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1 대한소아소화기영양학회지 : 제 14 권제 1 호 2011 DOI: /kjpgn 종설 만성복통을보이는환자어떤순서로접근을해야하나요? 부산대학교의학전문대학원소아과학교실 박재홍 Diagnostic Approaches to Chronic Abdominal Pain in Children Jae Hong Park, M.D. Department of Pediatrics, School of Medicine, Pusan National University, Busan, Korea Chronic abdominal pain (CAP) is a common complaint encountered in pediatric clinics and a great concern for patients and their caretakers as well as health care professionals. A constant challenge is detecting individuals with organic diseases or psychosomatic disorders from the majority of patients who have a functional disorder including functional dyspepsia, irritable bowel syndrome, functional abdominal pain, and abdominal migraine. Beginning with a detailed history and physical examination, physicians must determine a differential diagnosis of CAP by applying the symptom-based Rome III criteria to positively identify a functional disorder. These findings should then be further analyzed based on diagnostic clues and red flags that indicate the presence of specific organic diseases and/or the need for further testing. Once a functional diagnosis has been made or an organic disease is suspected, physicians can initiate an empiric therapeutic trial. Since psychological distress accompanies both organic and non-organic abdominal pain in children, a cooperative diagnostic approach involving pediatricians and psychiatrists is recommended. (Korean J Pediatr Gastroenterol Nutr 2011; 14: 26 32) Key Words: Abdominal pain, Chronic, Diagnosis, Child 서 소아에서만성복통의정확한빈도는잘모르지만소아청소년과외래환자의 2 4% 를차지하고있다 1). 최 접수 :2011 년 2 월 27 일, 수정 :2011 년 3 월 15 일, 승인 :2011 년 3 월 17 일책임저자 : 박재홍, , 경남양산시물금면범어리부산대학교어린이병원소아청소년과 Tel: , Fax: jhongpark@pusan.ac.kr 론 근연구를보면중학교학생의 13%, 고등학교학생의 17% 가매주복통을경험하며 2), 1년동안전체학생중 8% 가복통으로인해병원을찾는다 3). 또한성인을대상으로한연구에서는만성복통환자의삶의질이일반인구의삶에질에비해떨어졌다 3). 소아에서만성복통과관련된경제적비용에대해잘모르지만성인에서매년 억달러로추정되는과민성대장증후군과관련된비용과유사할것으로추정되고있다 4,5). 이질환의장기예후에대해서도잘밝혀져있지않으 26

2 박재홍 :Chronic Abdominal Pain in Children ㆍ 27 며, 한연구에서는소아기에시작된만성복통으로전문가의치료를받았던병력이있는젊은성인에서복통이없었던동료들에비해평생동안정신질환이나편두통의빈도가의미있게높았다 6). 질병의빈도가높고이로인한여러문제에도불구하고이질환에대한평가나치료에대한근거중심의지침이없는실정이다. 만성또는반복성복통을규정하는기준이명확하지않다. 오랫동안기질적원인이없는모든복통을반복성복통이라고하였으나, 1950년대에 Apley와 Naish 7) 가일상활동에영향을줄수있는심한복통이 3개월동안 3회이상있을때반복성복통이있다고정의하였다. 반복성복통은진단명이아니라증상의기술이다. 반복성복통은복통을일으키는여러종류의기능성위장관질환뿐아니라기질적질환을포함하고있다. Table 1에현재쓰이고있는장기간의지속적인또는간헐적인소아복통에대한다양한용어를나열하였다 8). 소아만성복통은원인에따라크게 3가지군으로분류할수있다. 첫째, 소수의빈도를보이는기질적복 Table 1. Currently Used Definitions to Describe Childhood Abdominal Pain Recurrent abdominal pain as defined by Apley and Naish RAP Chronic abdominal pain Rome II criteria for abdominal pain Functional abdominal pain Nonorganic abdominal pain Psychogenic abdominal pain IBS: irritable bowel syndrome. >3 episodes of abdominal pain, over a period of >3 mo, severe enough to affect activities A common abbreviation for recurrent abdominal pain that has been used in the literature to depict recurrent abdominal pain as defined by Apley and Naish; many physicians incorrectly use this term to imply functional abdominal pain Abdominal pain with a minimum duration of 3 mo; some clinicians believe that pain lasting >1 2 mo is chronic Abdominal pain for at least 12 wk, which need not be consecutive, in the preceding 12 mo; these criteria apply to IBS, functional dyspepsia, and functional abdominal pain Abdominal pain that occurs in the absence of anatomic abnormality, inflammation, or tissue damage A term that is often used interchangeably with functional abdominal pain A term that is often used interchangeably with functional abdominal pain Table 2. Initial Approach to Treating Children with Recurring Abdominal Pain 5 steps 1. Reaffirm strong relationship with child/family by taking complaint seriously 2. Perform complete history and physical examination (be aware of psychological comorbidities) 3. Look for red flags that indicate increased risk of organic causes of the pain and proceed to screening or specific testing 1) Screening tests: CBC, ESR, CRP, ALT, lipase. TTG/IgA, UA 2) Specific tests based upon diagnostic clues 4. Apply the Rome III diagnostic criteria and educate family 5. If a functional pain disorder is diagnosed, begin empiric treatment trials below If unclear, may use the algorithms for epigastric or lower abdominal pain below Upper epigastric abdominal pain DDx: Gastritis, GERD, functional dyspepsia Intervention: 2 weeks trial of PPI (eg. lansoprazole or omeprazole 1.5 mg/kg/d) or H2 receptor antagonists (eg. ranitidine 2 mg/kg, tid). If improved, stop after 2 months. If no improvement or recurrence, refer to GI for possible endoscopy Lower abdominal pain DDx: Constipation alone or with IBS Intervention: 2 weeks trial of PEG g/kg/d in 220 ml fluid. If improved, continue for 2 months. If no improvement, consider lab or stool evaluation and/or refer to GI CBC: complete blood count, ESR: erythrocyte sedimentation rate, CRP: C-reactive protein, ALT: alanine aminotransferase, TTG/IgA: tissue transglutaminase, IgA, UA: urine analysis, DDx: differential diagnosis, GERD: gastroesophageal reflux disease, PPI: proton pump inhibitor, GI: gastrointestinal, IBS: irritable bowel syndrome.

3 28 ㆍ대한소아소화기영양학회지 : 제 14 권제 1 호 2011 통, 둘째, 다수의환자에서나타나는기능성복통, 셋째, 분리불안, 공포증, 전환장애등정신과질환에동반된복통 ( 정신신체질환 ) 등이다. 이들은서로중첩되어증상이발현하기도하고 9), 어느군에서나정신사회적요인들이잠재되어직간접적인만성복통의유발요인으로작동할수있다 10). 따라서임상에서는만성복통환자중대부분의빈도를차지하는기능성복통에숨어있을수있는기질적복통과정신신체질환을어떻게찾아내느냐하는것이첫째문제이고기능성복통을증상유형별로감별하는진단적접근이두번째문제이다. 또한진단적접근을하는데어느정도의검사가필요한것인지, 어느단계에서전문가에게환자를의뢰해야하는가에대한어려움이있다. 본소고에서는외래에서흔히볼수있는만성복통환자에대한진단적접근법에대해살펴보고자한다. Table 3. Findings That Suggest Recurrent Abdominal Pain due to Organic Disease Recurrent fever (38 o C) Weight loss or poor weight gain Growth failure Pain localized away from the midline Perianal disease Hematemesis Bilious emesis Stools with gross or occult blood Anemia Elevated erythrocyte sedimentation rate 본 소아청소년과의사로서가장중요한역할은원인이밝혀지지않은복통을호소하는소아나청소년환자에서불편을줄여주고심각한질병을배제하고정상기능을회복하게하는것이다. Noe와 Li 11) 는다섯단계의접근을제안한바있다 (Table 2). 첫째, 의사와환자및부모와의관계를밀접하게유지한다. 이는비록기능성일가능성이있다할지라도복통에대한호소를진지하게경청하는것으로시작된 Table 4. Rome III Functional Gastrointestinal Disorders in Children and Adolescents H. Functional disorders: children and adolescents H1. Vomiting and aerophagia H1a. Adolescent rumination syndrome H1b. Cyclic vomiting syndrome H1c. Aerophagia H2. Abdominal pain-related FGIDs H2a. Functional dyspepsia H2b. Irritable bowel syndrome H2c. Abdominal migraine H2d. Childhood functional abdominal pain H2d1. Childhood functional abdominal pain syndrome H3. Constipation and incontinence H3a. Functional constipation H3b. Nonretentive fecal incontinence From Rasquin A. et al. Childhood functional gastrointestinal disorders: child/adolescent. 론 Table 5. Functional Gastrointestinal Disorders (FGID) Diagnosis Symptoms Pain General symptoms Bowel movements FRAP 12 weeks Nearly continuous IBS 12 weeks Relieved by defecation Functional 12 weeks Upper dyspepsia abdomen Abdominal 5 or more Paroxysmal migraine episodes of midline 2 hr or longer No characteristics of other FGID Loss of normal functioning Bloating distension, cramping, worsened by tight belts Heartburn, early satiety, bloating Symptom-free interval; more than two of the following: unilateral headache, aura, photophobia, family history of migraines No relation Abnormal frequency or form±mucus Not affected by defecation, no relation No relation From Kohli R and Li BU. Differential dagnosis of recurrent abdominal pain: new considerations. FRAP: functional recurrent abdominal pain, IBS: irritable bowel syndrome.

4 박재홍 :Chronic Abdominal Pain in Children ㆍ 29 다. 둘째, 철저한병력청취와신체검사를시행해야한다. 가능성있는동반된불안이나스트레스에대한주의깊은조사가필요하다. 셋째, 복통이기질적원인에의한것인지를빨간깃발징후 ( 경보증상 ) (Table 3) 로확인하고선별검사 (CBC, ESR, CRP, ALT, lipase, Tissue transglutaminase/iga, UA) 나진단적단서에따라특별검사를고려한다. 넷째, Rome III 진단기준 (Table 4, 5) 을적용하여진단하고진단적정당성이나복통의기전, 기능성복통의치료등에대해가족들을교육한다. 다섯째, 기능성복통이진단되면경험적치료를고려하고, 만약명확하지않으면심와부복통인지하복부복통인지에따라알고리즘을이용한다. 즉심와부복통일경우위염, 위식도역류와기능성소화불량증을구별해야하고경험적치료로 2주간의 PPI (lansoprazole 또는 omeprazole 1.5 mg/kg/d) 또는 H2 수용체길항제 (ranitidine 2 mg/kg, tid) 를투여한다. 만약증상의호전이있으면 2개월동안투여후치료를중단한다. 그러나호전이없거나재발하면내시경검사가가능한전문가에게의뢰한다. 하복부복통인경우는변비가있거나변비와동반된과민성대장증후군이있는지를감별하여 2주간의 polyethylene glycol을투여한다. 증상의호전이있으면 2개월약물을투여하고호전이없으면검사실검사나대변검사를하고전문가에게의뢰를고려한다. 특히자세한병력청취나신체검사 (Table 6) 를통하여복통의기원이기질적인것인지기능성인지감별이필요한데, Rome III 기준을이용하면특정기능성질환을진단할수있고특별한검사를하지않고치료를해볼수있다. 이러한진단개념은과거에광범위하고종종불필요한검사를통해기질적질환을배제함으로써기능성질환을진단했던과거의방법과차이가있다. 또한빨간깃발징후를이용하여기질적질환의가능성을확인하고진단을위해검사실검사, 방사선검사, 내시경검사를시행할수있다 (Table 7, 8). 결론적으로자세한병력과신체검사, Rome III 기준, 빨간깃발징후, 진단적실마리등의임상자료를이용하여진단하거나진단의범위를좁히고경험적치료를시작하거나필요한검사를선택할수있다 (Table 8, 9). 소아소화기전문의에게환자를의뢰해야하는몇가 Table 6. Differential Diagnosis of RAP Based on the Presenting Symptoms Complex RAP with dyspepsia Intestinal inflammation Gastroesophageal reflux disease Mucosal injury - H. pylori gastritis, NSAID-induced gastritis, duodenal ulcer Inflammatory bowel disease - Crohn's disease Henoch-Schölein purpura Dysmotility Gastroparesis Biliary dyskinesia Pseudo-obstruction Extraintestinal Chronic hepatitis B or C Pancreatitis (relapsing or chronic) Hydronephrosis (secondary to ureteropelvic junction obstruction) RAP with altered bowel habits Inflammation Irritable bowel syndrome Inflammatory bowel disease - ulcerative colitis, Crohn's Infections Parasitic - giardia, Blastocystis hominis Bacterial - yersinia, campylobacter, clostridium difficele Miscellaneous Lactose intolerance Drug-induced diarrhea RAP with functional pain Functional Functional recurrent abdominal pain Abdominal migraine Cyclic vomiting syndome Surgical Malrotation with intermittent volvulus Recurrent intussusception Post-surgical adhesion Genitourinary Dysmenorrhea Pelvic inflammatory disease Musculo-skeletal Tietze's syndrome Discitis Vasculitis Polyarteritis nodosa, systemic lupus erythematosus, mesenteric vein obstruction From Kohli R and Li BU. Differential diagnosis of recurrent abdominal pain: new considerations. 지기준이있다 (Table 10) 9). 만약경보증상을시사하는증상이나징후, 선별검사소견이있거나, 특정기질적

5 30 ㆍ대한소아소화기영양학회지 : 제 14 권제 1 호 2011 Table 7. Alarm Symptoms for Organic Causes of RAP Alarm symptom Pain-localized, eccentric, radiation to back/shoulder Weight loss, poor growth, delayed puberty Altered bowel pattern, GI bleeding Extra intestinal symptoms-fever, rash, uveitis, arthralgia, dysuria, jaundice History of foreign travel, exposure to contaminated water Family history of IBD, peptic ulcer disease, migraines Immunocompromised-congenital, acquired, post-transplant Medication use-nsaids, alternative therapies Abnormal labs-anemia, elevated ESR, parasites in stool Consider Duodenal ulcer, cholelithiasis, pancreatitis Celiac disease, IBD IBD, peptic injury, celiac disease IBD, SLE Hepatitis, Giardiasis, Yersinosis Peptic injury, IBD Opportunistic infections Gastritis IBD, celiac disease, parasites From Kohli R and Li BU. Differential diagnosis of recurrent abdominal pain: new considerations. GI: gastrointestinal, IBD: inflammatory bowel disease, ESR: erythrocyte sedimentation rate, SLE: systemic lupus erythematosus. Physical exam findings Fecal mass Non-fecal/RLQ mass Murphy's sign Organomegaly Reproducible pain on ribcage Fistula/deep perianal fissure Superficial perianal fissure Testing CBC ALT, GGT Lipase ESR or CRP Tissue transglutaminase, IgA UA & culture Urine Ca/Cr ratio Stool for H. pylori antigen UGI (to ligament of Treitz) Esophagogastroduodenoscopy Abdominal ultrasound GB ejection fraction Table 8. Findings and Testing Constipation Ileocecal Crohn's Biliary disease Chronic liver disease Costocholdritis Crohn's disease Constipation Diagnosis/Abnormalities Celiac disease (anemia), IBD (thrombocytosis, leukocytosis) Hepatobiliary inflammation or obstruction, IBD Pancreatitis IBD Celiac disease Hematuria, UTI Hypercalciuria Helicobacter pylori gastritis Intestinal malrotation, SMA syndrome Eosinophilic esophagitis, H. pylori gastritis, peptic duodenitis, Celiac disease Biliary obstruction, cholelithiasis or cholecystitis, hydronephrosis Biliary dyskinesia Noe JD and Li BU. Navigating recurrent abdominal pain through clinical clues, red flags, and initial testing. RLQ: right lower quadrant, CBC: complete blood count, ALT: alanine aminotransferase, GGT: gamma glutamyl transpeptidase, CRP: C-reactive protein, UA: urine analysis, UGI: upper gastrointestinal, GB: gallbladder, IBD: inflammatory bowel disease, UTI: urinary tract infection, SMA: superior mesenteric artery. 소화기질환이의심되면전원이필요하다. 또한경험적치료나 H2 수용체길항제를 1 2개월투여해도반응이없을때내시경검사와같은좀더진단적인검사가필요하다. 만성복통환자는정신사회적문제를가지는경우가흔하며기능성및기질적복통에서만성적인스트레스가원인으로지목되기도한다. 또한환자와보호자들이불안감이나우울감을흔히가지고있다 10). 따라서불

6 박재홍 :Chronic Abdominal Pain in Children ㆍ 31 Table 9. Key Diagnostic Features Diagnostic clues Location of pain Substernal (esophageal) Epigastric (gastric) RUQ (hepatobiliary) RLQ (TI, cecum, appendix) LLQ (rectosigmoid) Periumbilical (nonspecific) Exacerbating factors Foods (eg. milk protein, fat) Stress Time of day (night - organic) Relieving factors Acid suppression (peptic) Diet/food avoidance Changes in stool Red flags Blood in the stool Peripheral, normal form (distal) Mixed, normal form Bloody diarrhea Melena (proximal) Dysphagia (Eosinophilic esophagitis, achalasia) Vomiting (especially bilious) Weight loss (calorie loss) Extraintestinal manifestations Growth failure (IBD, celiac) Arthritis (IBD) Oral lesions (IBD) Skin rashes (IBD, celiac) Eye symptoms (IBD) Liver disease (IBD) Family history Peptic ulcer disease IBD Noe JD and Li BU. Navigating recurrent abdominal pain through clinical clues, red flags, and initial testing. RUQ: right upper quadrant, RLQ: right lower quadrant, LLQ: left lower quadrant, IBD: inflammatory bowel disease. 안, 우울, 생활스트레스를근거로기능성복통과기질적복통을구별할수는없다 12). 따라서소아만성복통환자의진단및치료과정에서잠복된정신사회적요인들을확인하고알려주어통합적인진료가이루어지도록하는것이바람직하다 13). 특히기능성복통의경우심리적, 정신적문제가중복되어나타나는경우가많기때문에의학적측면과사회적측면을고려한생물정신 Table 10. Pediatric Gastroenterology Referral Empiric therapy failure Unexplained symptoms for longer than 3 months Presence of alarm symptoms Organic GI cause suspected EGD required if: Failed acid suppression therapy for RAP Laboratory evidence of disease (IDA, ESR, celiac panel) Dyspepsia or RAP for longer than 3 months Colonoscopy required if: Prolonged rectal bleeding with RAP Laboratory evidence of disease (IDA, ESR, IBD, serology) Failed antispasmodic therapy for RAP GI: gastrointestinal, RAP: recurrent abdominal pain, IDA: iron deficiency anemia, ESR: erythrocyte sedimentation rate, IBD: inflammatory bowel disease. 사회적 (biopsychosocial) 접근을하는것이이상적인치료모델로인정되고있다 14). 빨간깃발징후의소견이기질적소화기계질병이없이정신과질환에의해나타나는경우가있기때문에주의를요한다 12). 따라서앞서언급한대로빨간깃발징후유무에따른접근에앞서철저한병력청취와신체검사를통해동반된불안이나스트레스, 가족간의갈등이있는지에대한주의깊은조사가필요하고소아청소년과의사가먼저치료를해보고호전이없으면소아정신과전문의에게자문을구하는것이바람직하다. 결 소아만성복통은흔히볼수있는증상이지만신체, 정신, 사회적문제를통합적으로평가하는진단적접근이필요하다. 만성복통의원인이기질적질환에의한것인지, 기능성복통인지, 아니면정신신체질환의증상인지를구별하여야한다. 철저한병력청취와신체검사를통하여 Rome III 기준에합당한지, 빨간깃발징후소견이동반되었는지, 정신사회적요인이동반되었는지등의임상자료를이용하여진단의범위를좁히고경험적치료를시작하거나검사를선택할수있다. 론

7 32 ㆍ대한소아소화기영양학회지 : 제 14 권제 1 호 2011 참고문헌 1) Starfield B, Hoekelman RA, McCormick M, Benson P, Mendenhall RC, Moynihan C, et al. Who provides health care to children and adolescents in the United States? Pediatrics 1984;74: ) Hyams JS, Burke G, Davis PM, Rzepski B, Andrulonis PA. Abdominal pain and irritable bowel syndrome in adolescents: a community-based study. J Pediatr 1996; 129: ) Frank L, Kleinman L, Rentz A, Ciesla G, Kim JJ, Zacker C. Health-related quality of life associated with irritable bowel syndrome: comparison with other chronic diseases. Clin Ther 2002;24: ) Drossman DA, Li Z, Andruzzi E, Temple RD, Talley NJ, Thompson WG, et al. U.S. householder survey of functional gastrointestinal disorders. Prevalence, sociodemography, and health impact. Dig Dis Sci 1993; 38: ) Talley NJ, Gabriel SE, Harmsen WS, Zinsmeister AR, Evans RW. Medical costs in community subjects with irritable bowel syndrome. Gastroenterology 1995;109: ) Campo JV, Di Lorenzo C, Chiappetta L, Bridge J, Colborn DK, Gartner JC Jr, et al. Adult outcomes of pediatric recurrent abdominal pain: do they just grow out of it? Pediatrics 2001;108:E1. 7) Apley J, Naish N. Recurrent abdominal pains: a field survey of 1,000 school children. Arch Dis Child 1958; 33: ) American Academy of Pediatrics Subcommittee on Chronic Abdominal Pain. Chronic abdominal pain in children. Pediatrics 2005;115: ) Kohli R, Li BU. Differential diagnosis of recurrent abdominal pain: new considerations. Pediatr Ann 2004; 33: ) Boey CC, Goh KL. Psychosocial factors and childhood recurrent abdominal pain. J Gastroenterol Hepatol 2002; 17: ) Noe JD, Li BU. Navigating recurrent abdominal pain through clinical clues, red flags, and initial testing. Pediatr Ann 2009;38: ) Di Lorenzo C, Colletti RB, Lehmann HP, Boyle JT, Gerson WT, Hyams JS, et al. American Academy of Pediatrics Subcommittee on Chronic Abdominal Pain; NASPGHAN Committee on Abdominal Pain. Chronic abdominal pain in children: a clinical report of the American Academy of Pediatrics and the North American Society for Pediatric Gastroenterology, Hepatology and Nutrition. J Pediatr Gastroenterol Nutr 2005;40: ) Hwang JB, Jeong SH. Practical diagnostic approaches to chronic abdominal pain in children and adolescents. J Korean Med Assoc 2009;52: ) von Baeyer CL. Understanding and managing children's recurrent pain in primary care: a biopsychosocial perspective. Paediatr Child Health 2007;12:121-5.

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271_284 의학강좌-황진복_정성훈 Continuing Education Column Practical Diagnostic Approaches to Chronic Abdominal Pain in Children and Adolescents Jin-Bok Hwang, MD Department of Pediatrics, Keimyung University School of Medicine E -