1. No category

Recurrent Abdominal Pain in Childhood Urolithiasis
Cesare Polito, Angela La Manna, Giuseppe Signoriello and Antonio Marte
Pediatrics 2009;124;e1088; originally published online November 9, 2009;
DOI: 10.1542/peds.2009-0825
The online version of this article, along with updated information and services, is
located on the World Wide Web at:
http://pediatrics.aappublications.org/content/124/6/e1088.full.html
PEDIATRICS is the official journal of the American Academy of Pediatrics. A monthly
publication, it has been published continuously since 1948. PEDIATRICS is owned,
published, and trademarked by the American Academy of Pediatrics, 141 Northwest Point
Boulevard, Elk Grove Village, Illinois, 60007. Copyright © 2009 by the American Academy
of Pediatrics. All rights reserved. Print ISSN: 0031-4005. Online ISSN: 1098-4275.
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Recurrent Abdominal Pain in Childhood Urolithiasis
WHAT’S KNOWN ON THIS SUBJECT: Flank pain, hematuria, and
dysuria are considered the warning signs of urinary tract
involvement in children with RAP.
WHAT THIS STUDY ADDS: In children with RAP and urolithiasis,
hematuria and dysuria are inconstant, and in children younger
than 8 years of age, the abdominal pain is often central/diffuse.
Infrequent pain attacks and a family history of urolithiasis are
additional warning signs of urinary stones.
AUTHORS: Cesare Polito, MD,a Angela La Manna, MD,a
Giuseppe Signoriello, MD,b and Antonio Marte, MDa,c
Departments of aPediatrics, bPublic Health, and cPediatric
Surgery, Second University of Naples, Naples, Italy
KEY WORDS
urolithiasis, hematuria, dysuria, recurrent abdominal pain
ABBREVIATION
RAP—recurrent abdominal pain
www.pediatrics.org/cgi/doi/10.1542/peds.2009-0825
doi:10.1542/peds.2009-0825
Accepted for publication Jun 12, 2009
Address correspondence to Cesare Polito, MD, Second University
of Naples, Department of Pediatrics, Via L. De Crecchio 2, 80138
Naples, Italy. E-mail: [email protected]
abstract
OBJECTIVE: Our goal was to establish the clinical presentation and
features of pain attacks in children with recurrent abdominal pain
(RAP) and urolithiasis.
METHODS: We compared the rate of previous appendectomy among
100 consecutive patients with that of 270 control subjects. We also
compared the frequency of pain attacks with that reported by children
with functional or organic gastrointestinal RAP.
PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275).
Copyright © 2009 by the American Academy of Pediatrics
FINANCIAL DISCLOSURE: The authors have indicated they have
no financial relationships relevant to this article to disclose.
RESULTS: Fifty-three patients had no history of dysuria or gross hematuria, and only 35 had hematuria at the first visit; 41 patients were
evaluated for urolithiasis only because of a family history of kidney
stones associated with RAP. Twenty-nine patients had been previously
hospitalized for abdominal symptoms. Sixteen patients and 4 control
subjects (1.5%) had undergone a previous appendectomy (P ⬍ .0001).
Two to 28 months before the diagnosis of urolithiasis, 37 patients
underwent abdominal ultrasonography, which did not show urinary
stones. Sixty-nine percent of subjects younger than 8 years of age had
central/diffuse abdominal pain. The mean frequency of pain attacks
was 4 to 9 times lower than in patients with functional or organic
gastrointestinal RAP.
CONCLUSIONS: 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 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. Pediatrics 2009;
124:e1088–e1094
e1088
POLITO et al
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ARTICLES
Abdominal pain is the presenting
symptom in 50% to 76.9% of children
with urolithiasis,1–5 and it may occur as
acute/subacute or recurrent abdominal pain (RAP).3,6,7 RAP is common
among children and adolescents and
has been associated with ⬎100 different conditions.6,8 In most cases, however, no organic disease can be found,
and most episodes of RAP are considered to be a functional disorder that
affects gastrointestinal motility6,8 and
is often associated with emotional
disorders.9
Pediatric urolithiasis is associated
with significant morbidity, particularly
because stones tend to recur; thus, its
occurrence should not be underestimated. 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. The location of
pain in the flank as well as hematuria
and dysuria are considered the only
warning signs indicating more indepth investigation of urinary tract involvement in children with RAP.6,10 To
date, no study has addressed the frequency of pain attacks in children with
urolithiasis.
Here we report the results of an observational study on children with RAP
and urolithiasis. The goal was to assess the frequency and location of pain
attacks, the occurrence of hematuria
and dysuria, the rate of previous inconclusive hospitalizations for abdominal
symptoms, and the rate of appendectomy, which may reflect failure to detect the urologic cause and depict the
severity and costs of RAP.
ciuria and/or hyperuricosuria, most of
whom had no urinary stones, have
been published.11,12
We evaluated 100 white patients aged 3
to 18 years with RAP who were first
diagnosed as having urolithiasis and
were consecutively observed from October 1, 1999, to November 14, 2008, in
our clinical setting, which is mainly devoted to pediatric nephrology/urology
patients, but also cares for general pediatrics patients and lacks emergency
service. Urolithiasis was defined as imaging identification of a calculus or
documented calculus passage. Micturating cystography was performed on
children with recurrent urinary tract
infections or pathologic ultrasound
findings, such as hypoplastic or dysmorphic kidneys or hydronephrosis, to
determine the vesicoureteric reflux.
Tc99m MAG3 dynamic renal scintigraphy was performed on children with
hydronephrosis to determine ureteropelvic obstruction. We did not systematically search for other possible
causes of RAP. However, we excluded
subjects with another potential source
of RAP, as well as those whose report
of symptoms was unreliable. Data collection was prospective and formed
the basis of this observational study.
We obtained approval from our institutional ethics committee, as well as
signed informed-consent forms from
the children’s parents.
METHODS
RAP was defined as at least 3 episodes
of diffuse or localized abdominal pain
over a period of at least 3 months.13
The basic investigation protocol included a detailed medical history,
physical examination, blood and urinary studies, and renal and urinary
tract ultrasound scans.
In 1999, we began a prospective observational study of the clinical presentation and outcome of children with urinary solute excretion abnormalities
leading to urolithiasis. Some of the
findings on participants with hypercal-
The prevalence of appendectomy in the
history of the patients under study was
compared with that of a control group
of 270 subjects, 142 of whom were
boys, aged 3 to 18.5 years (mean: 8.6
[SD: 3.9]). The control subjects were
PEDIATRICS Volume 124, Number 6, December 2009
consecutively observed for acute respiratory tract infection during a period of 2 years (2001–2003), and the
previous history of appendectomy was
specifically investigated by 1 of the authors (Dr Polito). We assumed that the
prevalence of appendectomy in this
group reflected the prevalence in the
general population.
All children and parents were questioned about the location and frequency of pain attacks. Evaluation during the first visit was performed by 2 of
the authors (Drs Polito and La Manna)
on 43 and 57 different patients, respectively. Hence, we compared the referred location of pain and the frequency of pain attacks recorded by the
2 independent observers in 2 different
groups of subjects. The location of pain
elicited on abdominal palpation by Drs
Polito and La Manna was also compared. The frequency of attacks in our
patients was compared with that reported in children with functional RAP
from our region14 and from the United
States,15 and with functional/psychosomatic or organic gastrointestinal
RAP from Norway16 and Sweden.17 No
specific attempt was made to consistently quantitate the severity of pain.
However, the pain was considered to
be significant if it caused the child to
interrupt an ongoing activity to complain of pain or the child became inactive after verbalizing the symptom of
pain.
Hypercalciuria was defined as calciuria of ⬎0.1 mmol (4 mg)/kg per day,
and hyperuricuria was defined as urinary uric acid exceeding 815 mg/1.73
m2 per day18 on at least 2 of 3 nonconsecutive 24-hour urine collections made
at home. The adequacy of urine collections was checked by comparing the
measured creatinine excretion with
normal values. Hyperoxaluria was defined as oxalate excretion of ⬎40 mg/
1.73 m2 per day and hypocitraturia as
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e1089
Patients with urolithiasis
aged 3–18 y, observed
during the study period
(n = 188)
l
l
Without RAP
----------------------------------------------------------------------------- With RAP
(n = 78)
(n = 110)
Hematuria/dysuria: 36
l
Acute/subacute pain
l
+hematuria/dysuria: 26
l………………Excluded
Acute-subacute pain: 12
l
Incidental discovery: 3
l
Ureteropelvic obstruction: 3
Urinary infection: 1
l
Vesicoureteric reflux: 1
l
Renal cysts: 2
l
l
Stipsis: 2
(n = 10)
Celiac disease: 1
Mental retardation: 1
l
l
l
l
Elected
(n = 100)
Outpatients: 78
Hospitalized: 22
FIGURE 1
Enrollment and election of the patients included in the study.
citrate excretion of ⬍400 mg/g creatinine.18 Cystinuria was assessed with
the nitroprusside test in all patients
and confirmed by quantitative measurement in nitroprusside-positive patients. Hematuria was defined as ⱖ5
red blood cells per high-power field in
a centrifuged urine sample or hemoglobin ⬎1⫹ at dipstick.
The ␹2 test, the ␹2 test for trend, and
the Wilcoxon rank test were used for
statistical analysis. A P value of ⬍.05
was considered significant.
RESULTS
Figure 1 shows the enrollment and
election of the patients included in the
study. Table 1 lists the clinical characteristics of the study participants. The
mean age was 9.8 (SD: 3.8) years. The
mean duration of RAP before the first
visit was 12.5 months (SD: 11.4 [range:
e1090
POLITO et al
3–50]). The mean duration of pain attacks was 127 minutes (SD: 105 [range:
10 – 600]). Nine patients had a urinary
infection at the first visit, and 2 had
previous urinary infections. Serum
electrolyte, calcium, phosphate, creatinine, uric acid, bicarbonate, and parathyroid hormone levels were normal in
all patients.
Internal Validation
There was no significant difference in
the referred central or lateral pain location (P ⫽ .45 for both subjects
younger and older than 8 years of age)
or in the frequency of pain attacks
(P ⫽ .79) recorded by Drs Polito and La
Manna. Pain on abdominal palpation
was elicited by Drs Polito and La
Manna in 27 and 18 subjects, respectively. There was no significant difference in the rates of central and lateral
pain elicited by the 2 observers (P ⫽
.45 for both subjects younger and
older than 8 years old).
History
A history of urolithiasis in at least 1
first- or second-degree relative was
present in 88 subjects. Two to 28
months (mean: 11.8) before the diagnosis of urolithiasis, 37 patients underwent abdominal ultrasound examination, the results of which were
negative for urinary stones; however,
15 patients had microcalculi,19 that is,
hyperechogenic spots ⱕ3 mm in diameter in renal calyces, 5 patients had
mild pyelectasis, and 2 patients had
mild pyelectasis plus microcalculi. The
ultrasound examinations were performed elsewhere in 25 cases and in
our setting in 12. In the present analysis, we considered as the “first visit” of
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ARTICLES
%
TABLE 1 Characteristics of 100 Children With
RAP and Urolithiasis
Characteristic
100
Lumbar/flank
n
Gender
Male
Female
Referral diagnosis
RAP
Gross hematuria and/or dysuria ⫹ RAP
Microhematuria ⫾ dysuria ⫹ RAP
Stone locationa
Upper tract
Pelvic
Staghorn
Ureteral
Documented passage
Urinary excretion abnormality, mean of
the abnormal values (range)
Hypercalciuria, 5.5 (4.1–11) mg/kg
per dc
Hyperuricuria, 880 (844–1121) mg/1.73
m2 per dc
Hypercalciuria, 6.3 (4.4–10) mg/kg per
dc ⫹ Hyperuricuria, 946 (844–1086)
mg/1.73 m2 per dc
Mild hyperoxaluria, 98 (64–130) mg/
1.73 m2 per d
Hypocitraturia, 177 (75–305) mg/g
creatinine
Cystinuria
No abnormality found
Mainly
hypogastric
42
58
Central/diffuse
49
36
15
50
82b
2
2
3
11
46
0
Age groups, y
3–8
8,1–13
13,1–18
18
N. of cases
(35)
(45)
(20)
Chi-square for trend p < 0.01
17
FIGURE 2
Prevalence of pain locations in 3 age groups. ␹2 for trend, P ⬎ .01.
5
4
2
8
a Associated with microcalculi in 57 patients. For imaging
documentation of stones, renal ultrasound was used for
all patients, plain radiograph film for 25 patients, and intravenous urography for 11 patients.
b Bilateral in 5 patients.
c Twenty-nine patients with hypercalciuria or/and hyperuricuria also had mild hyperoxaluria or/and hypocitraturia.
the latter 12 patients the time when
stones were first recorded.
A history of appendectomy was recorded significantly more often among
the subjects with urolithiasis (16%;
P ⬍ .0001) than in the control group (4
of 270 [1.5%]). The 16 subjects with urinary calculi underwent appendectomy
1 to 48 months before our first visit. In
9 of the 16 patients, dysuria and/or
gross hematuria occurred 3 days to 18
months (mean: 9.5 months) after appendectomy. In 2 of the 16 patients, microscopic hematuria was recorded 1
and 20 months after appendectomy at
our first visit. One of the patients who
underwent appendectomy also underwent a Meckel scan during another
hospitalization. Four additional paPEDIATRICS Volume 124, Number 6, December 2009
tients had previously been hospitalized
for possible appendicitis. Another 9
patients had been hospitalized at least
once for abdominal pain: 1 underwent
a Meckel scan, 1 underwent gastroscopy, and 1 underwent contrast radiography of the upper digestive tract
and gastroscopy. A total of 29 of our
patients had been hospitalized at least
once for abdominal symptoms.
Pain
Among the 35 patients younger than 8
years of age, the referred location of
pain was lateral/flank in 10 (29%), cen-
tral/diffuse in 24 (69%) and mainly hypogastric in 1. Among the 65 patients
older than 8 years, the pain was lateral/flank in 55 (85%), central/diffuse in
7 (11%), and mainly hypogastric in 3. A
significant decrease in the prevalence
of central/diffuse location of pain with
increasing age is apparent, with the
most relevant decrease after 8 years
(Fig 2). The mean frequency of pain attacks was 4 to 9 times lower than that
reported in children with functional or
organic gastrointestinal RAP (Table 2).
Eighty-four patients had 4 or fewer
days of pain per month.
TABLE 2 Mean (SD) Frequency of Pain Attacks in Children With RAP and Urolithiasis and in Four
Studies of Functional or Organic Gastrointestinal RAP
Study
Disorder (No. of Patients)
Mean
Age, y
Frequency, Mean
(SD), d/mo
Present series, Campania, Italy
Miele et al,14 Campania, Italy
Urolithiasis (100)
Functional dyspepsia (26)
Irritable bowel syndrome (26)
Functional dyspepsia (14)
Irritable bowel syndrome (11)
Functional abdominal pain (14)
Organic (20) and functional (24)
gastrointestinal RAP
Psychosomatic (48), possibly
psychosomatic (14), other
etiologies (38)
9.8
8.2
5.0
11.6
11.6
11.0
8.3
3.1 (4.0)a
12.4 (11.1)
15.6 (10.6)
23.9
18.1
17.2
11.9 (8.5)
9.5
19.8b
Ball and Weydert,15 Arizona
Størdal et al,16 Norway
Alfvén,17 Sweden
a
b
Median: 1.5; ⱖ9 days/month in 9 subjects; ⱖ7 days/month in 12 patients; range: 0.5–20.
Calculated from the reported frequency of 4.6 attacks per week.
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e1091
There was no significant difference in
the frequency of pain attacks between
boys and girls (P ⫽ .60), between subjects younger and older than 8 years
(P ⫽ .24), or between subjects with
central/diffuse and lateral/flank location of abdominal pain (P ⫽ .25).
Hematuria and Dysuria
Fifty-three patients had no history of
dysuria or gross hematuria, and only
35 had gross or microscopic hematuria at the first visit. Forty-one patients had no history of hematuria or
dysuria and normal urinalysis results
at the first visit. Of the 47 patients with
a history of gross hematuria or dysuria, 22 (47%) had no dysuria and normal urinalysis results at the first visit.
Central/diffuse location of abdominal
pain, with no history of dysuria and hematuria and normal urinalysis results
at our visit were recorded in 16 of our
patients and in 12 of 35 (34%) of those
aged 8 years or younger.
Of the 45 subjects with pain on palpation of the abdomen, as many as 32
(71%) had neither hematuria nor
dysuria at the time of the visit. Of the
37 patients who had negative ultrasound results before the first diagnosis of calculi, 21 (57%) had no history of dysuria or hematuria and
underwent additional follow-up investigations only because of a family
history of nephrolithiasis.
DISCUSSION
Because of the lack of populationbased studies, we do not know how
many children with RAP have urolithiasis. Moreover, authors of studies on
children with urolithiasis have reported the rate of those presenting
with abdominal/flank pain with no specification of the proportion of acute/
subacute and chronic-recurrent abdominal pain.1–5 The lack of emergency
service in our department likely enhanced the proportion of those with
recurrent pain in respect to those
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POLITO et al
with acute/subacute abdominal pain.
Therefore, the present series is not
representative of the universe of children with urolithiasis.
This study shows a low frequency of
pain attacks in children with urolithiasis, which has not yet been reported in
the literature. The mean frequency of
pain attacks was 4 to 9 times lower in
our patients than in children with functional or organic gastrointestinal RAP
from our own and other countries. In
contrast, the maximum difference in
the frequency of attacks among the
various kinds of functional or organic
gastrointestinal RAP was less than
twofold (Table 2). Hence, the low frequency of pain attacks clearly distinguishes the population of children with
urolithiasis from those with functional
or organic gastrointestinal RAP. We
cannot establish definite cutoff values.
In our series, however, the mean frequency of pain attacks was 3.1 days/
month, whereas the median was 1.5
days/month (Table 2). A frequency of
pain attacks of 4 days/month or less
may empirically suggest urolithiasis,
which has even been indicated as an
index of healing of functional RAP,15
whereas this frequency was recorded
in as many as 84% of our patients. RAP
occurs in up to 19% of all children and
adolescents, with a median prevalence of 8.4%,8 and is most often
functional.6,9,16,17 Therefore, it is likely
that the remaining 16% of our patients with more frequent pain attacks included a number of subjects
with functional RAP incidentally associated with urolithiasis.
Gross or microscopic hematuria and
dysuria are the main “red-flag” symptoms reported for involvement of the
urinary tract in children with RAP.6,8
Nevertheless, these symptoms occurred inconstantly in our patients. In
fact, half of our patients had no history
of dysuria or hematuria, and more
than one third had no history of dys-
uria or gross hematuria and normal
urinalysis results at the first visit. The
latter were investigated for urolithiasis because of RAP associated with a
family history of urinary calculi, which
accounts for a high risk of kidney
stones.20,21 Actually, more than half of
our patients who had a negative ultrasound scan result before the first diagnosis of urolithiasis had no history of
dysuria or hematuria and underwent
additional follow-up investigations because of a family history of kidney
stones. Moreover, approximately half
of our patients with a history of hematuria or dysuria did not have these
symptoms at the first visit. Finally, hematuria and dysuria did not necessarily correlate with pain; as many as 71%
of our patients with pain elicited by abdominal palpation had neither hematuria nor dysuria at the time of the visit.
Pain attacks, as well as hematuria and
dysuria, likely result from the mobilization and passage of calculi or crystals.
Hence, it is not surprising that the
occurrence of these symptoms was
largely intermittent or sporadic. Although no study has specifically addressed children with RAP and urolithiasis, the inconstant occurrence of
hematuria and dysuria has been reported in many series of children with
kidney stones.1–5,7 It is worth keeping
this fact in mind, because the lack of
occurrence of hematuria and dysuria
in clinical practice may erroneously
lead to exclusion of the urinary tract as
a possible cause of pain. The drawback
is that even in most scientific reports
on RAP, the urologic origin of pain
was excluded only on the basis of
“normal urinalysis and/or urine culture or of the lack of overt genitourinary problems”10; similar guidelines
were established by the Rome III
Committee for Functional Gastrointestinal Disorders.22
A central/diffuse location of abdominal
pain was prevalent among patients
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ARTICLES
younger than 8 years in our study, and
flank pain was the rule in patients
older than 8 years (Fig 2). This could
reflect the development of sensory discrimination during childhood and is in
keeping with the acquisition of body
outline around the age of 8.23 We previously found similar results in children
with hypercalciuria and/or hyperuricosuria, most of whom, however, had
no urinary stones.11 When abdominal
pain is central/diffuse and is not associated with dysuria and hematuria, as
in 34% of our patients aged under 8
years, it might well mimic functional RAP.
Imaging studies performed immediately after pain attacks may fail to reveal urinary calculi, because the
stones could have been passed shortly
before the evaluation. In fact, 2 to 28
months before the diagnosis of urolithiasis, 37% of our patients underwent
abdominal ultrasound scanning that
did not show urinary calculi. This is in
keeping with reports that ⬎10% of
children with hypercalciuria and/or
hyperuricosuria and no demonstrable
stones on first evaluation may form
calculi within 1 to 4 years.19,24–26 Actually, in 15 of our 37 patients, ultrasound showed microcalculi that could
be considered the first step in stone
formation.19,24 The finding of microcalculi, however, depends on interobserver
and intraobserver variability and skills,
and microcalculi are not generally rec-
ognized.27,28 The possibility of a falsenegative ultrasound scan or plain radiograph film in a subject with bowel
distension caused by recent colic
should also be taken into account. Lowdose unenhanced computed tomography is more accurate than ultrasonography in detecting calculi and has been
recommended for all children with persistent urolithiasis symptoms and nondiagnostic ultrasound scans.28 Compared
with ultrasound, however, computed tomography involves higher costs and radiation, which are significant issues in
children with possible urolithiasis because of the frequent recurrence of this
condition.
The inconstant occurrence of hematuria
and dysuria, the central/diffuse location
of abdominal pain in most young children, and the lack of calculi shown on
imaging studies performed after an episode of pain may result in failure to identify the urologic origin of pain. This could
explain, for the most part, the high rates
of previous inconclusive hospitalizations
for abdominal pain (29%) and appendectomy in the present series. Actually, the
prevalence of appendectomy in our control group (1.5%) is comparable to that
estimated from a large survey in the
United States29 and is significantly (P ⬍
.0001) lower than the rate (16%) for our
patients.
Searching for urolithiasis in children
with RAP may be difficult and expensive. In fact, a negative imaging study
result after a pain attack does not exclude the previous and/or subsequent
occurrence of urinary stones and may
need to be repeated later. This is particularly important in the presence of a
urinary solute excretion abnormality
such as hypercalciuria or hypocitraturia, which, in turn, may require repeated30 and costly31 evaluations to be
ascertained. Moreover, despite an upward trend in incidence, overt pediatric urolithiasis remains infrequent in
Western countries,5,28 whereas RAP is
frequent. 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.
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.
5. VanDervoort K, Wiesen J, Frank R, et al. Urolithiasis in pediatric patients: a single center
study of incidence, clinical presentation and
outcome. J Urol. 2007;177(6):2300 –2305
6. Pearl RH, Irish MS, Caty MG, et al. The approach to common abdominal diagnoses in
infants and children: part II. Pediatr Clin
North Am. 1998;45(6):1287–1326
7. Vachvanichsanong P, Malagon M, Moore ES.
Recurrent abdominal and flank pain in children with idiopathic hypercalciuria. Acta
Paediatr. 2001;90(6):643– 648
8. Chitkara DK, Rawat DJ, Talley NY. The epidemiology of childhood recurrent abdominal
pain in Western countries: a systematic
review. Am J Gastroenterol. 2005;100(8):
1868 –1875
9. Campo JV, Bridge J, Ehmann M, et al. Recurrent abdominal pain, anxiety and depression in primary care. Pediatrics. 2004;
113(4):817– 824
10. Weydert JA, Ball TM, Davis MF. Systematic
review of treatments for recurrent abdominal pain. Pediatrics. 2003;111(1). Available
at: www.pediatrics.org/cgi/content/full/
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11. Polito C, Cioce F, Signoriello G, et al. Central/
diffuse abdominal perception of urological
pain in children. Acta Paediatr. 2006;95(1):
82– 85
CONCLUSIONS
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Recurrent Abdominal Pain in Childhood Urolithiasis
Cesare Polito, Angela La Manna, Giuseppe Signoriello and Antonio Marte
Pediatrics 2009;124;e1088; originally published online November 9, 2009;
DOI: 10.1542/peds.2009-0825
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