Abdominal Pain in Children: From the Eternal City to the Examination Room

Nonspecific Gastrointestinal Symptoms as the First Sign of Ganglioneuroblastoma Intermixed-Case Report and Literature Review

Nonspecific gastrointestinal symptoms remain a problem for pediatricians because, out of a thousand trivial cases, there are rare diseases that require in-depth diagnostics and extensive knowledge to identify them. These complaints may be caused by a neoplastic process. We present the case of a 5-year-old boy whose diagnostic pathway lasted about 3 months. He was admitted to hospital due to severe abdominal pain. Physical examination revealed a bloated, hard, and painful abdomen. In the standing X-ray, the features of intestinal obstruction were visualized. An ultrasound examination showed a possible malignant lesion in the location of the left adrenal gland. After the surgical removal of the pathological mass and histopathological examination, the diagnosis of ganglioneuroblastoma intermixed was made. This tumor, along with neuroblastoma, ganglioneuroma, and ganglioneuroblastoma nodular, belongs to neuroblastic tumors (NTs), which originate from primitive cells of the sympathetic nervous system. NTs are quite rare, but they are still the majority of extracranial solid tumors in children, and their symptoms often appear relatively late when the neoplastic process is already advanced. The purpose of this review is to present current information about ganglioneuroblastoma, with a special emphasis on nonspecific gastrointestinal symptoms as first sign of this tumor and its diagnostics.

Acute care diagnostics in children for general radiologists - not alone in the hospital at night

BACKGROUND

Radiologic care for children and adolescents during night and weekend shifts is challenging. This is especially true when a dedicated pediatric radiology front or background service is not available.

METHODS

The purpose of this review is to present the approach, the most relevant diagnoses, and their differential diagnoses based on four common example cases - abdominal pain, respiratory/chest pain, headache, and refusal to walk. Essentials such as clinical classification (e. g., disease dynamics) and practical instructions (e. g., necessity of acute cross-sectional imaging) are presented.

RESULTS AND CONCLUSION

For the abdomen, appendicitis ranks first among acute diseases. Other important diseases are intussusception and volvulus. Far more frequently, however, gastroenteritis is the cause of abdominal pain. Usually no imaging is required in this case. In unclear clinical situations, ultrasound may be indicated. In suspected pulmonary infections, chest imaging is limited to inconclusive cases and suspicion of complications such as pleural empyema. Major emergencies include (spontaneous) pneumothorax and aspiration. Headache is a common symptom. Immediate imaging is only necessary in cases of suspected acute inflammatory (meningitis/encephalitis) or vascular disease (e. g., hemorrhage due to vascular malformations). MRI is the primary imaging modality in these cases. Restricted walking/refusal to walk is a classic nonspecific sign, particularly of acute musculoskeletal disease, especially in younger children. Clinical examination is essential to narrow down the field of investigation. Besides the frequent and symptomatic coxitis fugax, the rare but serious (septic) arthritis/osteomyelitis must not be overlooked.

KEY POINTS

· Radiological care of children and adolescents is challenging, especially during night and weekend shifts.. · However, in close cooperation with the referring colleagues/clinics, the appropriate approach can be effectively determined even if the symptoms are not clear.. · The selection of the optimal imaging method is based on guidance and guidelines, but also on the condition of the child/adolescent.. · A silent or whimpering child is cause for alarm..

CITATION FORMAT

· Beer M, Mentzel H, Steinborn M et al. Acute care diagnostics in children for general radiologists - not alone at night in the hospital. Fortschr Röntgenstr 2023; 195: 205 - 216.

Herbal Approaches to Pediatric Functional Abdominal Pain

Chronic abdominal pain is one of the most common problems seen by both pediatricians and pediatric gastroenterologists. Abdominal-pain-related functional gastrointestinal disorders (AP-FGIDs) are diagnosed in children with chronic and recurrent abdominal pain meeting clinical criteria set forth in the Rome IV criteria. AP-FGIDs affect approximately 20% of children worldwide and include functional dyspepsia (FD), irritable bowel syndrome (IBS), functional abdominal pain (FAP), and abdominal migraine. IBS accounts for 45% of pediatric AP-FGIDs. The pathophysiology of functional abdominal pain involves an interplay of factors including early life events, genetics, psychosocial influences, and physiologic factors of visceral sensitivity, motility disturbance, altered mucosal immune function, and altered central nervous system processing. Treatment approaches are varied and can include dietary, pharmacologic, and complementary medicine interventions, as well as psychosocial support, depending on the many aspects of the disorder and the needs of the individual patient. There is a strong interest in complementary and integrative medicine approaches to pediatric pain from both patients, providers, and families. In this article, we discuss popular herbal treatments typically used in the field of complementary medicine to treat pediatric AP-FGIDs: peppermint oil, Iberogast®, cannabis, fennel, and licorice. While high-quality data are rather limited, studies generally show that these remedies are at least as effective as placebo, and are well tolerated with minimal side effects. We will need more placebo-controlled, double-blind, and unbiased prospective studies to document and quantify efficacy.

Biliary Dyskinesia: Fact or fiction?

Nearly 20,000 pediatric patients undergo cholecystectomy annually, and abnormal gallbladder emptying ("biliary dyskinesia") has replaced cholelithiasis as the leading indication for this operation in the USA. Nonetheless, patients with abnormal gallbladder emptying nuclear medicine scans do not uniformly benefit from cholecystectomy. This article reviews the available data on presentation, workup and treatment of patients with abnormally low and high rates of gallbladder emptying.

Updates in diagnosis and management of chronic abdominal pain

Chronic abdominal pain is a common problem seen by pediatricians and pediatric gastroenterologist alike. There should not be evidence of underlying organic pathology, with diagnosis based upon the Rome IV criteria. Although it frequently occurs, routine diagnostic testing is not always necessary. Providing assurance and helpful coping strategies is key in the management of chronic abdominal pain. Sometimes other expertise is needed when developing these strategies.

Review of childhood pain highlights the role of negative stress

AIM

Recurrent pain of unknown origin is a major problem in children. The aim of the present review was to examine the hypothesis of negative stress as an aetiology of recurrent pain from different aspects.

METHODS AND RESULTS

Epidemiological studies, clinical experience and hormonal data give support for such a hypothesis. Negative stress as a tentative aetiology for recurrent pain is reviewed. Stress, muscular tension, the startle reaction and its tentative relation to pain is illuminated. Deviations of hormonal secretion supporting a stress aetiology are mentioned. The role of central sensitisation for recurrent pain is discussed. Possible aetiological implications of recurrent pain as a local symptom or a general disorder are presented. Brain changes due to stress are shortly reviewed. Stress and pain in the clinic are highlighted. The importance of biological, psychological and social factors, as well as genetic elements, is discussed.

CONCLUSION

Stress elicits neurobiological mechanisms. They may lead to many neurophysiological deviances. Increase of muscle tension and neuromuscular excitability and enhanced startle reaction may be of importance for recurring pain. The identification of stress as a primary cause of recurrent pain can have huge implications for understanding signs and treatment in clinical practice.

Relationship Between Abdominal Symptoms and Fructose Ingestion in Children with Chronic Abdominal Pain

BACKGROUND

Limited valid data are available regarding the association of fructose-induced symptoms, fructose malabsorption, and clinical symptoms.

AIM

To develop a questionnaire for valid symptom assessment before and during a carbohydrate breath test and to correlate symptoms with fructose breath test results in children/adolescents with functional abdominal pain.

METHODS

A Likert-type questionnaire assessing symptoms considered relevant for hydrogen breath test in children was developed and underwent initial validation. Fructose malabsorption was determined by increased breath hydrogen in 82 pediatric patients with functional abdominal pain disorders; fructose-induced symptoms were quantified by symptom score ≥2 and relevant symptom increase over baseline. The results were correlated with clinical symptoms. The time course of symptoms during the breath test was assessed.

RESULTS

The questionnaire exhibited good psychometric properties in a standardized assessment of the severity of carbohydrate-related symptoms. A total of 40 % (n = 33) had malabsorption; symptoms were induced in 38 % (n = 31), but only 46 % (n = 15) with malabsorption were symptomatic. There was no significant correlation between fructose malabsorption and fructose-induced symptoms. Clinical symptoms correlated with symptoms evoked during the breath test (p < 0.001, r2 = 0.21) but not with malabsorption (NS). Malabsorbers did not differ from non-malabsorbers in terms of symptoms during breath test. Symptomatic patients had significantly higher pain and flatulence scores over the 9-h observation period (p < 0.01) than did nonsymptomatic patients; the meteorism score was higher after 90 min.

CONCLUSIONS

Fructose-induced symptoms but not fructose malabsorption are related to increased abdominal symptoms and have distinct timing patterns.