management abd pain

8/10/2019 Management Abd Pain

1/19

MANAGEMENT

OF ABDOMINAL PAIN

Aswitha D Boediarso

BKGAI / UK GASTROHEPATOLOGI IDAI JAYA


2/19

Abdominal pain :

Common symptom

Lesion :

Intra abdomen Extra abdomen

For early diagnostic :

Careful anamnesis

Physical examination

Further investigation

Surgical case or not ?


3/19

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


4/19

RECURRENT ABDOMINAL PAIN

Apleyscriteria (1958)

Intermittent abdominal pain at least 3episodes of pain, severe enough toaffect activities, over a period longerthan three months


5/19

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


6/19

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


7/19

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


8/19

G2.1. Functional Dyspepsia

G2.1.1. Ulcer-like dyspepsia

G2.1.2. Dysmotility-like dyspepsia

G2.1.3. Unspecified dyspepsia


9/19

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


10/19

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


11/19

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


12/19

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


13/19

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


14/19

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


15/19

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


16/19

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


17/19

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


18/19

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


19/19

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

management abd pain

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