Göksel VATANSEVER, Aydan KANSU, Ceyda Tuna KIRSAÇLIOĞLU, Arzu Meltem DEMİR, Zarife KULOĞLU

Çocuklarda Kronik Karın Ağrısının Nedenlerinin Değerlendirilmesi ve Maliyet Analizi

Amaç: Kronik karın ağrısı (KKA) olan çocuklarda öykü, fizik inceleme ve tanıya yönelik yapılan tetkikler ile organik ve fonksiyonel karın ağrısının sıklığının belirlenmesi ve tetkiklerin hasta başına maliyetinin hesaplanması amaçlanmıştır. Gereç ve Yöntem: Çocuk gastroenteroloji polikliniğinde KKA ile izlenen 4-18 yaş arası çocukların geriye dönük olarak demografik verileri, öykü özellikleri, alarm belirti/bulgu varlığı, fizik muayene, laboratuvar, görüntüleme, endoskopik ve histopatolojik bulguları değerlendirildi. Olguların tanı aşamasında yapılan tetkiklerinin toplam maliyeti ve hasta başına maliyeti hesaplandı. Bulgular: KKA olan 324 hastanın (yaş ortalaması 11,26±3,80 yıl, %67’si kız), 222’si (%68,3) fonksiyonel gastrointestinal bozukluklar (FGİB), 102’si (%31,7) organik nedenli karın ağrısı tanısı aldı. Organik nedenli karın ağrısı grubunda gastrit (%31,1), gastroözofageal reflü (%22,6), Helikobakter pilori enfeksiyonu (%19,8) ve çölyak hastalığı (%7,5) saptandı. FGİB grubunu ise fonksiyonel dispepsi (%40,1), fonksiyonel karın ağrısı (%32,5), fonksiyonel kabızlık (%21,5), irritabl bağırsak sendromu (%5,5) ve siklik kusma (%0,4) oluşturdu. Kusma (p=0,01), karın ağrısının 1 saatten uzun sürmesi (p=0,01), şiddetli olması (p=0,01) ve uykudan uyandırması (p=0,014), kilo kaybı (p=0,045), ateş (p=0,035), artrit (p=0,014) ve üst gastrointestinal sistem kanaması (p=0,011) öyküsü, fizik muayenede herhangi bir patolojik bulgu varlığı (p=0,01) organik nedenli karın ağrısında daha sıktı. Tanı için yapılan tetkiklerin hasta başı maliyeti organik nedenli KKA’da (163,79 TL), FGİB’ye göre (50,66 TL) yaklaşık 3 kat fazlaydı. Sonuç: Çocukluk çağında KKA’nın en sık nedeni FGİB’ye bağlı karın ağrısıdır. Alarm belirtilerinin varlığı, daha çok organik nedenleri düşündürmektedir. Ayrıntılı bir öykü ve fizik muayene ile organik nedenler dışlanabilmekte, gereksiz maliyetler önlenebilmektedir.

Evaluation of Children with Chronic Abdominal Pain and Cost Analysis

Objectives: We aimed to identify the frequency of functional and organic abdominal pain by history, physical examination and diagnostic tests in children who presented with chronic abdominal pain (CAP) and to determine the cost per patient. Materials and Methods: The children who presented to pediatric gastroenterology outpatient clinic with CAP, aged 4-18 years, were reviewed for demographic data, history, physical examination, laboratory, imaging, endoscopic and histopathological findings retrospectively. The total cost of examinations performed at the diagnosis stage of the cases and the amount per patient were calculated. Results: Among 324 patients (11.26±3.80 years, 67% female), 222 (68.3%) patients were detected to have functional abdominal pain due to functional gastrointestinal disorders (FGID) and 102 (31.7%) were found to have organic causes. Gastritis in the organic-caused abdominal pain group (31.1%), gastroesophageal reflux (22.6%) Helicobacter pylori infection (19.8%) and celiac disease (7.5%) were the most frequent causes. Within patients in the FGID group, 40.1% had functional dyspepsia, 32.5% had functional abdominal pain, 21.5% had functional constipation, 5.5% had irritable bowel syndrome, and 0.4% had cyclic vomiting. The severity degree (p=0.01), duration time (for more than 1 hour) (p=0.01) and awaking from sleep (p=0.014) of abdominal pain, presence of vomiting (p=0.01), weight loss (p=0.045), fever (p=0.035), arthritis (p=0.014), upper pathological finding in physical examination were more frequent in patients with organic causes. The average cost of diagnostic tests per patient in the organic group (163.79 TL) was approximately 3 times higher than in the FGID group (50.66 TL). Conclusion: The most common etiology of chronic abdominal pain in childhood is due to FGID. The presence of alarm symptoms suggests more organic causes. Organic etiology can be excluded by detailed medical history and physical examination without unnecessary cost.

PDF

___

1. Mani J, Madani S. Pediatric abdominal migraine: current perspectives on a lesser known entity. Pediatric Health Med Ther. 2018;9:47-58.
2. Wright NJ, Hammond PJ, Curry JI. Chronic abdominal pain in children: help in spotting the organic diagnosis. Arch Dis Child Educ Pract Ed. 2013;98:32-39.
3. Rasquin A, Di Lorenzo C, Forbes D, et al. Childhood functional gastrointestinal disorders: child/adolescent. Gastroenterology. 2006;130:1527-1537.
4. Bremner AR, Sandhu BK. Recurrent abdominal pain in childhood: the functional element. Indian Pediatr. 2009;46:375-379.
5. Neyzi O, Furman A, Bundak R, et al. Growth references for Turkish children aged 6 to 18 years. Acta Paediatr. 2006;95:1635-1641.
6. Puzanovova M, Rudzinski E, Shirkey KC, et al. Sex, psychosocial factors, and reported symptoms influence referral for esophagogastroduodenoscopy and biopsy results in children with chronic abdominal pain. J Pediatr Gastroenterol Nutr. 2008;47:54-60.
7. Malaty HM, Abudayyeh S, Fraley K, et al. Recurrent abdominal pain in school children: effect of obesity and diet. Acta Paediatr. 2007;96:572-576.
8. Plocek A, Wasowska-Krolikowska K, Toporowska-Kowalska E. Rome III classification of functional gastrointestinal disorders in children with chronic abdominal pain. Med Wieku Rozwoj 2010;14:350-356.
9. Alfvén G. One hundred cases of recurrent abdominal pain in children: diagnostic procedures and criteria for a psychosomatic diagnosis. Acta Paediatr. 2003;92:43-49.
10. Motamed F, Mohsenipour R, Seifirad S, et al. Red flags of organic recurrent abdominal pain in children: study on 100 subjects. Iran J Pediatr. 2012;22:457-462.
11. El-Chammas K, Majeskie A, Simpson P, et al. Red flags in children with chronic abdominal pain and Crohn’s disease-a single center experience. J Pediatr. 2013;162:783-787.
12. Thapar N, Benninga MA, Crowell MD, et al. Paediatric functional abdominal pain disorders. Nat Rev Dis Primers. 2020;6:89.
13. Brusaferro A, Farinelli E, Zenzeri L, et al. The Management of Paediatric Functional Abdominal Pain Disorders: Latest Evidence. Paediatr Drugs. 2018;20:235-247.
14. Soon GS, Saunders N, Ipp M, et al. Community-based case-control study of childhood chronic abdominal pain: role of selected laboratory investigations. J Pediatr Gastroenterol Nutr. 2007;44:524-526.
15. Blecker U, Gold BD. Gastritis and peptic ulcer disease in childhood. Eur J Pediatr. 1999;158:541-546.
16. Hyman PE. Chronic and Recurrent Abdominal Pain. Pediatr Rev. 2016;37:377-390.
17. Mansour MM, Al Hadidi KhM, Omar MA. Helicobacter pylori and recurrent abdominal pain in children: is there any relation? Trop Gastroenterol. 2012;33:55-61.
18. Spee LA, Madderom MB, Pijpers M, et al. Association between helicobacter pylori and gastrointestinal symptoms in children. Pediatrics. 2010;125:e651-669.
19. Zeyrek D, Zeyrek F, Cakmak A, et al. Association of Helicobacter pylori and giardiasis in children with recurrent abdominal pain. Turkiye Parazitol Derg. 2008;32:4-7.
20. Tuna Kırsaçlıoğlu C, Kuloğlu Z, Üstündağ G, et al. Recurrent Abdominal Pain in Children: Is it Organic or Functional? Turkiye Klinikleri J Pediatr. 2016;25:74-81.
21. Martigne L, Delaage PH, Thomas-Delecourt F, et al. Prevalence and management of gastroesophageal reflux disease in children and adolescents: a nationwide cross-sectional observational study. Eur J Pediatr. 2012;171:1767-1773.
22. El-Serag HB, Gilger MA, Shub MD, et al. The prevalence of suspected Barrett’s esophagus in children and adolescents: a multicenter endoscopic study. Gastrointest Endosc. 2006;64:671-675.
23. Dalgic B, Sari S, Basturk B, et al. Prevalence of celiac disease in healthy Turkish school children. Am J Gastroenterol. 2011;106:1512-1517.
24. Farahmand F, Modaresi V, Najafi M, et al. Prevalence of celiac disease in Iranian children with recurrent abdominal pain referred to a pediatric referral center. Iran J Pediatr. 2011;21:33-38.
25. Palasciano G, Portincasa P, Vinciguerra V, et al. Gallstone prevalence and gallbladder volume in children and adolescents: an epidemiological ultrasonographic survey and relationship to body mass index. Am J Gastroenterol. 1989;84:1378-1382.
26. Cobankara V, Fidan G, Türk T, et al. The prevalence of familial Mediterranean fever in the Turkish province of Denizli: a field study with a zero patient design. Clin Exp Rheumatol. 2004;22(4 Suppl 34):S27-30.
27. Sandhu BK, Fell JM, Beattie RM, et al. Guidelines for the management of inflammatory bowel disease in children in the United Kingdom. J Pediatr Gastroenterol Nutr. 2010;50 Suppl 1:S1-13.
28. Malaty HM, Fan X, Opekun AR, et al. Rising incidence of inflammatory bowel disease among children: a 12-year study. J Pediatr Gastroenterol Nutr. 2010;50:27-31.
29. Di Lorenzo C, Colletti RB, Lehmann HP, et al. Chronic Abdominal Pain In Children: a Technical Report of the American Academy of Pediatrics and the North American Society for Pediatric Gastroenterology, Hepatology and Nutrition. J Pediatr Gastroenterol Nutr. 2005;40:249-261.
30. American Academy of Pediatrics Subcommittee on Chronic Abdominal Pain; North American Society for Pediatric Gastroenterology Hepatology, and Nutrition. Chronic abdominal pain in children. Pediatrics. 2005;115:e370- 381.
31. Devanarayana NM, Mettananda S, Liyanarachchi C, et al. Abdominal pain-predominant functional gastrointestinal diseases in children and adolescents: prevalence, symptomatology, and association with emotional stress. J Pediatr Gastroenterol Nutr. 2011;53:659-665.
32. Okumura T, Tanno S, Ohhira M, et al. Prevalence of functional dyspepsia in an outpatient clinic with primary care physicians in Japan. J Gastroenterol. 2010;45:187-194.
33. Chitkara DK, Rawat DJ, Talley NJ. The epidemiology of childhood recurrent abdominal pain in Western countries: a systematic review. Am J Gastroenterol. 2005;100:1868-1875.
34. Gieteling MJ, Bierma-Zeinstra SM, Passchier J, et al. Prognosis of chronic or recurrent abdominal pain in children. J Pediatr Gastroenterol Nutr. 2008;47:316-326.
35. Rajindrajith S, Devanarayana N, Mettananda S, et al. Constipation and functional faecal retention in a group of school children in a district in Sri Lanka. Sri Lanka Journal of Child Health. 2009;38:60-64.
36. van den Berg MM, Benninga MA, Di Lorenzo C. Epidemiology of childhood constipation: a systematic review. Am J Gastroenterol. 2006;101:2401- 2409.
37. Miele E, Simeone D, Marino A, et al. Functional gastrointestinal disorders in children: an Italian prospective survey. Pediatrics. 2004;114:73-78.
38. Lee LY, Abbott L, Mahlangu B, et al. The management of cyclic vomiting syndrome: a systematic review. Eur J Gastroenterol Hepatol. 2012;24:1001- 1006.
39. Dhroove G, Chogle A, Saps M. A million-dollar work-up for abdominal pain: is it worth it? J Pediatr Gastroenterol Nutr. 2010;51:579-583.
40. Türkiye İstatistik Kurumu, Sağlık Harcama İstatistikleri, 2019. Haber Bülteni 19 Kasım 2020;Sayı:33659 https://data.tuik.gov.tr/Bulten/Index?p=Saglik- Harcamalari-Istatistikleri-2019-33659.