Diagnosis of functional dyspepsia in children

Differential diagnostic measures for functional dyspepsia are carried out in 3 stages.

• I - identification of patients at high risk of organic dyspepsia based on anamnestic, clinical and available laboratory data. referral for urgent gastroenterological examination.
• II - elimination or correction of etiological factors and pathogenetic mechanisms of functional dyspepsia in a group of children with a low risk of organic dyspepsia.
• III - determination of the form of functional gastrointestinal disorders in accordance with the classification.

Among the diseases that make up the group of organic dyspepsia in children, the most significant is gastric ulcer and duodenal ulcer; the prevalence of this disease is 1 per 1000 of the population aged 0 to 14 years. Among young children, cases of peptic ulcer are isolated, in the age group of 4-9 years, the prevalence does not exceed 0.4%, and among adolescents, the incidence of peptic ulcer reaches 3 per 1000. Rarer causes of organic dyspepsia in childhood are chronic cholecystitis and pancreatitis, cholelithiasis (cholelithiasis), gastrointestinal diverticulitis.

Clinical diagnosis of the listed diseases is not an easy task even for an experienced gastroenterologist, however, exacerbations, and especially complications, are accompanied by very vivid symptoms, referred to in the literature as anxiety symptoms.

Symptoms of anxiety in organic dyspepsia

Symptoms	Diseases	Complications
Intense and unrelenting pain	Peptic ulcer, cholecystitis, pancreatitis, cholelithiasis, diverticulum	Penetration, perforation, obstruction, diverticulitis
Increased temperature, intoxication, inflammatory changes in the blood	Cholecystitis, pancreatitis, cholelithiasis, diverticulum	Abscess, empyema, obstruction, diverticulitis
Blood in vomit or stool, pallor, weakness, fainting, drop in blood pressure, anemia	Ulcer disease, diverticulum	Bleeding
Weight loss	Severe general diseases with abdominal syndrome, tumors

Since peptic ulcer disease predominates in the structure of dyspepsia syndrome in children, early diagnostics of this disease is recognized as a priority task. Epidemiological criteria that increase the risk of peptic ulcer disease: age over 10 years (= 10 times), belonging to the male sex (3-4 times), aggravated heredity (6-8 times). Clinically, the presence of peptic ulcer disease is indicated by night and "hunger" pains, severe rare pain, heartburn and sour belching. If a child has at least one of the listed alarm symptoms, EGDS is indicated as a matter of priority. Contraindications to EGDS are acute circulatory disorders, pulmonary and cardiac insufficiency, pronounced anatomical and topographic changes in the esophagus, mental illness, severe condition of the patient, risk of bleeding.

Ultrasound is a non-invasive and accessible method of screening for pathological conditions. If a child has not had an ultrasound of the liver, pancreas and gallbladder for a long time, the study is indicated to exclude developmental abnormalities of these organs, tumors and cysts, cholelithiasis, portal hypertension and liver cirrhosis. The prevalence of these conditions in childhood is low and there is no data that the rate is higher in the population of patients with dyspepsia syndrome. Nevertheless, screening for these diseases is necessary for the earliest possible diagnosis, so a single ultrasound of the abdominal cavity is mandatory for a child with dyspepsia syndrome. Determination of the contractile function of the gallbladder during the initial visit should be considered unnecessary and unreasonably increases the time and cost of the examination.

The most probable etiological factors of functional dyspepsia include psychosocial ones. The discovery of an unfavorable situation in the family, problems with peers, at school, increased workloads requires trust and patience from both the patient and the doctor. It is these situations that most often lead to the development of neurotic reactions, asthenic and anxiety syndrome.

Asthenic syndrome is characterized by fatigue, loss of physical and mental strength, exhaustion, weakness, hyperesthesia, sleep disorders, intolerance to normal loads. Anxiety - low mood with a feeling of internal tension, anxiety for oneself or loved ones, restlessness, excessive chaotic motor activity, which intensifies in the evenings. Numerous tests allow pediatricians to diagnose neurotic syndromes that require specialist consultation.

Dyspepsia can play the role of one of the visceral symptoms of vegetative dysfunctions. To facilitate diagnosis and clarify the form of vegetative gastrointestinal disorder, it is convenient to use the modified AM Vein table.

Signs underlying the study of the vegetative tone of the gastrointestinal tract (no AM Veinu in modification, 2000)

Sign	Sympathetic response	Parasympathetic response
Salivation	Reduced, saliva thick	Increased, liquid saliva
Acidity	Normal	Increased, sour belching, heartburn
Intestinal motility	Reduced, atonic constipation	Increased, diarrhea, spastic constipation
Nausea	Uncharacteristic	Characteristic
Type of pain	Constant	Paroxysmal

The prevalence of certain symptoms in a patient can be used to judge the type of vegetative dystonia and prescribe appropriate vegetative-tropic drugs. In most cases, children with functional dyspepsia have a predominance of parasympathetic regulation of the gastrointestinal tract.

The role of H. pylori in the development of dyspepsia syndrome is still unclear. It has been indisputably proven that the persistence of H. pylori causes inflammatory changes in the gastric mucosa, but these disorders often do not correlate with the clinical symptoms of dyspepsia. Epidemiological studies have not found reliable differences in the frequency of H. pylori in the group of people with and without dyspepsia, and therefore testing for H. pylori is advisable only in cases where eradication of the pathogen is regulated by current standards (Maastricht, 2000).

An important factor that can cause dyspepsia syndrome is helminthic and parasitic invasions. The leading mechanism in this case is not considered to be inflammation of the mucous membrane of the upper gastrointestinal tract, but the effect of toxins on the functional state of the muscular and secretory apparatus. In addition to lamblia, which are protozoa, at least 10 helminthiases are known that occur with dyspeptic syndrome. Signs of invasion: combined damage to various parts of the gastrointestinal tract, allergic conditions, eosinophilia or anemia, pronounced asthenovegetative syndrome. In such cases, a coprological study with enrichment or concentration of the material is necessary (according to Fulleborn, Shulman or the formalin-ether enrichment method). Native examination of feces for helminth eggs and lamblia cysts, even multiple, does not have sufficient sensitivity, and a false-negative result of the study misleads the doctor. More informative are immunological examination of blood and detection of parasite antigens in fecal material.

When functional dyspepsia is combined with intestinal dysfunctions, diseases that occur with malabsorption syndrome, such as lactase deficiency or celiac disease, should be excluded. For this purpose, coprological examination, tests for reduced carbohydrates, and specific immunological tests are performed.

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