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OBJECTIVES@#To study the clinical efficacy of ultrasound-guided endoscopic retrograde appendicitis therapy in children with appendix-related chronic abdominal pain.@*METHODS@#A retrospective analysis was performed on the medical data of 30 children with the chief complaint of chronic abdominal pain who were admitted from August 2019 to May 2021. All the children were found to have inflammation of the appendix or intracavitary stool and fecalith by ultrasound and underwent ultrasound-guided endoscopic retrograde appendicitis therapy. The medical data for analysis included clinical manifestations, endoscopic findings, white blood cell count, neutrophil percentage, length of hospital stay, and cure rate.@*RESULTS@#Among the 30 children with chronic abdominal pain, there were 13 boys (43%) and 17 girls (57%), with a mean age of (9±3) years (range 3-15 years) at diagnosis. The median duration of the disease was 12 months, and the median length of hospital stay was 3 days. The children had a median white blood cell count of 6.7×109/L and a neutrophil percentage of 50%±13%. Fecalith and a large amount of feces were flushed out of the appendix cavity for 21 children (70%) during surgery. The follow-up rate was 97% (29/30), and the median follow-up time was 11 months (range 5-26 months). Of the 29 children, abdominal pain completely disappeared in 27 children (93%).@*CONCLUSIONS@#Ultrasound-guided endoscopic retrograde appendicitis therapy is effective in children with chronic abdominal pain caused by feces or fecalith in the appendix cavity.
Subject(s)
Adolescent , Child , Child, Preschool , Female , Humans , Male , Abdominal Pain/etiology , Appendicitis/surgery , Appendix/surgery , Fecal Impaction , Retrospective Studies , Ultrasonography, InterventionalABSTRACT
Intestinal malrotation is a congenital anomaly caused by incomplete rotation or absence of rotation of the primitive intestine along the axis of the upper mesenteric artery during embryonic development. Embryonic development and its anatomical variations were described by Dott in 1923. Intestinal malrotation is a rare condition among adults - prevalent in a mere 0.0001% to 0.19% of the population -, and it may be associated with other anatomical deformities. It can be asymptomatic or manifest with varying intensity, from obstruction to necrosis of intestinal segments. In general, this abnormality is diagnosed in the first year of life; however, symptomsmay appear later in life,making diagnosis in adults difficult on account of non-specific symptoms. In the present study, we report a case of intestinal malrotation associated with chronic non-specific symptoms progressing to mesenteric angina. (AU)
Subject(s)
Humans , Female , Aged , Torsion Abnormality/complications , Torsion Abnormality/diagnostic imaging , Mesenteric Artery, Superior , Internal Hernia , Meckel Diverticulum/diagnosisABSTRACT
Background: Chronic idiopathic pain syndromes are amongst the most challenging and demanding conditions to treat across the whole age spectrum. Despite these patients having undergone numerous diagnostic work-ups, their pain remains a challenge to all known diagnostic and treatment methods.Methods: To evaluate role of diagnostic laparoscopy in chronic abdominal pain a prospective observational study was done. The present study was conducted on patients with undiagnosed chronic abdominal pain coming to the Department of Surgery, Dr. D. Y. Patil Medical College, Hospital and Research Centre, Pimpri, Pune. 75 patients with chronic abdominal pain who attend the General Surgery Department (OPD) were included in the study. Patients were included in the study after taking their voluntary informed consent. The categorical variables were assessed using Pearson chi-square. The quantitative variables were assessed using T-test. The test was considered significant only if the p value comes out to be less than 0.05.Results: Based on the findings of the study after performing diagnostic laparoscopy for 75 patients with chronic abdominal pain it was found that most common finding was of appendicitis (32%) followed by abdominal Koch’s (24%) and post-operative pain relief using VAS showed p value of less than 0.05 at 3 months of follow up post diagnostic laparoscopy.Conclusions: The present study concluded that laparoscopy is an effective diagnostic role in evaluating patients with chronic abdominal pain, in whom conventional methods of investigations have failed to elicit a certain cause. The advantage of diagnostic laparoscopy over non-invasive methods is the ability to perform therapeutic procedure at the same time in cases of chronic abdominal pain. Diagnostic laparoscopy is safe, cosmetically better and having less morbidity.
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Introducción: los trastornos funcionales gastrointestinales son motivo de consulta frecuente en Gastroenterología, y presentan un serio problema social y en la dinámica familiar. El síndrome de intestino irritable en la población pediátrica es poco diagnosticado, y el dolor abdominal crónico es motivo de consulta frecuente en la infancia y adolescencia. Objetivo: analizar los aspectos más actuales en su diagnóstico y tratamiento, y su relación con el dolor abdominal crónico. Métodos: se revisaron las bases documentales de PubMed, Scielo y Latindex y el Registro Especializado del Grupo Cochrane de datos relacionados con el síndrome de intestino irritable hasta diciembre de 2017, así como las guías de tratamiento postuladas por distintas organizaciones médicas, basadas en los criterios de Roma y de la Medicina Basada en la Evidencia. Desarrollo: se realizó una revisión del tema referido a la infancia, y se incluyeron concepto y patogénesis más aceptadas, así como los criterios de Roma establecidos para el diagnóstico. Se hizo énfasis en la etiología, diagnóstico clínico y pruebas diagnósticas. Se analizaron algunos aspectos del tratamiento. Conclusiones: el síndrome de intestino irritable es relativamente frecuente como causa de dolor abdominal crónico funcional, y el interrogatorio dirigido según los criterios de Roma es útil para su diagnóstico. La mayoría de los pacientes con síndrome de intestino irritable en la infancia deben ser atendidos en la atención primaria(AU)
Introduction: gastrointestinal functional disorders are a frequent reason for consultation in Gastroenterology services, and represent a serious social problem and in family dynamics. Irritable bowel syndrome in the pediatric population is poorly diagnosed, and chronic abdominal pain is a frequent reason for consultation in childhood and adolescence. Objective: to analyze the ultimate aspects in its diagnosis and treatment, and its relation with chronic abdominal pain. Methods: PubMed, Scielo and Latindex documentary databases and the Cochrane Specialized Register of data related to irritable bowel syndrome until December 2017 were revised, as well as the treatment guidelines presented by different medical organizations based on the criteria of Rome and of Evidence-Based Medicine. Development: a review of the subject referring to childhood was carried out, and the most accepted concept and pathogenesis were included, as well as Rome criteria established for the diagnosis. Etiology, clinical diagnosis and diagnostic tests were emphasized. Some aspects of the treatment were analyzed. Conclusions: Irritable bowel syndrome is relatively common as a cause of chronic functional abdominal pain, and questioning conducted according to Rome criteria is useful for diagnosis. The majority of patients with irritable bowel syndrome in childhood should be treated in the primary care level(AU)
Subject(s)
Humans , Male , Female , Child, Preschool , Child , Adolescent , Irritable Bowel Syndrome/epidemiology , Abdomen, Acute/complications , Abdomen, Acute/etiology , Adolescent Health/standards , Irritable Bowel Syndrome/complicationsABSTRACT
Objective To investigate the value of laparoscopy in the diagnosis and treatment of unexplained chronic abdominal pain.Methods From January 2014 to February 2016, clinical data of 56 unexplained chronic abdominal pain undergoing laparoscopic surgery were analyzed retrospectively.Laparoscopic exploration was performed firstly and then the corresponding abnormalities were diagnosed and dealt with accordingly.Results The disease causes were explicit in 48 cases (85.7%), including 25 cases of abdominal adhesions, 8 cases of chronic appendicitis, 2 cases of small intestinal diverticulum, 2 cases of intestinal tuberculosis, 2 cases of lymphoma, 5 cases of endometriosis, 2 cases of tubal adhesions, 1 case of peritoneal metastasis of gastric cancer after surgery, and 1 case of appendiceal mucinous adenocarcinoma.Surgical treatment was performed in 43 cases, 3 of whom were converted to laparotomy.There were no postoperative complications in the 56 cases.The follow-up rate was 92.9% (52/56), and lost of follow-up was in 4 cases.The follow-up duration was from 3 months to 3 years (median, 19.4 months).There was 1 death case (peritoneal carcinomatosis).There were 35 cases (62.5%) of complete relief of abdominal pain (no recurrence of preoperative abdominal pain symptoms) and 12 cases (21.4%) of pain relief (preoperative pain decreased or interval extended).The total effective rate was 83.9% (47/56).Conclusion Laparoscopy is of high value in the diagnosis and treatment of unexplained chronic abdominal pain.
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El dolor abdominal crónico es un motivo frecuente de consulta externa y de urgencias. Los médicos tradicionalmente consideran que el origen del mismo son las estructuras intraabdominales, incluido el tracto gastrointestinal. Rara vez tienen en cuenta la pared abdominal como la causa de la molestia y someten a los pacientes a numerosos e interminables procedimientos diagnósticos, como laparoscopias y cirugías, entre otros. Por lo menos el 50% de estos pacientes tiene dolor de la pared abdominal por lesión del nervio cutáneo anterior y el diagnóstico se hace identificando el signo de Carnett. Se presenta un caso típico con esta patología, cuyo enfoque inicial ilustra los errores y altos costos en el abordaje de esta patología
Chronic abdominal pain is a frequent cause of outpatient and emergency visits. Doctors traditionally consider that its origin is in intra-abdominal structures, including the gastrointestinal tract. They rarely take into account the abdominal wall as a cause of discomfort and subject patients to numerous and endless diagnostic procedures, including laparoscopy and surgery. At least 50% of these patients have abdominal wall pain due to injuries to the anterior cutaneous vein the diagnosis of which is made by identifying Carnetts sign. A typical case of this pathology is here. The initial approach illustrates the errors and high costs that can be involved in the approach to this pathology
Subject(s)
Abdominal Pain , Nerve Agents , Cost AllocationABSTRACT
Background: Patients with chronic abdominal pain can undergo numerous diagnostic tests with little change in their pain. This study was under taken to assess the efficacy of performing diagnostic and therapeutic laparoscopy in patients with chronic abdominal pain for longer than 12 weeks. Methods: All patients undergoing laparoscopy for chronic abdominal pain were included in the study for a period of 1 year from July 2015 to June 2016. The patient’s demographic data, length of time with pain, diagnostic studies, intraoperative findings, interventions and follow-up were determined. Results: A total of 50 patients with an average age of 35.75 years underwent diagnostic laparoscopy for the evaluation and treatment of chronic abdominal pain. The average length of time with pain was 32.96 weeks (range 12-96). 4 cases required conversion to an open procedure and no complications occurred. Findings included abdominal Koch's in 18, appendicitis in 16, cholecystitis in 2, cirrhosis in 2; ovarian cyst in 2, bilateral fimbrial cyst in 2 and 8 patients had no obvious pathology. 82.6% of patients had pain relief at the time of follow up. Conclusions: Laparoscopy has a diagnostic and therapeutic role in patients with chronic pain abdomen.
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Background: Chronic abdominal pain (CAP) is a prevalent condition with a wide etiology and is often associated with significant health care utilization. A functional diagnosis, particularly, Functional abdominal pain syndrome (FAPS) is more challenging and has been a less extensively studied condition in adults as compared to other common functional gastrointestinal disorders. Hence, this study attempts to formulate a definite line of investigations, study various causes of chronic abdominal pain and to evaluate FAPS, in a population from Central India. Methods: 100 patients in the age-group of 10-60 years with chronic abdominal pain were selected. A careful history, clinical examination and investigations were performed and final diagnosis was made on the basis of the available data. Results: Eighty-nine out of hundred patients were found to be having some organic disorder causing CAP while eleven had functional gastrointestinal disorders. FAPS was diagnosed in three patients on the basis of Rome III diagnostic criteria while one had unspecified functional abdominal pain. Conclusions: CAP is a multifactorial condition yet, a thorough history coupled with a complete physical examination and investigative profile help to a great extent in diagnosing the cause. FAPS should be diagnosed on the basis of a careful clinical history and characteristic pain behaviour during physical examination. A cost-effective and conservative approach should be adopted for investigations. Unlike the organic causes, FAPS should be treated with a biopsychosocial approach with a variable combination of pharmacological, cognitive-behavioural and psychological interventions.
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The term gossypiboma is used to describe as a mass due to retained surgical sponge after surgery. It is rare, but serious complication that is seldom reported because of the legal implications. The present study was carried out at the tertiary health center from January 2013 to April 2015. Five cases were studied prospectively. Gossypiboma usually has a varied and a vague presentation that makes it difficult to detect on radiological investigations. Sometimes, it can remain quiescent and could even present years after the operation. Though rare, gossypiboma should be kept in mind as a differential diagnosis in post-operative cases presenting as vague pain or recurrent chronic abdominal pain or long term foul smelling sinus discharge even years after the operation. Four out of five cases had colonic perforation, which was managed by primary closure. Fecal diversion was not required in any of the patient. Gossypiboma is avoidable, but serious rare post-operative complication. It is usually asymptomatic and has non-specific radiological findings. Hence, the diagnosis is often delayed. Gossypiboma can cause wide variety of complications like perforation and adhesion to the adjacent structures.
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Background: Patients with chronic abdominal pain can undergo numerous diagnostic tests with little change in their pain. This study was under taken to assess the efficacy of performing diagnostic and therapeutic laparoscopy in patients with chronic abdominal pain for longer than 12 weeks. Methods: All patients undergoing laparoscopy for chronic abdominal pain were included in the study for a period of 1 year from Nov. 2011 to Oct. 2012. The patient’s demographic data, length of time with pain, diagnostic studies, intraoperative findings, interventions and follow-up were determined. Results: A total of 25 patients (19 women and 6 men) with an average age of 34.64 years underwent diagnostic laparoscopy for the evaluation and treatment of chronic abdominal pain. The average length of time with pain was 32.96 weeks (range 12-96). 2 cases required conversion to an open procedure and no complications occurred. Findings included abdominal Koch's in 9, appendicitis in 8, cholecystitis in 1, cirrhosis in 1; ovarian cyst in 1, bilateral fimbrial cyst in 1 and 4 patients had no obvious pathology. 82.6% of patients had pain relief at the time of follow up. Conclusion: Laparoscopy has a diagnostic and therapeutic role in patients with chronic pain abdomen.
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Functional chronic abdominal pain is very common in pediatrics,but the understanding of the diagnosis and treatment in clinics are to be strengthened.The diagnosis,differential diagnosis and treatment progress of 4 kinds of main functional chronic abdominal pain in children are reviewed such as functional dyspepsia,irritable bowel syndrome,functional abdominal pain and functional abdominal pain syndrome,abdominal migraine according to Rome Ⅲ diagnostic criteria of functional gastrointestinal diseases in children.
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En este artículo se presenta el caso de un paciente con intoxicación crónica por plomo, cuya principal manifestación clínica fue dolor abdominal. Esta es una intoxicación quegeneralmente se presenta en pacientes que están en contacto laboral con este metal. En este artículo se revisan las manifestaciones clínicas más frecuentes y el manejo de estapatología, ya que de no identificarse y tratarse de forma oportuna, cursa con una alta morbimortalidad...
This article presents a case of chronic lead poisoning, which principal manifestation was abdominal pain. This usually occurs in patient who works with the metal. We reviewed the most frequent clinical manifestation and management. If is untreated thispoisoning has a high morbidity and mortality...
Subject(s)
Humans , Abdominal Pain/diagnosis , Poisoning , Lead Poisoning , Lead/radiation effectsABSTRACT
Chronic pancreatitis occurs by the prolonged inflammation of pancreatic tissue that induces the irreversible destruction of the organ, leading to a global pancreatic insufficiency. The most common manifestations are abdominal pain, diarrhea, malabsorption, and possibly diabetes mellitus. Chronic pancreatitis treatment includes dietary restrictions, enzymatic supplementation, vitamins, and endoscopic or surgical methods depending on the degree of ductal involvement. In addition to the known therapies, new therapies are under development and research.
La pancreatitis crónica se desarrolla por la inflamación prolongada del tejido pancreático que induce la destrucción irreversible del órgano, llevando a una insuficiencia pancreática global. Las manifestaciones más frecuentes son dolor abdominal, diarrea, malabsorción y eventualmente diabetes mellitus. El tratamiento en pancreatitis crónica incluye restricciones dietarias, suplementación enzimática, vitamínica, y métodos endoscópicos o quirúrgicos, dependiendo del grado de compromiso ductal. Además de lo descrito, están en desarrollo y experimentación nuevas terapias.
Subject(s)
Humans , Pancreatitis, Chronic/surgery , Pancreatitis, Chronic/diet therapy , Pancreatitis, Chronic/drug therapy , Antioxidants/therapeutic use , Abdominal Pain/etiology , Abdominal Pain/therapy , Endoscopy, Digestive System , Steatorrhea/etiology , Steatorrhea/therapy , Pancreatitis, Chronic/complications , Malabsorption Syndromes/etiology , Malabsorption Syndromes/therapy , Enzyme Therapy , Genetic TherapyABSTRACT
Childhood chronic abdominal pain usually doesn't have an organic etiology. It may cause social impairment and emotional distress in children as well as their families. In view of cognitive and behavioral aspect, passive coping style, maladaptive social modeling, and reinforced secondary gain could contribute to the development and maintenance of pediatric somatization. Integrative etiological model includes biological factors due to the enteric sensitization process, psychosocial factors which encompass family influences, psychodevelomental vulnerability, and life event-related stress. These factors interact with each other and manifest as various psychosomatic symptoms. In the treatment of childhood chronic abdominal pain, multimodal treatment program, which includes cognitive behavioral therapeutic methods, emotional support, family education, selective serotonin reuptake inhibitor, and so on, is known to be most effective.
Subject(s)
Child , Humans , Abdominal Pain , Biological Factors , Combined Modality Therapy , SerotoninABSTRACT
Organic diseases are prevalent in about 5 to 10% of children with chronic abdominal pain. The most common diseases of the upper digestive tract include gastroesophageal reflux disease (GERD), chronic gastritis with or without Helicobacter pylori (H. pylori), and peptic ulcer. The H. pylori infections acquired during childhood persist lifelong without eradication. Although the majority of H. pylori infected children remain asymptomatic, H. pylori infection may cause various digestive and extra-digestive diseases. There are still debates about a causal relationship between H. pylori-gastritis and abdominal symptoms in the absence of peptic ulcer disease. The number of Korean children infected with antibiotic resistant H. pylori is increasing even though the prevalence decreases after eradication. The choices of rescue therapy are limited in children after eradication failure. Antioxidant supplements with regimens against H. pylori have been tried with limited effects. Here I wanted to review the findings of recent reports on common upper digestive diseases such as GERD, peptic ulcer, and H. pylori infection in children with chronic abdominal pain.
Subject(s)
Child , Humans , Abdominal Pain , Gastritis , Gastroesophageal Reflux , Gastrointestinal Tract , Helicobacter pylori , Peptic Ulcer , PrevalenceABSTRACT
Nas últimas décadas, o uso da laparoscopia na ginecologia apresentou aumento expressivo. Ainda é considerada por grande parte dos ginecologistas como a primeira etapa na abordagem das mulheres com dor pélvica crônica. Esta revisão de literatura analisou as indicações da laparoscopia em pacientes com dor pélvica crônica, considerando separadamente os diagnósticos etiológicos mais comuns. Foram utilizadas as bases de dados do Medline-PubMed, Lilacs e Cochrane Library. Esta revisão mostrou que é preciso cautela na indicação do procedimento endoscópico, dado que, em alguns casos, como na endometriose profunda, as complicações são graves e os resultados muitas vezes insatisfatórios, o que justifica maior incentivo ao uso de tratamentos clínicos na abordagem inicial. A laparoscopia deve ser, portanto, empregada como elemento terapêutico em casos criteriosamente selecionados
In the recent decades, the use of laparoscopy in gynecology has had a significant growth. It is still considered by many gynecologists as the first step in the evaluation of women with chronic pelvic pain. This literature review analyzed the indications of laparoscopy in patients with chronic pelvic pain, considering separately the most common etiologies. The databases of Medline, PubMed, Lilacs and Cochrane Library were used. This review showed the need of caution in the indication of endoscopic procedure, because in some cases, as in deep endometriosis, complications are serious and results are often unsatisfactory, which justifies a great incentive to the use of treatment in the initial approach. Laparoscopy should therefore be used as a therapeutic option in carefully selected cases
Subject(s)
Humans , Female , Adult , Tissue Adhesions/etiology , Medical History Taking/methods , Chronic Disease , Pelvic Pain/diagnosis , Pelvic Pain/etiology , Pelvic Pain/therapy , Endometriosis/complications , Physical Examination , Laparoscopy/adverse effects , Laparoscopy , Evidence-Based PracticeABSTRACT
Abdominal pain is one of the most common symptoms we encounter in primary care clinics, and the patients being hospitalized for abdominal pain account for 5-6% of all the inpatients. Careful history taking and physical exams are always necessary for the diagnosis of patients having abdominal pain, because their problems may be transient and insignificant but also can be severe. For the elderly patients, common causes of abdominal pain are unspecific abdominal pain, functional disease, constipation, kidney stone, urinary tract infection, inflammatory bowel disease, biliary tract disease, acute appendicitis, diverticulitis, abdominal aortic aneurysm, peptic ulcer, intestinal obstruction, mesenteric ischemia, malignant tumor, gastroenteritis, etc. and myofacscial pain can also be the cause. We treated an elderly female patient who had suffered severe abdominal pain due to myofascial pain syndrome of the iliopsoas muscle undiagnosed for over 3 years. Therefore we report this case with review of several literatures.
Subject(s)
Aged , Female , Humans , Abdominal Pain , Aortic Aneurysm, Abdominal , Appendicitis , Biliary Tract Diseases , Constipation , Diverticulitis , Gastroenteritis , Inflammatory Bowel Diseases , Inpatients , Intestinal Obstruction , Ischemia , Kidney Calculi , Muscles , Myofascial Pain Syndromes , Peptic Ulcer , Primary Health Care , Urinary Tract InfectionsABSTRACT
Trichuris trichiura (T. trichiura) is soil-transmitted parasite and widely spreads all over the world. High infection rates occur especially in the poor hygiene area. T. trichiura is transmitted by the water and food contaminated with T. trichiura eggs. Most of mildly infected individuals could be asymptomatic, whereas heavily infected patients manifest with anemia, diarrhea, nausea, vomiting, abdominal pain, and weight loss. Serious manifestations such as intestinal obstruction and perforation were reported to be caused by Trichuriasis. Diagnostic methods are stool examination of T. trichiura eggs and eosinophil count in blood. Sometimes, colonoscopy can be useful diagnostic tool and treatment. We observed that the North Korean refugee with chronic abdominal pain and the patient with abdominal pain and loose stool have been diagnosed as T. trichiura infection confirmed by colonoscopy. After treatment, the patient's symptom has improved. Therefore we report two cases of trichuriasis with literature review.
Subject(s)
Humans , Abdominal Pain , Anemia , Colonoscopy , Diarrhea , Eggs , Eosinophils , Hygiene , Intestinal Obstruction , Nausea , Ovum , Parasites , Refugees , Trichuriasis , Trichuris , Vomiting , Water , Weight LossABSTRACT
Chronic abdominal pain (CAP) in children and adolescents remains one of the pathogenetically ambiguous disorders and a great trouble to their caretakers as well as patients. Although the symptom does not usually lead to a crucial problem, the parents may be terribly worried, the child may be in distress, and the practitioner may be concerned about ordering tests to confirm a serious occult disease. Systemized diagnostic approaches are needed to overcome this unique difficulty. The presence of red flag symptoms or signs is a general indication to pursue diagnostic testing for organic etiologies of CAP on the basis of specific symptoms in an individual case. Functional abdominal pain can be normally diagnosed when there are no red flag symptoms or signs. According to the Rome III criteria for pediatric functional gastrointestinal disorders, functional disorders of CAP can be classified into functional dyspepsia, irritable bowel syndrome, abdominal migraine, and chronic functional abdominal pain syndrome. Cyclic vomiting syndrome and pathologic aerophagia are also major functional causes of CAP. Modern concepts of the pathogenesis of functional abdominal pain include brain-gut interaction, visceral hypersensitivity, autonomic dysfunction, and psychosocial factors. In addition, psychiatric disorders, presented with red flag symptoms or signs, may induce the CAP in children and adolescents. We introduce practical and systemized diagnostic approaches by illustrating clinical cases of CAP in children and adolescents.
Subject(s)
Adolescent , Child , Humans , Abdominal Pain , Diagnostic Tests, Routine , Dyspepsia , Gastrointestinal Diseases , Hypersensitivity , Irritable Bowel Syndrome , Migraine Disorders , Parents , Rome , VomitingABSTRACT
Functional gastrointestinal disorders are among the most common medical problems in children. Abdominal pain-related functional gastrointestinal disorders can be categorized as functional dyspepsia, irritable bowel syndrome, abdominal migraine and childhood functional abdominal pain according to the Rome III criteria for pediatric functional gastrointestinal disorders. The aim of this paper was to examine the evidence supporting the use of the range of therapeutic options available for functional gastrointestinal disorders.