Post on 02-Jun-2018
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MANAGEMENT
OF ABDOMINAL PAIN
Aswitha D Boediarso
BKGAI / UK GASTROHEPATOLOGI IDAI JAYA
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Abdominal pain :
Common symptom
Lesion :
Intra abdomen Extra abdomen
For early diagnostic :
Careful anamnesis
Physical examination
Further investigation
Surgical case or not ?
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Childhood Gastrointestinal Disorders
Developing Country. Indonesia
Gastrointestinal disorders is one of the mostcommon symptoms in daily practice
Evaluation sometimes present difficulties No standard evaluation, expensive work-up,
limitation of diagnostic facilities
Uncertain diagnosis
Rome II criteria for functional GI disorders Making same perception in FGIDs
New criteria, not implicated yet by the pediatrician
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RECURRENT ABDOMINAL PAIN
Apleyscriteria (1958)
Intermittent abdominal pain at least 3episodes of pain, severe enough toaffect activities, over a period longerthan three months
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Childhood Functional
Gastrointestinal Disorders
G1. Vomiting
G2. Abdominal pain
G3. Functional diarrhea
G4. Disorders of defecation
Rome II Criteria
Consensus, based on clinical experience
Rasquin-Weber A, et al, Gut 1999
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Childhood Functional GI Disorders
G2. ABDOMINAL PAIN
G2.1. Functional dyspepsiaG2.2. Irritable bowel syndrome
G2.3. Functional abdominal pain
G2.4. Abdominal migraineG2.5. Aerophagia
Rome II Criteria
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FUNCTIONAL DYSPEPSIA
Children mature enough to provide anaccurate pain history
At least 12 weeks, not to be consecutive,preceding 12 months
Persistent or recurrent pain or discomfort
Centered in the upper abdomen (above the umbilicus)
No evidence that dyspepsia is associated with defecation
No evidence that organic disease to explain the symptoms
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G2.1. Functional Dyspepsia
G2.1.1. Ulcer-like dyspepsia
G2.1.2. Dysmotility-like dyspepsia
G2.1.3. Unspecified dyspepsia
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G2.1.1. Ulcer-like dyspepsia
Pain centered in the upper abdomen is thepredominant (most bothersome) symptom
G2.1.2. Dysmotility-like dyspepsia
An unpleasant or discomfort in the upper
abdomen : upper abdominal fullness, earlysatiety, bloating, or nausea
G2.1.3. Unspecified nonspecific) dyspepsia
Symptoms do not fulfil the criteria for eitherulcer or dysmotility-like dyspepsia
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IRRITABLE BOWEL SYNDROME
Children old enough to provide an accurate pain history
At least 12 weeks, not to be consecutive, preceding 12
months
(1)Abdominal pain or discomfort that has 2 out of 3 features
a) Relieved with defecation;
b) Onset associated with a change in frequency of stool;
c) Onset associated with a change in form of stool;
(2) No structural or metabolic abnormalities to explain sympt
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FUNCTIONAL ABDOMINAL PAIN
At least 12 weeks of
Continuous periumbilical pain, school-agedchild or adolescent
No or occasional relation of pain with physiologicalevents (e.g. eating, menses, or defecation);
Some loss of daily functioning; and
The pain is not feigned (e.g. malingering); and
The patient has insufficient criteria for otherFGID
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ABDOMINAL MIGRAINE
Midline abdominal pain, two hours to several days,interventing symptoms-free interval weeks to months
Three or more paroxysmal episodes of intense
Two of following features :
Headache and photophobia during episodes
Family history of migraine
Headache confined to one side, an aura
No evidence of metabolic, gastrointestinal, CNSstructural or biochemical diseases
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AEROPHAGIA
At least 12 weeks, not be consecutive,preceding 12 months
Two or more the following signs and
symptoms Air swallowing
Abdominal distension due to intraluminal air
Repetitive belching and/or increased flatus
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Tabel. Sakit perut berulang fungsional
Diagnosis Gejala Nyeri Gejala umum Defekasi
Dispepsiafungsional
12 minggu Abdomenbagian atas
Mudah kenyangKembungRasa panas di perut
Tidak adahubungan
Sindrom usus
iritabel
12 minggu Nyeri hilang
dengandefekasi
Kembung
Keram
Kelainan frekuensi
KelainankonsistensiLendir dalam tinja
Migren perut 3 atau lebihepisod selama2 jam ataulebih, dalam
12 bulan
ParoksismalGaris tengahabdomen
Interval bebas gejala,Sakit kepala sebelah,Fotofobia,Aura,
Riwayat keluarga
Tidak adahubungan
Sakit perutfungsional
12 minggu Hampirkontinu
Tidak memenuhi kriteriakelainan saluran cernafungsional lainnya
Tidak adahubungan
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ALARM SYMPTOMS RED FLAG
Age < 4 years and > 15 years
Pain localized, away from umbilicus
Changes in bowel function (cons-tipation, diarrhea, incontinence)
Vomiting, anorexia, rectal bleeding
Sudden onset, contant, minute-day
Pain awakes child at night
Radiates to back, shoulder, lower
ekstremities Sign of UTI
Rash athralgia
Family history : Hp, IBD, ulcus pept
Stopping sports activities
Clinical sign of chronic diseases(sick, FTT, fever, anemia)
BW
Distension, organomegaly, tumor
Abnormal bowel sound
Scars, hernia
Perianal fistulas, anal fissures, --
Beyond abdomen, manifestation ofsystemic disorders
Functional Abdominal Pain
History Physical Examination List 1
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APPROACH
List of Alarm Symptoms / Red Flag (historyand physical examination)
Diary
It is wise to not perform invasive test, have await and see attitude with lots of support
Continuing observation and periodic examination
Two line approach which include psychosomatic aswell as medical investigation
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Sakit perut berulang
Anamnesis dan PF
Kategori gejala
Dispepsia(Nyeri epigastrium, berhubungan
dengan makanan, mual, muntah,
regurgitasi, nyeri dada, kembung,
cepat kenyang)
Gangguan pola
defekasi
(diare/konstipasi)
Nyeri
(gejala tunggal)
Sindrom nyeri
siklik
TANDA BAHAYA TIDAK
YA
Kelainan fungsional :1. Sakit perut (gejala tunggal) :
sakit perut fungsional
2. Sakit + dispepsia : dispepsia
fungsional
3. Sakit + gangguan defekasi :
irritable bowel syndrome
4. Nyeri siklik : migrainabdominal
1. Darah perifer lengkap dan hitung jenis
2. LED
3. Pemeriksaan panel metabolik
4. Darah samar tinja
DIARE1. Pemeriksaan telur parasit
2. ELISA Giardia
3. Toksin C.difficile
4 . Lac t ose b rea th t es t
Dispepsia1. Serologi H.pylori
Nyeri kuadran kanan
atas dan bawah
abdomen, nyeri siklik1. USG abdomen
2. Barium enema/ meal
3. C4 serum
Gambar. Algoritme evaluasi dan manajemen sakit perut berulang
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ABDOMINAL PAIN
LIST II
Alarm Symptoms
Red Flag
Laboratorium
blood, urine, fecal,
etc
Age
Early assessment
Time onset, location, charac pain
Associated symptoms
Diseases indicators
The child life style, habit
Home and social environment
ORGANIC FUNCTIONAL
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ABDOMINAL PAIN
ORGANIC FUNCTIONAL
Surgery Medical
Distended abd
pain prior
vomiting,
bilious vomiting
masses,
peritonitis, etc
Further
Investigation
related to
suspected organ
G1 G3G2 G4 G5
Therapy as FAP 1-2 months
Observation Medical psycho
No improvement
No alarm Sympyoms
Improvement
Colaboration with Psychologist