Abdominal migraine: an under-diagnosed cause of recurrent abdominal pain in children

(Headache 2011;51:707‐712) Objective.— Our objective was to demonstrate that, despite recognition by both the gastroenterology and headache communities, abdominal migraine (AM) is an under‐diagnosed cause of chronic, recurrent, abdominal pain in childhood in the USA. Background.— Chronic, recurrent abdominal pain occurs in 9‐15% of all children and adolescents. After exclusion of anatomic, infectious, inflammatory, or other metabolic causes, “functional abdominal pain” is the most common diagnosis of chronic, idiopathic, abdominal pain in childhood. Functional abdominal pain is typically categorized into one, or a combination of, the following 4 groups: functional dyspepsia, irritable bowel syndrome, AM, or functional abdominal pain syndrome. International Classification of Headache Disorders—(ICHD‐2) defines AM as an idiopathic disorder characterized by attacks of midline, moderate to severe abdominal pain lasting 1‐72 hours with vasomotor symptoms, nausea and vomiting, and included AM among the “periodic syndromes of childhood that are precursors for migraine.” Rome III Gastroenterology criteria (2006) separately established diagnostic criteria and confirmed AM as a well‐defined cause of recurrent abdominal pain. Methods.— Following institutional review board approval, a retrospective chart review was conducted on patients referred to an academic pediatric gastroenterology practice with the clinical complaint of recurrent abdominal pain. ICHD‐2 criteria were applied to identify the subset of children fulfilling criteria for AM. Demographics, diagnostic evaluation, treatment regimen and outcomes were collected. Results.— From an initial cohort of 600 children (ages 1‐21 years; 59% females) with recurrent abdominal pain, 142 (24%) were excluded on the basis of their ultimate diagnosis. Of the 458 patients meeting inclusion criteria, 1824 total patient office visits were reviewed. Three hundred eighty‐eight (84.6%) did not meet criteria for AM, 20 (4.4%) met ICHD‐2 formal criteria for AM and another 50 (11%) had documentation lacking at least 1 criterion, but were otherwise consistent with AM (probable AM). During the observation period, no children seen in this gastroenterology practice had received a diagnosis of AM. Conclusion.— Among children with chronic, idiopathic, recurrent abdominal pain, AM represents about 4‐15%. Given the spectrum of treatment modalities now available for pediatric migraine, increased awareness of cardinal features of AM by pediatricians and pediatric gastroenterologists may result in improved diagnostic accuracy and early institution of both acute and preventative migraine‐specific treatments.     

再发性腹痛儿童幽门螺杆菌IgG测定及分析

目的　探讨儿童再发性腹痛 (RAP)与幽门螺杆菌 (HP)感染的关系。方法　采用酶联免疫吸附法检测血清中相应的HP -IgG抗体。 结果　 2 662例再发性腹痛儿童 ,HP -IgG阳性者 789例 ,检出率 2 9 64 %;男女性别感染率无显著性差异 ,P >0 0 5。结论　①再发性腹痛儿童HP感染状况不容忽视 ;②血清学方法可作为HP感染初步筛选试验 ,根据其结果再进行1 3 C尿素呼气试验 ( 1 3 C -UBT)判断HP感染状态。两种试验方法结合诊断HP感染具有创伤小、准确、快速、相对经济的优点     

Headache and recurrent abdominal pain: a controlled study by the means of the Child Behaviour Checklist (CBCL)

Headache and recurrent abdominal pain (RAP) are common disorders in children and adolescents, frequently referred to paediatricians. Both disorders show similarities in trigger and comorbid factors, their burden on family and individual life, and a paroxysmal trend with risks of chronicization over time. However, very few studies have compared directly headache and RAP. The main aim of this study was to compare the psychological profile of headache and RAP patients vs. healthy controls. A total of 210 children and adolescents [99 boys, 111 girls; age range 4-18 years; mean age (m.a.) = 11.04, SD 4.05] were assessed: 70 headache patients (m.a. 12.4 years; SD 2.9; F = 35, M = 35), 70 RAP patients (m.a. 9 years; SD 3.6; F = 30, M = 40) and 70 controls (m.a. 11.7 years; SD 4.6; F = 46, M = 24). The diagnoses had been made according to international systems of classification both for headache (ICHD-II criteria) and RAP (Rome II criteria). The psychological profile had been made according to the Child Behaviour Checklist 4-18 (CBCL). anova one-way analysis was used to compare CBCL scales and subscales between groups. Headache and RAP showed a very similar trend vs. control for the main scales of the CBCL, with a statistically significant tendency to show problems in the Internalizing scale (anxiety, mood and somatic complaints) and no problems in the Externalizing (behavioural) scale. Only for the Attention Problems subscale migraineurs showed a significant difference compared with RAP. In conclusion, headache and RAP show a very similar psychological profile that should be considered not only for diagnostic and therapeutic purposes, but also from the aetiological aspect.     

Rebound abdominal pain: noncephalic pain in abdominal migraine is exacerbated by medication overuse

Abdominal migraine usually has its onset during childhood or adolescence and resolves in adulthood, often being replaced by typical migraine headaches. Rarely, migraine headache and recurrent abdominal pain coexist in some patients during adulthood. We report a patient who developed abdominal migraine without headaches beginning for the first time at the age of 22 years. The abdominal symptoms increased in frequency coincident with medication overuse and resolved after the overuse was treated. Analgesic overuse may cause a worsening of noncephalic pain in patients with extra-cephalic variants of migraine.     

Cortical correlates of an attentional bias to painful and innocuous somatic stimuli in children with recurrent abdominal pain

Recurrent abdominal pain (RAP) is a common gastrointestinal problem during childhood. It is not only a pediatric health problem, but may represent a risk factor for chronic pain, psychosomatic symptoms, and psychopathological problems later in life. Alterations in central pain processing and an attentional bias to potentially aversive somatic sensations could contribute to the unfavorable outcome of RAP during childhood. Fourteen children with RAP and 15 control children (age: 10-15 year) participated in an attentional task. Children had to respond to rare targets (tones) and ignore frequent either painful (pain threshold) or non-painful mechanical stimuli delivered at the hand. Event-related cortical potentials in response to the somatic stimuli and the tones were measured and stimulus intensity ratings, reaction time and number of errors were obtained. Painful as compared to non-painful stimuli elicited significantly larger N1, P2 and P3 components of the somatosensory-evoked potential (SEP) in all children. The RAP children responded with a significantly larger P3 to both painful and non-painful stimuli. No group differences were found for the auditory-evoked potentials. Perceived stimulus and pain intensity, reaction time and number of errors did not differ between groups. Similar to findings in adults with functional gastrointestinal disorders (FGIDs), children with RAP did not show somatic hyperalgesia as revealed by unaltered pain thresholds and middle latency pain-evoked SEPs. However, they displayed an attentional bias to painful and non-painful (innocuous) somatic stimuli as indicated by an enhanced P3. This may represent an important mechanism not only for the maintenance of RAP, but also for the development of psychosomatic symptoms.     

Effects of stress on pain threshold and tolerance in children with recurrent abdominal pain

Models of stress-induced hyperalgesia state that exposure to stress can exaggerate subsequent pain experiences. Studies using both animal and human subjects have shown evidence for hyperalgesia as a function of stress [e.g., Jorum E. Analgesia or hyperalgesia following stress correlates with emotional behavior in rats. Pain 1988;32:341-48; Peckerman A, Hurwitz BE, Saab PG, Llabre MM, McCabe PM, Schneiderman N. Stimulus dimensions of the cold pressor test and the associated patterns of cardiovascular response. Psychophysiology 1994;31:282-90; Gameiro et al. Nociception and anxiety-like behavior in rats submitted to different periods of restraint stress. Physiol. Behav. 2006;87:643-49; Lucas et al. Visceral pain and public speaking stress: neuroendocrine and immune cell responses in healthy subjects. Brain Behav. Immun. 2006;20:49-56]. However, the role of stress in pediatric pain is not well understood. This study examined stress reactivity and pain tolerance and sensitivity in a population of children with Recurrent abdominal pain (RAP). Forty-nine children meeting criteria for RAP (28 female; mean age 13years; range 9-17years) were randomly assigned to either a condition in which they completed an experimental stressor paradigm (stress interview, serial subtraction task) followed by a pain task (cold pressor) or a condition in which they received the pain task prior to the stress tasks. Children who underwent the stress tasks before the pain task exhibited lower levels of pain tolerance than those who received the pain task first (p<.01); no differences were found between the two groups in pain threshold or pain intensity ratings. Further, pain tolerance was not related to individual differences in physiological reactivity (heart rate change) to the stressor. The present research demonstrates the first evidence of the occurrence of stress-induced hyperalgesia in a pediatric pain population.     

The expanded role of the barium enema in the evaluation of patients presenting with acute abdominal pain

The role of the barium enema in the evaluation of patients with acute abdominal pain is well established. It is utilized in the diagnosis and treatment of several suspected clinical entities, including appendicitis, diverticulitis, intussusception, and volvulus. There is another group of patients in whom a vague clinical presentation and an indeterminate bowel gas pattern fail to clarify the diagnosis. The role of the barium enema has been expanded as an early diagnostic aid in the evaluation of these patients. Based on abdominal film findings, three patient categories are presented, in whom the early use of a "judicious" barium enema may safely and quickly contribute to the preoperative definition of the underlying disease process, allowing for the correct mode of therapy to be undertaken.     

磁控胶囊内镜在儿童再发性腹痛中的诊断价值

目的探讨磁控胶囊内镜在儿童再发性腹痛（RAP）中的应用价值。方法回顾性分析2021年1月-2021年6月上海交通大学医学院附属儿童医院内镜中心125例行磁控胶囊内镜检查的RAP患儿的临床资料,分析镜下病变检出情况和胶囊内镜在消化道各部位运行时间等。结果125例患者中,35例拟行全小肠检查（1例因吞服失败而未完成）,90例在磁控条件下行食管及胃部检查。磁控胶囊内镜在食管内的中位运行时间为8.5 (5.3,12.5) s,在胃内的中位运行时间为49.0 (17.7,94.0) min,行全小肠检查的患儿,胶囊内镜在小肠内的中位运行时间为252.0 (192.5,340.0) min,全小肠检查完成率为97.1%(34/35）,检查完成后所有胶囊内镜均顺利排出体外。上消化道病变检出率为71.8%(89/124）,小肠病变检出率为68.6%(24/35）。磁控胶囊内镜对儿童RAP的总体病变检出率为73.4%(91/124）。结论磁控胶囊内镜在RAP患儿胃肠道病变检查中有较高的病变检出率,且安全无痛苦,具有一定的临床应用价值。     

Acute abdominal pain in the older adult

Abdominal pain in older adults is a concerning symptom common to a variety of diagnoses with high morbidity and mortality. Organizing the differential into categories based on pathology (inflammatory, obstructive, vascular, or other causes) provides a framework for the history, physical, and diagnostic studies. An organized approach and treatment and considerations specific to the geriatric population are discussed.     

胶囊内镜在慢性腹痛患者中的应用价值

目的探讨胶囊内镜在慢性腹痛中的诊断价值和安全性。方法对2008年8月至2009年11月期间不明原因的慢性腹痛患者24例进行胶囊内镜检查,同期12例体检者作为对照组。观察两组患者的小肠运转时间、病变及部位、图像质量及顺应性。结果所有受检者在胶囊内镜检查过程中无任何不适和并发症,均顺利完成检查,所得图像清晰。胶囊1～3d自然排出。腹痛组小肠转运时间为（252．69±95．19）min,体检组小肠运转时间为（209．33±34．32）min。其中腹痛组4例胶囊未通过回盲瓣,体检组1例胶囊未通过回盲瓣。检出病变有胃溃疡、小肠炎症、克罗恩病、小肠NSAIDs溃疡、息肉、间质瘤及肠道寄生虫等。结论胶囊内镜检查无痛苦,成功率高,对病变检出率高,对不明原因慢性腹痛患者有较好的诊断价值。     

The use of analgesics in patients with acute abdominal pain

Analgesics in patients with acute abdominal pain are often withheld for fear that they may change physical examination findings and thus may be unsafe. We conducted a randomized, prospective, placebo-controlled trial to investigate changes in physical examination following the administration of placebo, 5 mg, or 10 mg of morphine to 49 patients with acute abdominal pain. One patient was withdrawn secondary to inadequate documentation. Of the 48 patients who completed the trial, a statistically significant change in physical examination was noted in both groups receiving analgesics, but not in the placebo group. No adverse events or delays in diagnosis were attributed to the administration of analgesics. We conclude that physical examination does change after the administration of analgesics in patients with acute abdominal pain and that a larger study is needed to evaluate analgesic safety in this subpopulation of emergency department patients.     

The effects of oral contraceptives on detection and pain thresholds as well as headache intensity during menstrual cycle in migraine

(Headache 2011;51:92‐104) Background.— Clinically, oral contraceptives (OC) can influence pain in both migraine headache and temporomandibular pain disorders. Estrogen as an ingredient of OC might be a responsible factor for these observations. We conducted the present study to test whether OC are able to alter the severity of headache attacks as well as the detection or pain thresholds over the course of the menstrual cycle in patients with migraine. Methods.— Thirteen healthy and regularly menstruating women and 26 migraineurs (13 using OC and 13 not using OC) were studied on the days 1, 4, 14, and 22 of their menstrual cycle. In all participants, saliva was collected first for determination of estrogen on each study day. Then, detection thresholds (warmth, cold, electrical current) and pain thresholds (cold, heat, pressure, electrical current) were assessed. Migraineurs were asked for headache attacks occurring in a period of 24 hours before testing and to estimate pain intensity on a verbal rating scale. Results.— On day 4 of the menstrual cycle, migraineurs using OC suffered significantly more from severe migraine attacks than migraineurs not taking OC. With respect to detection and pain thresholds, no effects of OC could be observed as concerning the differences between migraineurs with or without OC medication. On day 22, the severity of migraine headache was significantly related with the pain thresholds for pressure and electrical current, suggesting paradoxically more severe headache attacks in patients presenting with higher pain thresholds. Healthy volunteers disclosed higher salivary estrogen levels than migraineurs and migraineurs not using OC higher concentrations than migraineurs using OC throughout the menstrual cycle. Conclusions.— In this study, the use of OC intensified migraine (however only at the end of menstruation) however had no influence on detection and pain thresholds in migraineurs. Possible reasons for this dissociation will be discussed.     

彩色多普勒超声对功能性再发性腹痛儿童肠系膜上动脉的血流动力学研究

目的通过研究功能性再发性腹痛（RAP）儿童肠系膜上动脉（SMA）血流动力学的变化,探讨功能性RAP与SMA血流动力学变化的相关性。方法超声测量40例功能性RAP儿童SMA的直径、血流量、收缩期峰值速度（PSV）、舒张末期速度（EDV）、搏动指数及阻力指数,并与45例健康儿童（对照组）比较。结果功能性RAP儿童组SMA的PSV、EDV、直径、血流量较对照组降低（P〈0．01）,搏动指数及阻力指数在两组间差异无统计学意义（P〉0．05）。结论功能性RAP儿童的SMA部分血流动力学指标降低,其变化对于功能性RAP的临床诊断具有参考价值。     

急诊腹痛症状早期预警方法研究进展

急诊科就诊患者较多、拥挤是普遍现象,其中需要紧急救治的患者常常被延误治疗。医师延误对病情的评估、疾病的诊断和治疗,将导致不良结局的出现。腹痛占急诊就诊的6.8%,是急诊患者的最常见临床症状,其诊断繁多,包括良性疾病和威胁生命的疾病〔1〕。由于不同的腹痛病因引起的临床特点不同,从而使急诊医师更多地依赖于实验室检查。一项对急诊的研究表明,65%的相同的非创伤性腹痛患者至少要接受一项影像学检查〔2〕。实验室检查不仅增加了开销,延长了留观时间,而且加重了急诊室的拥挤现象。有调查显示,在过去     

Pneumonia in unexpected locations: An occult cause of pediatric abdominal pain

Although pneumonia is a known cause of pediatric abdominal pain, it may go unrecognized on a patient's initial evaluation. This is particularly true when the infection lies outside of the typically described basilar location. We report three pediatric patients in whom acute abdominal pain was the sole or primary manifestation of a nonbasilar pneumonia.     

膝胸卧位改善无痛胃肠镜联合检查后腹痛腹胀的效果观察

目的 探讨膝胸卧位改善无痛胃肠镜联合检查后腹痛腹胀的应用效果。方法 选取2021年1月至12月于空军军医大学第一附属医院消化内镜中心接受无痛胃肠镜联合检查后腹痛腹胀评分≥4分的受检者,采用随机数字表法将其分为试验组和对照组,每组各50名。试验组采用膝胸卧位排气,对照组采用一次性肛管排气。比较2组受检者首次排气时长、症状缓解时长、采取措施前后腹痛腹胀评分变化,干预后腹痛腹胀减轻的效果及受检者的满意情况。 结果 试验组和对照组在年龄、性别、文化程度及接受内镜检查的操作时长方面均无统计学差异。试验组首次排气时长和症状缓解时长明显低于对照组,差异有统计学意义(p＜0.05),两组在干预措施前后腹痛腹胀评分的差值均具有统计学意义,且试验组改善高于对照组,差异有统计学意义(P<0.05)。试验组对腹痛腹胀改善有效率及患者的满意度均明显高于对照组,差异有统计学意义(P<0.05)。结论 膝胸卧位能显著改善无痛胃肠镜联合检查后患者的腹痛腹胀症状,效果优于肛管排气,且患者的满意度高,值得临床推广。