Chronic abdominalpain and diarrhea are common symptoms in children. In any given 6-month period, up to half of the children in the United States report persistent abdominalpain, which often leads to a medical evaluation. 1–5 When evaluating children with chronic abdominalpain and diarrhea, clinicians have the challenge of determining how much of an evaluation is necessary because a functional gastrointestinal disorder (FGID) is most likely. Rome IV criteria (international guidelines used to deﬁne FGIDs) state that the
Initially, lupus can be dif ﬁ cult to diagnose because the symptoms are nonspeci ﬁ c and overlap with those of more common conditions like a viral illness. On admission, the patient did not seem to meet the criteria until additional symptoms emerged. As his disease progressed, additional rheumatologic evaluation with blood tests and imaging were necessary. During his hospital admission, he fulﬁlled the clinical and laboratory criteria for lupus (arthritis, pleuritis, anemia, with positive ANA and anti-dsDNA antibody results). The anti-dsDNA antibodies are relatively speci ﬁ c for SLE but can also be seen in infections and malignancy. 34
GES on total symptom score, vomiting, and nausea in Gp. 1 However, our results indicate improvements for patients with Gp in both the nonsevere and severe pain groups at the one- and two-hour gastric-emptying time points, whereas the O’Grady meta-analysis of high- frequency GES for Gp only revealed a significant improvement at the four-hour interval. Additionally, these researchers observed benefits in follow-up visits after pGES implantation that included an improved sense of physical and psychological well-being and a dramatic reduction in the need for parenteral and nonoral enteral nutrition. 1
Participants were randomized to receive oral fidaxomicin (200 mg twice daily) or oral vancomycin (125 mg 4 times daily) for 10 days. Participants were evaluated daily during the 10-day treatment period for cure or treatment failure on the basis of symptoms of fever, nausea, vomiting, abdominalpain, flatus, and the number of daily bowel movements. If subjects were cured, recurrence was assessed by means of weekly phone calls during 4 weeks of follow-up. Fecal samples were collected before the first dose of study drug, at end of treatment, and at recurrence of symptoms and assayed for toxins A and B. All concomitant medications were recorded. Subjects were considered to have taken CAs if they received 1 or more oral or intravenous doses of antibiotic(s) during the treatment or follow-up periods.
The current guidelines provided by the IMWG (2013) define SP as biopsy-confirmed plasma cell proliferation in the bone or soft tissue in the presence of normal bone marrow and normal skeletal survey. Guidelines also recommend using the term SP when less than 10% of bone marrow is involved without osteolytic lesions. A plasmacytoma with more than 10% of plasma cell proliferation in bone marrow has always been indicative of MM . With this in mind, we classified our patient as having MM. The major difficulty in MM is the dis- ease definition because it is clinicopathological; it needs overt clinical manifestations of serious end organ dam- age, such as osteolytic bone lesions and renal failure, before the diagnosis can be made. We found a rare ap- pendicular plasmacytoma in our patient; his symptoms varied at the initial presentation. This is often deleteri- ous for patients because they receive treatment at an advanced stage of the disease; however, current treat- ment options have greatly improved, showing that prompt treatment of a high risk initial presentation of a patient with plasmatic cell neoplasia can extend sur- vival rates [5, 6].
Infectious Disease Division,The First Affiiated Hospital of Chongqing Medical University, Chongqing 400016, P.R.
Received November 6, 2014; Accepted December 23, 2014; Epub January 1, 2015; Published January 15, 2015 Abstract: Background: Doctors perform colonoscopies when presented with various symptoms, including unex- plained weight loss, rectal bleeding, changes in bowel habits, however many other symptoms such as abdominalpain, diarrhea and constipation may be more popular in outpatient department. As a result, we want to evaluate the three symptoms which is more need to have a colonoscopy. Abdominalpain, diarrhea and constipation are the main reasons for patients to visit the outpatient department of gastroenterology. And the colonoscopy is regularly recommended for outpatients with the above symptoms in China. The aim of this study was to evaluate the value of colonoscopy on the diagnosis of each single symptom of the three above and answer the question of my title-which symptom is more indispensable to have a colonoscopy? Methods: Colonoscopic findings of 580 outpatients with a single of these three common lower gastrointestinal symptoms were systematically analyzed in retrospect. Results:
The diagnosis of functional abdominalpain is a diagnosis of exclusion in patients who usually present to the ED with symptoms of chronic or recurrent abdominalpain. Several definitions have been proposed to describe chronic or recurrent abdom- inal pain; however, most investigators agree that it represents pain lasting for a period of at least 3 months and is either chronic or episodic. 151 In evaluating the child with chronic or recurrent abdominalpain, the emergency physician must determine the likelihood of serious conditions by performing a preliminary evaluation, including a thorough history and physical examination. This strategy should point the clinician to specific red flags that require a more thorough evaluation, such as weight loss, reduced growth, significant vomiting, chronic severe diarrhea, hematochezia, hema- temesis, unexplained fever, and a family history of inflammatory bowel disease. 151 The suggested initial laboratory evaluation should include a complete blood count with differential, basic metabolic panel, inflammatory markers (eg, CRP test, erythro- cyte sedimentation rate), liver enzyme and function tests, pancreatic enzyme tests, and UA. Further investigations depend on the possible differential diagnosis sug- gested by the history and physical examination.
Irritable bowel syndrome seems to be most common in young women, par- ticularly those who have young children. This frequency has been attributed to the life pressures to which these women are subjected. Symptoms of irritable bowel are also more frequent in others under stress, including children. The abdominalpain from an irritable bowel may be a vague discomfort or pain in the left lower quadrant (LLQ), RLQ, or midabdomen. It occasionally radiates to the back. This pain may be relieved by defecation and may be associated with other well-recognized symptoms of irritable bowel: mucus in the stool, constipa- tion alternating with diarrhea, and small marble-like stools.
selected patients. Loperamide may prevent diarrhea when taken before a meal or an activity that often leads to the symptom. Constipation is treated initially with dietary fiber supplementation. If response is unsatisfactory, commercial fiber analogs may help. The heterogeneous smooth-muscle relaxants are questionably beneficial for pain; trial deficiencies leave their efficacy in doubt. 31 Furthermore, their availability varies in Australia, Canada, Europe, and the United States. Antidepressant drug therapy in lower than antidepressant doses may be beneficial even if there is no major psychiatric co morbidity. For example, desipramine benefits women with moderate to severe IBS who do not discontinue the drug owing to side effects, and the effect appears unrelated to the drug dose. Paroxetine improves the physical component of quality of life of patients with severe IBS and is more effective than a high-fiber diet in improving global status. The narrow therapeutic window for antidepressants suggests they be limited to patients with moderate or severe IBS.
2. How Common is IBS?
If you suffer from the symptoms of IBS you are not alone. IBS is one of the most common gastro- intestinal disorders in the United States affecting more than 58 million people. IBS affects all races and both men and women, however approximately 4 out of 5 (or 80 percent) of IBS sufferers are women. The reason for this is unclear. Women may be more conscientious in seeking health care, or there may be gender-based biological differences that explain this higher incidence among women.
ovarian cyst, mittelschmerz, typhlitis, ectopic pregnancy, and mesenteric adenitis. Acute onset of Crohn disease should be suspected if there is right lower quadrant mass and diarrhea. Children with urolithiasis rarely present with the excruciating pain of stone passage seen in adults. Col- icky pain in the abdomen or flank is more common. Hema- turia, either microscopic or macroscopic, occurs in the vast majority of children. The presence of fever greater than 101°F suggests pyelonephritis and salpingitis in addition to a perforated appendix. Urinalysis should be performed in all patients with right lower quadrant abdominalpain, flank pain, or pain radiating into the groin. Pelvic exami- nation with appropriate examinations for sexually trans- mitted diseases is indicated in an adolescent female who has just completed a menstrual period and presents with lower abdominalpain and fever. The patient may report an increased vaginal discharge or irregular bleeding. A compli- cation of salpingitis that evokes clinical signs of peritonitis and shock is a ruptured tubo-ovarian abscess. Typical pri- mary dysmenorrhea consists of crampy, dull, midline, or generalized lower abdominalpain at the onset of the men- strual period. The pain may coincide with the start of bleeding or precede the bleeding by several hours. Associ- ated symptoms include backache, thigh pain, diarrhea, nausea, vomiting, and headache. Endometriosis must be considered when there is chronic, cyclic, undiagnosed pelvic pain in teenagers. Unilateral abdominalpain at the midpoint of the menstrual cycle (time of ovulation), with or without spotty bleeding for 24 hours, is characteristic of mittelschmerz. Typhlitis should be considered in a neu- tropenic patient receiving antineoplastic drugs who pre- sents with right lower quadrant abdominalpain, fever, diarrhea, nausea, and vomiting. Localized tenderness may progress rapidly to diffuse signs of peritonitis as a result of intestinal perforation. Urine or serum pregnancy testing should be performed in adolescent females of reproductive age with lower abdominalpain. Mesenteric adenitis is a commonly used term to describe clustering of inflamed lymph nodes in the region of the terminal ileum in patients undergoing appendectomy. Mesenteric adenitis should not be considered a separate diagnosis but rather a sequela of viral or bacterial gastroenteritis.
Chronic abdominalpain (long-standing intermit- tent or constant abdominalpain) is common in chil- dren and adolescents. In most children, chronic ab- dominal pain is functional, that is, without objective evidence of an underlying organic disorder. Yet, an important part of the physician’s job is to determine which children have an organic disorder. A review of the current evidence, however, indicates that there are no studies showing that pain frequency, severity, location, or effects on lifestyle help to discriminate between functional and organic disorders. Children with chronic abdominalpain are more likely than children without chronic abdominalpain to have headache, joint pain, anorexia, vomiting, nausea, ex- cessive gas, and altered bowel symptoms, but there is insufficient evidence that the presence of the asso- ciated symptoms can help the physician discriminate between functional and organic disorders. Although children with chronic abdominalpain and their par- ents are more often anxious or depressed, the pres- ence of anxiety, depression, behavior problems, or recent negative life events does not seem to be useful in distinguishing between functional and organic ab- dominal pain.
chronic abdominalpain are more likely than children without chronic abdominalpain to have headache, joint pain, anorexia, vomiting, nausea, excessive gas, and altered bowel symptoms, the presence of these associated symptoms is unlikely to help the physi- cian discriminate between functional and organic disorders. In contrast, the presence of alarm symp- toms or signs (see recommendation 3 below for a list) may suggest a higher likelihood of organic disease and is an indication for the performance of diagnos- tic tests, whereas in the absence of alarm symptoms, diagnostic studies are unlikely to have a significant yield of organic disease. Furthermore, there is no evidence that emotional or behavioral symptoms predict the clinical course or that families of children with chronic abdominalpain differ in broad areas of family functioning. Although clinicians prescribe a range of treatments, there are only limited or incon- clusive studies of pharmacologic or behavioral ther- apy in children.
Comments About Flowchart 2.1
1. Diseases causing hypogastric pain/suprapubic pain in a male patient differ in type and frequency of presentation from those affecting a female patient.
2. Absence of associated urinary symptoms should prompt the GP to consider a bowel disease as the most likely explanation of the symptom. In young patients, a history of recurrent and migrating abdominal discomfort, bloating, and modi fi cation of bowel habits with alternation of diarrhea and constipation can suggest an irritable bowel syndrome. In patients with vascular risk factors and/or comorbidity, acute hypogastric pain may be the result of dissection of an arterial iliac aneurysm or bowel infarction. If any of these latter conditions are suspected, an referral to an emergency department is mandatory.
Another limitation of this study is the high awareness of the importance of early diagnosis and treatment of OT in our department. This is especially true in cases of women with previous torsion and women undergoing fertility treatment. Although this subgroup was too small to allow separate analysis for statistically significant differences, it seems that the physicians in our department tended to operate on women with history of previous torsion and/or fertility treatments even when other symptoms such as sudden/nocturnal onset of pain, duration <24 h, and vomiting were lacking. Despite this, the rate of torsion was similar (46.1% in past torsion cases) or even significantly higher (60% in fertility patients) relative to the general population. We believe this high awareness can be justified considering the risk of diagnostic laparoscopy versus the risk of ovarian loss.
How can the pain be so bad if it is “only a muscle”?
This is perhaps the most common question asked by patients and parents in patients diagnosed with Abdominal Wall Pain. The reason is that there are a lot more pain fibres in the abdominal muscles than there are anywhere in the abdomen. The reason that I give is that the abdominal wall has two main functions – as muscles keeping us upright and in helping us to sit up, and to protect the insides – the “vital organs”. To do this these muscles have been endowed with lots of pain fibres. When we were cave people, if we were going to be poked with a spear, if the spear went through the abdominal muscles into the intestines, death was a sure thing due to infection. By having lots of pain fibres, the muscles can detect the spear, and let us fall back or protect ourselves, before the spear goes too deep. Therefore, given the huge amount of pain fibres in the abdominal wall compared to those in the vital organs, it is quite understandable that the pain is “that bad”!