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作者：Laurie Barclay, MD  
出處：WebMD醫學新聞

　　November 13, 2009 — 根據11月9日線上版小兒科期刊的一篇觀察研究結果，反覆腹痛(recurrent abdominal pain，RAP)和尿路結石的孩童，不一定會出現血尿和排尿困難。
　　
　　義大利拿波里第二大學的Cesare Polito醫師等人寫道，在篩選這些需要尿道評估的RAP孩童時，辨識尿路相關臨床標記是很重要的。脅腹的疼痛位置與血尿及排尿困難被視為主要的警訊徵兆，RAP孩童需要更深入詳盡的尿道檢查。迄今，並無研究論及尿路結石孩童的疼痛發作頻率。
　　
　　研究目標是描述100名RAP和尿路結石病童的疼痛發作臨床表現及特徵，和270名控制組對象比較之前的闌尾切除比率，比較孩童自我報告之功能性或器質性胃腸RAP疼痛發作頻率。
　　
　　第一次訪視時，53名病患沒有排尿困難或肉眼性血尿病史；只有35人有血尿；41名病患因為有與RAP相關的腎結石家族史而接受尿路結石檢查。29名病患之前有因腹痛症狀而住院的紀錄。有16名病患和4名控制組曾進行闌尾切除術(1.5%；P < .0001)。
　　
　　尿路結石診斷之前2-28個月，有37名病患做過腹部超音波，結果為尿路結石陰性。8歲以下的病患中，69%的腹痛位置在中央或擴散到其周圍。有RAP和尿路結石的病患中，平均疼痛發作頻率比功能性或器質性胃腸道RAP患者少4-9次。
　　
　　研究作者寫道，由於不一定會發生排尿困難和血尿，疼痛位置在脅腹之外區域、疼痛發作之後進行的影像檢查沒有發現結石，可能會造成忽略泌尿系統引起的疼痛，而進行一些無效的治療方法。有家族尿路結石病史且/或不常發作疼痛的RAP孩童，即使沒有排尿困難和血尿，或疼痛位置不在側邊的幼童，應考慮其尿路結石的可能性。
　　
　　研究限制包括，觀察性研究設計且樣本數相對較少。
　　
　　研究作者結論表示，對於RAP且有尿路結石家族史的門診孩童，即使沒有特定的尿路徵兆與症狀、即使是幼童、儘管疼痛部位在整個腹部中間或擴散，似乎可以建議每一到兩年進行至少兩次的腎臟超音波檢查與三次尿液溶質排泄異常之非連貫性完整評估。進行非診斷性超音波掃描之後，電腦斷層掃描在急診特別有用。不常發作疼痛的病患(每個月4天以下)限制使用這些調查，將有助於改善此方法的成本效益。
　　
　　研究作者皆宣告沒有相關財務關係。
　　
　　Pediatrics。線上發表於2009年11月9日。


Hematuria/Dysuria May Be Inconstant in Children With Recurrent Abdominal Pain/Urolithiasis

By Laurie Barclay, MD
Medscape Medical News

November 13, 2009 — Hematuria and dysuria may not always be present in children with recurrent abdominal pain (RAP) and urolithiasis, according to the results of an observational study reported online in the November 9 issue of Pediatrics.

"Identification of the clinical hallmarks of urinary tract involvement is crucial in selecting those children with RAP who require focused evaluation of the urinary tract," write Cesare Polito, MD, from Second University of Naples in Naples, Italy, and colleagues. "The location of pain in the flank as well as hematuria and dysuria are considered the only warning signs indicating more in-depth investigation of urinary tract involvement in children with RAP. To date, no study has addressed the frequency of pain attacks in children with urolithiasis."

The objective of this study was to describe the clinical presentation and features of pain attacks in 100 consecutive pediatric patients with RAP and urolithiasis. Rate of previous appendectomy in these cases was compared vs that in 270 control subjects, and frequency of pain attacks in these cases was compared vs that reported by children with functional or organic gastrointestinal RAP.

When first seen, 53 patients had no history of dysuria or gross hematuria; only 35 had hematuria; and 41 patients underwent workup for urolithiasis only because of a family history of kidney stones associated with RAP. History of previous hospitalization for abdominal symptoms was present in 29 patients. Appendectomy had previously been performed in 16 patients and in 4 control subjects (1.5%; P < .0001).

Abdominal ultrasonography was performed in 37 patients 2 to 28 months before the diagnosis of urolithiasis, and results were negative for urinary calculi. Among patients younger than 8 years, abdominal pain was central or diffuse in location in 69%. In patients with RAP and urolithiasis, the mean frequency of pain attacks was 4 to 9 times lower vs patients with functional or organic gastrointestinal RAP.

"Because of the inconstant occurrence of dysuria and hematuria, the location of pain in areas other than the flank, and the lack of calculi shown on imaging studies performed after pain attacks, the urologic origin of pain may be overlooked and ineffective procedures performed," the study authors write. "The possibility of urolithiasis should be considered in children with RAP who have a family history of urolithiasis and/or infrequent pain attacks, even when dysuria and hematuria are lacking, and in younger children even when pain is not lateral."

Limitations of this study include observational design and relatively small sample size.

"It seems advisable to perform at least 2 renal ultrasound examinations 1 to 2 years apart and 3 nonconsecutive complete evaluations of urinary solute excretion abnormalities in outpatient children with RAP and a family history of urolithiasis, even in the absence of specific urinary signs and symptoms, and in younger patients, although the pain may be central or diffuse in the whole abdomen," the study authors conclude. "Computed tomography may be particularly useful in the emergency department after a nondiagnostic ultrasound scan. Restricting these investigations to patients with infrequent painful episodes (4 days/month or less) will help improve the cost/benefit ratio of this approach."

The study authors have disclosed no relevant financial relationships.

Pediatrics. Published online November 9, 2009.