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MANAGEMENT

OF ABDOMINAL PAIN

Aswitha D Boediarso
BKGAI / UK GASTROHEPATOLOGI IDAI JAYA

Abdominal pain :
Common symptom
Lesion :
Intra abdomen

Extra abdomen

For early diagnostic :


Careful anamnesis

Physical examination
Further investigation

Surgical case or not ?

Childhood Gastrointestinal Disorders


Developing Country. Indonesia

Gastrointestinal disorders is one of the most


common symptoms in daily practice
Evaluation sometimes present difficulties
No standard evaluation, expensive
limitation of diagnostic facilities
Uncertain diagnosis

work-up,

Rome II criteria for functional GI disorders


Making same perception in FGIDs
New criteria, not implicated yet by the pediatrician

RECURRENT ABDOMINAL PAIN

Apleys criteria (1958)


Intermittent abdominal pain at least 3
episodes of pain, severe enough to
affect activities, over a period longer
than three months

Childhood Functional
Gastrointestinal Disorders
Rome II Criteria

Consensus, based on clinical experience


G1.
G2.
G3.
G4.

Vomiting
Abdominal pain
Functional diarrhea
Disorders of defecation
Rasquin-Weber A, et al, Gut 1999

Childhood Functional GI Disorders


G2. ABDOMINAL PAIN

Rome II Criteria
G2.1.
G2.2.
G2.3.
G2.4.
G2.5.

Functional dyspepsia
Irritable bowel syndrome
Functional abdominal pain
Abdominal migraine
Aerophagia

FUNCTIONAL DYSPEPSIA
Children mature enough to provide an
accurate 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

G2.1. Functional Dyspepsia

G2.1.1. Ulcer-like dyspepsia


G2.1.2. Dysmotility-like dyspepsia
G2.1.3. Unspecified dyspepsia

G2.1.1. Ulcer-like dyspepsia


Pain centered in the upper abdomen is the
predominant (most bothersome) symptom
G2.1.2. Dysmotility-like dyspepsia
An unpleasant or discomfort in the upper
abdomen : upper abdominal fullness, early
satiety, bloating, or nausea
G2.1.3. Unspecified (nonspecific) dyspepsia
Symptoms do not fulfil the criteria for either
ulcer or dysmotility-like dyspepsia

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

FUNCTIONAL ABDOMINAL PAIN


At least 12 weeks of
Continuous periumbilical pain, school-aged
child or adolescent
No or occasional relation of pain with physiological
events (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 other


FGID

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, CNS


structural or biochemical diseases

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

Tabel. Sakit perut berulang fungsional

Diagnosis

Gejala

Nyeri

Gejala umum

Defekasi

Dispepsia
fungsional

12 minggu

Abdomen
bagian atas

Mudah kenyang
Kembung
Rasa panas di perut

Tidak ada
hubungan

Sindrom usus
iritabel

12 minggu

Nyeri hilang
dengan
defekasi

Kembung
Keram

Kelainan frekuensi
Kelainan
konsistensi
Lendir dalam tinja

Migren perut

3 atau lebih
episod selama
2 jam atau
lebih, dalam
12 bulan

Paroksismal
Garis tengah
abdomen

Interval bebas gejala,


Sakit kepala sebelah,
Fotofobia,
Aura,
Riwayat keluarga

Tidak ada
hubungan

Sakit perut
fungsional

12 minggu

Hampir
kontinu

Tidak memenuhi kriteria


kelainan saluran cerna
fungsional lainnya

Tidak ada
hubungan

Functional Abdominal Pain

ALARM SYMPTOMS RED FLAG


History

Age < 4 years and > 15 years


Pain localized, away from umbilicus
Changes in bowel function (constipation, 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

Physical Examination

List 1

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 of
systemic disorders

APPROACH
List of Alarm Symptoms / Red Flag (history
and physical examination)
Diary
It is wise to not perform invasive test, have a
wait and see attitude with lots of support
Continuing observation and periodic examination
Two line approach which include psychosomatic as
well as medical investigation

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.
2.
3.
4.

Darah perifer lengkap dan hitung jenis


LED
Pemeriksaan panel metabolik
Darah samar tinja

DIARE
1.
2.
3.
4.

Pemeriksaan telur parasit


ELISA Giardia
Toksin C.difficile
Lactose breath test

Dispepsia
1. Serologi H.pylori

Nyeri kuadran kanan


atas dan bawah
abdomen, nyeri siklik

1. Sakit perut (gejala tunggal) :


sakit perut fungsional
2. Sakit + dispepsia : dispepsia
fungsional
3. Sakit + gangguan defekasi :
irritable bowel syndrome
4. Nyeri siklik : migrain
abdominal

1. USG abdomen
2. Barium enema / meal
3. C4 serum

Gambar. Algoritme evaluasi dan manajemen sakit perut berulang

ABDOMINAL PAIN
LIST II
Age

Alarm Symptoms
Red Flag

Laboratorium
blood, urine, fecal,
etc

Early assessment
Time onset, location, charac pain
Associated symptoms
Diseases indicators
The child life style, habit
Home and social environment

ORGANIC

FUNCTIONAL

ABDOMINAL PAIN

FUNCTIONAL

ORGANIC

Surgery
Distended abd
pain prior
vomiting,
bilious vomiting
masses,
peritonitis, etc

G1

Medical
Further
Investigation
related to
suspected organ

G2

G3

G4

G5

Therapy as FAP 1-2 months


Observation

No improvement

Medical psycho

Improvement

No alarm Sympyoms
Colaboration with Psychologist

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