
Pain alone: Call functional abdominal pain
Pain + associated symptoms: Call FAPS
Pain in upper abdomen: Call Functional Dyspepsia
Pain + altered bowel movements: Call IBS
Paroxysmal episodes of pain: Call abdomen migraine
Yes No
Evaluate
further
Initiate
appropriate
treatment
Vlieger AM, Benninga MA. In Walker textbook of Pediatric GI Disease 5; Vol 1: