- Email: [email protected]
Recurrent abdominal pain in Malaysian children: clinical profiles and outcome
Correspondence
activity
References ’ Sat-tori M, Andorno S, La Terra G, Boldorini R, Leone et al. Evaluation of iron status in patients with chronic Ital J Gastroenterol Hepatol 1998;30:396-401. ? Deugnier Y, Boucher E. Iron terol Hepatol 1998;30:467-9.
and hepatitis
viruses.
F, Pittau hepatitis
S, C.
Ital J Gastroen-
’ Van Thiel DH, Colantoni A, De Maria N. Hepatic iron, serum indices of iron status and chronic hepatitis C: activity, stage and response to therapy. Ital J Gastroenterol Hepatol 1998;30:402-4. I Barbaro G, Di Lorenzo G, Ribersani M, Soldini M, Giancaspro G, Bellomo G, et al. Serum ferritin and hepatic glutathione concentrations in chronic hepatitis C patients related to the hepatitis C virus genotype. J Hepatol 1999;30:774-82. ’ De Maria N, Colantoni A, Fagiuoli S, Liu GJ, Rogers BK, Farinati F, et al. Association between reactive oxygen species and disease
in chronic
C. Free Radic
Biol
Med
1996;21:291-5.
6 Knodell RG, Ishak KG, Black WC, Chen TS, Craig R, Kaplowitz et al. Formulation and application of a numerical scoring system assessing histological activity in asymptomatic chronic active patitis. Hepatology 198 1; I :43 l-5. ’ Izumi N, Enomoto N, Uchihara M, Murakami 0, et al. Hepatic iron contents and response patients with chronic hepatitis C. Relationship patitis C virus. Dig Dis Sci 1996;41:989-94. * Wakabayashi T. Structural changes tosis: swelling and megamitochondria 1999;46:223-37.
N, for he-
T, Ono K, Noguchi to interferon alpha in to genotypes of he-
of mitochondria formation.
related to apopActa Biochim Pal
’ Tsai NCS, Zuckerman E, Han SH, Goad K, Redeker A, Fong T-L. Effect of iron depletion on long-term response to interferon alpha in patients with chronic hepatitis C who previously did not respond to interferon therapy. Am J Gastroenterol 1997; 92: 183 1-4.
Recurrent abdominal pain in Malaysian clinical profiles and outcome Sir Most reports on recurrent abdominal pain in children have come from the West. We wish to report our analysis of the clinical profiles, results of investigations and outcome of 76 consecutive children referred to the University of Malaya Medical Centre between March 1997 and September 1998 for non-menstrual abdominal pain fulfilling Apley’s criteria of “at least three episodes of abdominal pain severe enough to affect normal activities over a period longer than three months” 1?. This study is of particular interest as very few studies on this subject are available from South-east Asia. A total of 45 males and 31 females were included in the study (M:F ratio=lS:l). There were 20 Malays, 38 Chinese and 18 Indians. Ages ranged from under 5 years to 1.5 years. Clinical findings and investigation results were recorded. Outcome one year after presentation was also noted. Only 2 out of 76 children (2.6%) had abnormalities on physical examination (scoliosis and fever). Full blood count was normal in 75 (98.7%) children, erythrocyte sedimentation rate in 74 (97.4%) and stool microscopy in 74 (97.4%). All children had normal serum electrolytes, amylase, liver enzymes and urine microscopy. Abdominal ultrasound was normal in 75 out of 76 (98.7%) children. The above-mentioned abnormalities were all minor and could not explain the recurrent abdominal pain. Of the 76 children, 56 had upper gastrointestinal endoscopy. Apart from duodenal ulcers found in 2 children, endoscopies were normal. Gastric histopathology showed inflammation in 25 children, 5 (8.9%) of whom also had histological evidence of Helicobacter pylori (H. pylori) infection, including the two children with duodenal ulcers. H. pylori was eradicated using a combination of clarithromycin, amoxycillin and lansoprazole but only in 3 out of 5 (60%) was an improvement observed in symptoms. In the 3 children who responded to H. pylori eradication, two of whom had duodenal ulcers, the response was seen within two weeks and, therefore, it was assumed that the organism could be a cause of abdomi-
hepatitis
to the Editor
children:
nal pain in these children. Eradication was confirmed at repeat endoscopy. In conclusion, three (3.9%) out of the 76 children studied were diagnosed with organic problems and responded to treatment of the organic condition (2 with H. pylori and duodenal ulcers and 1 with H. pylori without duodenal ulcer). It should also be noted that the presence of H. pylori does not always imply a causal association as can be seen in 2 children who continued to have pain following eradication of the organism. The remainder of the children, in whom no organic causes were found, were managed with only reassurance. One year after the initial presentation, 39 (52.7%) patients no longer complained of pain, 21 (28.4%) patients still had pain which was a lot better, while in 14 (18.9%) patients, the pain was either the same or worse. This preliminary report from South-east Asia shows that most children (over 95%) with recurrent abdominal pain have no organic pathology and over 50% of them no longer complain of pain after a year. It supports the findings of previous studies from the West which show that in 90 to 95% of cases with recurrent abdominal pain, no organic cause could be identified and that H. pylori infection in the absence of peptic ulcer disease, is not an important cause of recurrent abdominal pain 2-h.
C.C. M. Boey, K.L. Gohl Department of Paediatrics, I Department of Medicine, University of Malaya Medical Centre, Kuala Lampur, Malaysia. Fax: +603- 79556 114
References ’ Apley J. Naish N. Recurrent abdominal pains: A field survey school children. Arch Dis Child 1958;33: 165-70.
of 1000
83
Correspondence
’ Apley titic i Bain Am ’ Bury Aust
to the Editor
J. The child with abdominal Publications; 1975. HW. Chronic vague abdominal 1974;21:99 l- 1000. RG. A study of 111 children Paed J 1987;23: 117-9.
Open access
pains.
London:
pain in children. with
upper
recurrent
Blackwell
Scien-
Ped Clin North abdominal
pain.
gastrointestinal
Sir Increased numbers of referrals for gastrointestinal (Gl) consultation delay diagnosis because each patient requires an additional visit for consultation prior to the GI procedure. To overcome this problem, some GI units have started to use an open access endoscopy service in which the general practitioner can refer the patient directly to the GI unit, in the same way that patients are referred to radiology units for chest X-rays and abdominal ultra-sonography thus open access endoscopy allows general practitioners to refer patients directly for endoscopic procedures rm6. Our study aimed to assess patients undergoing upper GI endoscopy for the appropriate indications, to compare differences between physicians in various medical specialities (general practitioners, gastroenterology specialists and hospital physicians) and to check the differences in waiting times between the three
6 Macarthur C. Helicobacter pylori abdominal pain: lack of evidence Can J Gastroenterol 1999; 13:607-
gastroJ Am
infection and childhood recurrent for a cause and effect relationship. 10.
endoscopy These data confirm our approach favouring the continuation of the open access policy, which strengthens the links between the community and hospital medical care. This policy reduces waiting time, prevents unnecessary examinations and irrelevant medication. It also enhances the link between the general practitioner and the hospital specialist, as well as the relationship between the community and hospital medical care.
Z. Fireman, V. Agrast, Y. Kopelman, A. Segal, A. Sternberg Gastroenterology Department, Hillel Yaffe Medical Center, Hadera; Bruce Rappaport Faculty of Medicine, Technion, Haifa, Israel. Fax: +972-6-6304408. E-mail: fireman@post. tau. ac. il
sub-groups.
The study group comprised 995 patients referred to the GI department over a six-month period (June 1 “-December 3 1, 1999). Prior to the study period the waiting time for hospitalized patients requiring oesophago-gastro-duodenoscopy (EGD) was 23 days and for out-patients it was lo-14 days, not counting the waiting time for consultation. They were divided into three groups: 578 (51%) referred by family or community physicians, 231 (23.2%) internal hospital ward patients and 186 (18.7%) referrals from gastroenterologists. Significant statistical differences were found between the sub-groups with dyspepsia, abdominal pains and anaemia (p=O.OOOl), vomiting and heartburn (p=O.OOl), weight loss (p=O.Ol), chest pains (p=O.O3). There were no differences between patients with dysphagia. The average waiting time was 6.45615 days. As expected, hospital patients had the shortest waiting time -2.3kl.5 days (p=O.OOOl). While there were no meaningful differences in the endoscopic findings of the three referring groups, the rate of normal examinations was lower.
84
’ Macarthur C, Saunders N, Feldman W. Helicobacter pylori, duodenal disease, and recurrent abdominal pain in children. Med Assoc 1995;273:729-34.
References ’ Mahajan RJ, Barthel JS, Marshall JB. Appropriateness of referrals for open access endoscopy. Arch Intern Med 1996;156:2065-9. z Heatley RV. Open access upper gastrointestinal endoscopy. Br Med J 1993;306: 1224. 1 Mansi C, Mela GS, Savarino V, Mele MR, Valle F, Celle G. Open access endoscopy: a large-scale analysis of its use in dyspeptic patients. J Clin Gastroenterol 1993; 16: 149-53. -I Bramble MG, Cooke WM, Corbett WA, Cann PA, Clarke D, Contractor B, et al. Organizing unrestricted open access gastroscopy in South Tees. Gut 1993;34:422-7. 5 Adang RP, Vismans JF, Talmon JL, Hasman A, Ambergen AW, Stockbrugger RW. Appropriateness of indications for diagnostic upper gastrointestinal endoscopy: association with relevant endoscopic disease. Gastrointest Endosc 1995;42:390-7. h Cann PA, Bramble access gastroscopy 1993;306:1750.
MG, Corbett WA, Contractor service is efficient and
B, Hungin AS. Open effective. Br Med J
activity
References ’ Sat-tori M, Andorno S, La Terra G, Boldorini R, Leone et al. Evaluation of iron status in patients with chronic Ital J Gastroenterol Hepatol 1998;30:396-401. ? Deugnier Y, Boucher E. Iron terol Hepatol 1998;30:467-9.
and hepatitis
viruses.
F, Pittau hepatitis
S, C.
Ital J Gastroen-
’ Van Thiel DH, Colantoni A, De Maria N. Hepatic iron, serum indices of iron status and chronic hepatitis C: activity, stage and response to therapy. Ital J Gastroenterol Hepatol 1998;30:402-4. I Barbaro G, Di Lorenzo G, Ribersani M, Soldini M, Giancaspro G, Bellomo G, et al. Serum ferritin and hepatic glutathione concentrations in chronic hepatitis C patients related to the hepatitis C virus genotype. J Hepatol 1999;30:774-82. ’ De Maria N, Colantoni A, Fagiuoli S, Liu GJ, Rogers BK, Farinati F, et al. Association between reactive oxygen species and disease
in chronic
C. Free Radic
Biol
Med
1996;21:291-5.
6 Knodell RG, Ishak KG, Black WC, Chen TS, Craig R, Kaplowitz et al. Formulation and application of a numerical scoring system assessing histological activity in asymptomatic chronic active patitis. Hepatology 198 1; I :43 l-5. ’ Izumi N, Enomoto N, Uchihara M, Murakami 0, et al. Hepatic iron contents and response patients with chronic hepatitis C. Relationship patitis C virus. Dig Dis Sci 1996;41:989-94. * Wakabayashi T. Structural changes tosis: swelling and megamitochondria 1999;46:223-37.
N, for he-
T, Ono K, Noguchi to interferon alpha in to genotypes of he-
of mitochondria formation.
related to apopActa Biochim Pal
’ Tsai NCS, Zuckerman E, Han SH, Goad K, Redeker A, Fong T-L. Effect of iron depletion on long-term response to interferon alpha in patients with chronic hepatitis C who previously did not respond to interferon therapy. Am J Gastroenterol 1997; 92: 183 1-4.
Recurrent abdominal pain in Malaysian clinical profiles and outcome Sir Most reports on recurrent abdominal pain in children have come from the West. We wish to report our analysis of the clinical profiles, results of investigations and outcome of 76 consecutive children referred to the University of Malaya Medical Centre between March 1997 and September 1998 for non-menstrual abdominal pain fulfilling Apley’s criteria of “at least three episodes of abdominal pain severe enough to affect normal activities over a period longer than three months” 1?. This study is of particular interest as very few studies on this subject are available from South-east Asia. A total of 45 males and 31 females were included in the study (M:F ratio=lS:l). There were 20 Malays, 38 Chinese and 18 Indians. Ages ranged from under 5 years to 1.5 years. Clinical findings and investigation results were recorded. Outcome one year after presentation was also noted. Only 2 out of 76 children (2.6%) had abnormalities on physical examination (scoliosis and fever). Full blood count was normal in 75 (98.7%) children, erythrocyte sedimentation rate in 74 (97.4%) and stool microscopy in 74 (97.4%). All children had normal serum electrolytes, amylase, liver enzymes and urine microscopy. Abdominal ultrasound was normal in 75 out of 76 (98.7%) children. The above-mentioned abnormalities were all minor and could not explain the recurrent abdominal pain. Of the 76 children, 56 had upper gastrointestinal endoscopy. Apart from duodenal ulcers found in 2 children, endoscopies were normal. Gastric histopathology showed inflammation in 25 children, 5 (8.9%) of whom also had histological evidence of Helicobacter pylori (H. pylori) infection, including the two children with duodenal ulcers. H. pylori was eradicated using a combination of clarithromycin, amoxycillin and lansoprazole but only in 3 out of 5 (60%) was an improvement observed in symptoms. In the 3 children who responded to H. pylori eradication, two of whom had duodenal ulcers, the response was seen within two weeks and, therefore, it was assumed that the organism could be a cause of abdomi-
hepatitis
to the Editor
children:
nal pain in these children. Eradication was confirmed at repeat endoscopy. In conclusion, three (3.9%) out of the 76 children studied were diagnosed with organic problems and responded to treatment of the organic condition (2 with H. pylori and duodenal ulcers and 1 with H. pylori without duodenal ulcer). It should also be noted that the presence of H. pylori does not always imply a causal association as can be seen in 2 children who continued to have pain following eradication of the organism. The remainder of the children, in whom no organic causes were found, were managed with only reassurance. One year after the initial presentation, 39 (52.7%) patients no longer complained of pain, 21 (28.4%) patients still had pain which was a lot better, while in 14 (18.9%) patients, the pain was either the same or worse. This preliminary report from South-east Asia shows that most children (over 95%) with recurrent abdominal pain have no organic pathology and over 50% of them no longer complain of pain after a year. It supports the findings of previous studies from the West which show that in 90 to 95% of cases with recurrent abdominal pain, no organic cause could be identified and that H. pylori infection in the absence of peptic ulcer disease, is not an important cause of recurrent abdominal pain 2-h.
C.C. M. Boey, K.L. Gohl Department of Paediatrics, I Department of Medicine, University of Malaya Medical Centre, Kuala Lampur, Malaysia. Fax: +603- 79556 114
References ’ Apley J. Naish N. Recurrent abdominal pains: A field survey school children. Arch Dis Child 1958;33: 165-70.
of 1000
83
Correspondence
’ Apley titic i Bain Am ’ Bury Aust
to the Editor
J. The child with abdominal Publications; 1975. HW. Chronic vague abdominal 1974;21:99 l- 1000. RG. A study of 111 children Paed J 1987;23: 117-9.
Open access
pains.
London:
pain in children. with
upper
recurrent
Blackwell
Scien-
Ped Clin North abdominal
pain.
gastrointestinal
Sir Increased numbers of referrals for gastrointestinal (Gl) consultation delay diagnosis because each patient requires an additional visit for consultation prior to the GI procedure. To overcome this problem, some GI units have started to use an open access endoscopy service in which the general practitioner can refer the patient directly to the GI unit, in the same way that patients are referred to radiology units for chest X-rays and abdominal ultra-sonography thus open access endoscopy allows general practitioners to refer patients directly for endoscopic procedures rm6. Our study aimed to assess patients undergoing upper GI endoscopy for the appropriate indications, to compare differences between physicians in various medical specialities (general practitioners, gastroenterology specialists and hospital physicians) and to check the differences in waiting times between the three
6 Macarthur C. Helicobacter pylori abdominal pain: lack of evidence Can J Gastroenterol 1999; 13:607-
gastroJ Am
infection and childhood recurrent for a cause and effect relationship. 10.
endoscopy These data confirm our approach favouring the continuation of the open access policy, which strengthens the links between the community and hospital medical care. This policy reduces waiting time, prevents unnecessary examinations and irrelevant medication. It also enhances the link between the general practitioner and the hospital specialist, as well as the relationship between the community and hospital medical care.
Z. Fireman, V. Agrast, Y. Kopelman, A. Segal, A. Sternberg Gastroenterology Department, Hillel Yaffe Medical Center, Hadera; Bruce Rappaport Faculty of Medicine, Technion, Haifa, Israel. Fax: +972-6-6304408. E-mail: fireman@post. tau. ac. il
sub-groups.
The study group comprised 995 patients referred to the GI department over a six-month period (June 1 “-December 3 1, 1999). Prior to the study period the waiting time for hospitalized patients requiring oesophago-gastro-duodenoscopy (EGD) was 23 days and for out-patients it was lo-14 days, not counting the waiting time for consultation. They were divided into three groups: 578 (51%) referred by family or community physicians, 231 (23.2%) internal hospital ward patients and 186 (18.7%) referrals from gastroenterologists. Significant statistical differences were found between the sub-groups with dyspepsia, abdominal pains and anaemia (p=O.OOOl), vomiting and heartburn (p=O.OOl), weight loss (p=O.Ol), chest pains (p=O.O3). There were no differences between patients with dysphagia. The average waiting time was 6.45615 days. As expected, hospital patients had the shortest waiting time -2.3kl.5 days (p=O.OOOl). While there were no meaningful differences in the endoscopic findings of the three referring groups, the rate of normal examinations was lower.
84
’ Macarthur C, Saunders N, Feldman W. Helicobacter pylori, duodenal disease, and recurrent abdominal pain in children. Med Assoc 1995;273:729-34.
References ’ Mahajan RJ, Barthel JS, Marshall JB. Appropriateness of referrals for open access endoscopy. Arch Intern Med 1996;156:2065-9. z Heatley RV. Open access upper gastrointestinal endoscopy. Br Med J 1993;306: 1224. 1 Mansi C, Mela GS, Savarino V, Mele MR, Valle F, Celle G. Open access endoscopy: a large-scale analysis of its use in dyspeptic patients. J Clin Gastroenterol 1993; 16: 149-53. -I Bramble MG, Cooke WM, Corbett WA, Cann PA, Clarke D, Contractor B, et al. Organizing unrestricted open access gastroscopy in South Tees. Gut 1993;34:422-7. 5 Adang RP, Vismans JF, Talmon JL, Hasman A, Ambergen AW, Stockbrugger RW. Appropriateness of indications for diagnostic upper gastrointestinal endoscopy: association with relevant endoscopic disease. Gastrointest Endosc 1995;42:390-7. h Cann PA, Bramble access gastroscopy 1993;306:1750.
MG, Corbett WA, Contractor service is efficient and
B, Hungin AS. Open effective. Br Med J