{"id":175,"date":"2020-03-04T17:45:49","date_gmt":"2020-03-04T17:45:49","guid":{"rendered":""},"modified":"2020-03-04T17:45:49","modified_gmt":"2020-03-04T17:45:49","slug":"vaiku-umaus-pilvo-skausmo-priezastys","status":"publish","type":"post","link":"https:\/\/www.pasveik.lt\/lt\/rekomenduojamos-naujienos\/vaiku-umaus-pilvo-skausmo-priezastys\/175\/","title":{"rendered":"Vaik\u0173 \u016bmaus pilvo skausmo prie\u017eastys"},"content":{"rendered":"

\u016amus pilvo skausmas\u00a0\u2013 viena da\u017eniausi\u0173 problem\u0173, d\u0117l kurios vaikai tiriami ir gydomi pirmin\u0117s sveikatos prie\u017ei\u016bros \u012fstaigose ar vaik\u0173 skubiosios pagalbos skyriuose. Da\u017eniausios vaik\u0173 \u016bmaus pilvo skausmo prie\u017eastys praeina savaime ir gyvybei gr\u0117sm\u0117s nekelia. Gydytojui svarbu identifikuoti t\u0105 ma\u017e\u0105 dal\u012f pacient\u0173, kuriems pilvo skausm\u0105 suk\u0117lusi prie\u017eastis yra sud\u0117tinga ar net pavojinga gyvybei, kada laiku b\u016bt\u0173 parinkta gydymo taktika. Nustatyti tiksli\u0105 diagnoz\u0119 gali b\u016bti i\u0161\u0161\u016bkis, nes patologij\u0173, sukelian\u010di\u0173 \u016bm\u0173 pilvo skausm\u0105 vaikams, yra labai daug. Sunkum\u0173 kyla dar ir d\u0117l ma\u017eojo paciento kalbos barjero ar t\u0117v\u0173\u00a0\/\u00a0glob\u0117j\u0173 nenoro bendradarbiauti bei klaidingos j\u0173 simptom\u0173 interpretacijos. \u0160iame straipsnyje apra\u0161omos tiek gyvybei pavojingos, tiek nepavojingos \u016bmaus pilvo skausmo prie\u017eastys, aptariamos kitos galimos skausmo prie\u017eastys.<\/span><\/p>\n

Gyvybei pavojingos pilvo skausmo prie\u017eastys<\/b><\/span><\/p>\n

Trauma.<\/b><\/span> Jei paciento anamnez\u0117je yra trauma, b\u016btinas kruop\u0161tus \u012fvertinimas d\u0117l galim\u0173 intraabdominalini\u0173 pa\u017eeidim\u0173. Da\u017eniausi traumos mechanizmai, kai galimas reik\u0161mingas pilvo organ\u0173 pa\u017eeidimas (<\/span>parenchiminio organo ply\u0161imas ar ertminio organo perforacija)\u00a0\u2013 motorini\u0173 transporto priemoni\u0173 susid\u016brimas, p\u0117s\u010diojo partrenkimas, \u012fvair\u016bs griuvimai, sporto traumos, smurtas prie\u0161 vaik\u0105 [1, 2]. Esant pilvo organ\u0173 pa\u017eeidimui d\u0117l traumos, klinikinio tyrimo metu stebimos hematomos (pvz., automobilio saugos dir\u017eo srityje), pilvo i\u0161sip\u016btimas, jautrumas palpuojant, pilvapl\u0117v\u0117s dirginimo po\u017eymiai, o auskultuojant gali b\u016bti girdimi susilpn\u0117j\u0119 arba i\u0161nyk\u0119 peristaltikos garsai\u00a0[3].
Apendicitas.<\/b> \u016aminis apendicitas yra da\u017eniausia chirurginio gydymo reikalaujanti vaik\u0173 liga. Tyrim\u0173 duomenimis, ji diagnozuojamas 1\u20138\u00a0proc. vaik\u0173, kuriems atlikti skub\u016bs tyrimai d\u0117l \u016bmaus pilvo skausmo [4, 5]. Trys pagrindiniai klinikiniai po\u017eymiai, leid\u017eiantys \u012ftarti apendicito diagnoz\u0119, yra nepraeinantis ir progresuojantis skausmas apatinio de\u0161iniojo pilvo kvadranto srityje, skausmo lokalizacijos kitimas i\u0161 periumbilikalin\u0117s zonos \u012f de\u0161in\u012fj\u012f apatin\u012f kvadrant\u0105 (Kocherio simptomas) ir pilvo raumen\u0173 \u012fsitempimas [6]. B\u016btina prisiminti, kad skausmo lokalizacij\u0105 lemia kirm\u0117lin\u0117s ataugos topografija. Retrocekin\u0117s ir dubenin\u0117s apendikso pad\u0117ties atveju skausmas da\u017eniau pasirei\u0161kia i\u0161kart de\u0161iniojo apatinio kvadranto srityje, da\u017enas \u0161ono skausmas, skausmo iradiacija \u012f lytinius organus (berniukams) [6]. Taip pat b\u016bdingas v\u0117mimas, pykinimas, apetito stoka [7]. Apendicitu sergantis pacientas paprastai vengia jud\u0117ti, guli lovoje sulenk\u0119s kelius [6]. Ligos prad\u017eioje gali pasireik\u0161ti subfebrilus kar\u0161\u010diavimas, o vystantis komplikacijoms temperat\u016bra pakyla daugiau nei 38,5\u00a0\u00b0\u00a0[7]. Atlikus kraujo tyrim\u0105, da\u017enai nustatoma leukocitoz\u0117, neutrofilija, C reaktyviojo baltymo koncentracijos padid\u0117jimas, ta\u010diau \u012fsid\u0117m\u0117tina, kad kraujo tyrimas be pakitim\u0173 apendicito diagnoz\u0117s nepaneigia [8]. Tyrim\u0173 duomenimis, min\u0117ti kraujo tyrim\u0173 pakitimai yra susij\u0119 su didesne komplikacij\u0173 rizika [9, 10]. Auksiniu diagnostikos standartu i\u0161lieka ultragarsinis pilvo tyrimas. Tiriant ultragarsu, didesn\u0117 nei 0,6\u20130,7\u00a0cm diametro kirm\u0117lin\u0117 atauga laikoma pakitusia [11]. Pa\u017eym\u0117tina, kad \u016bminis apendicitas neda\u017enai nustatomas ikimokyklinio am\u017eiaus vaikams (2\u20139\u00a0proc. vis\u0173 vaik\u0173 apendicito atvej\u0173) [12]. Be to, vaikams iki 3 met\u0173 d\u0117l bendr\u0173j\u0173 ligos simptom\u0173 ir specifini\u0173 po\u017eymi\u0173 stokos \u0161i patologija gali b\u016bti diagnozuota per v\u0117lai, tod\u0117l \u012ftarus apendicit\u0105 \u0161ios am\u017eiaus grup\u0117s pacientus rekomenduojama steb\u0117ti stacionare [13, 14].<\/p>\n

\u017darn\u0173 invaginacija.<\/b> \u017darn\u0173 invaginacija\u00a0\u2013 proksimalinio \u017earnos segmento \u012fsimovimas \u012f distaliau esan\u010di\u0105 jos dal\u012f. Tai da\u017eniausia vaik\u0173 \u012fgytojo \u017earn\u0173 nepraeinamumo prie\u017eastis. Da\u017eniausiai \u0161i patologija pasirei\u0161kia vaikams nuo 2 m\u0117nesi\u0173 iki 2 met\u0173 [15]. Tyrim\u0173 duomenimis, dauguma invaginacij\u0173 yra idiopatin\u0117s. Tik ma\u017edaug 25\u00a0proc. atvej\u0173 galima identifikuoti invaginacij\u0105 i\u0161provokavus\u012f veiksn\u012f\u00a0\u2013 tai gali b\u016bti Mekelio divertikulas, \u017earnos polipai, limfinio audinio hiperplazija, Berkito limfoma, kt.\u00a0[16]. Invaginacijos sukeltas skausmas yra stiprus, pasirei\u0161kia staiga, kartojasi epizodais, tod\u0117l vaikas nenuraminamai verkia, kojas lenkia ir laiko pritrauktas prie pilvo. Tarp skausmo epizod\u0173 b\u016bna ramyb\u0117s period\u0173, kai vaikas elgiasi \u012fprastai. Taip pat b\u016bdingas v\u0117mimas: prad\u017eioje\u00a0\u2013 skrand\u017eio turiniu, v\u0117liau\u00a0\u2013 su tul\u017eimi. Ta\u010diau vadinamoji klasikin\u0117 invaginacijos simptom\u0173 triada\u00a0\u2013 kolikos tipo skausmas, tu\u0161tinimasis su krauju (konsistencija ir spalva literat\u016broje apib\u016bdinami kaip pana\u0161\u016bs \u012f raudon\u0173j\u0173 serbent\u0173 \u017eel\u0117) ir ap\u010diuopiamas darinys pilve, \u012fvairi\u0173 tyrim\u0173 duomenimis, nustatoma ma\u017eiau nei 15\u201350\u00a0proc. sergan\u010di\u0173 vaik\u0173 [17\u201319]. K\u016bdikiams pirmieji invaginacijos po\u017eymiai gali b\u016bti ir apatija ar elgesio poky\u010diai [20, 21]. Negydant invaginacija sukelia \u017earnos i\u0161emij\u0105, v\u0117liau\u00a0\u2013 \u017earnos nekroz\u0119, perforacij\u0105 ir peritonit\u0105 [17]. Pagrindinis invaginacijos diagnostikos metodas yra ultragarsinis pilvo tyrimas. Invaginatui b\u016bdingas vadinamasis taikinio po\u017eymis [17].<\/p>\n

Malrotacija su vidurin\u0117s pirmyk\u0161t\u0117s \u017earnos (angl. midgut<\/i>) apsisukimu.<\/b> Malrotacija\u00a0\u2013 tai \u012fgimtasis netaisyklingas \u017earnos dali\u0173 i\u0161sid\u0117stymas [22]. Vidurin\u0117s pirmyk\u0161t\u0117s \u017earnos apsisukimas yra pagrindin\u0117 malrotacijos komplikacija [23]. D\u0117l vidurin\u0117s pirmyk\u0161t\u0117s \u017earnos apsisukimo naujagimiams pasirei\u0161kia v\u0117mimas (da\u017eniau su tul\u017eies priemai\u0161a), matomi abdominalinio diskomforto \u017eenklai. Daugiau nei pusei pacient\u0173 malrotacija pasirei\u0161kia kaip gyvybei pavojinga b\u016bkl\u0117 per pirm\u0105j\u012f gyvenimo m\u0117nes\u012f [23]. Diagnoz\u0119 patvirtina ultragarsinis pilvo tyrimas (klasikinis radinys\u00a0vadinamasis \u2013 s\u016bkurio (angl. whirlpool<\/i>) <\/i>po\u017eymis) [24].<\/p>\n

\u012estrigusi kirk\u0161nies ar bambos i\u0161var\u017ea.<\/b> K\u016bdikiai, sergantys \u012fstrigusia kirk\u0161nies i\u0161var\u017ea, yra irzl\u016bs, verkia. Priklausomai nuo \u012fstrigimo trukm\u0117s ir nuo to, ar yra i\u0161sivys\u010diusi \u017earn\u0173 obstrukcija, vystosi v\u0117mimas ir pilvo i\u0161sip\u016btimas. Fizinio i\u0161tyrimo metu kirk\u0161nies srityje ap\u010diuopiamas kietos konsistencijos darinys, kuris gali plisti \u012f kap\u0161el\u012f ar did\u017ei\u0105sias lytines l\u016bpas. Darinys jautrus palpuojant, odoje matoma edema ir eritema. Laiku neatk\u016brus \u012fstrigimo, galima \u012fstrigusi\u0173 organ\u0173 nekroz\u0117. Bambos i\u0161var\u017eos da\u017enos ankstyvoje k\u016bdikyst\u0117je, bet \u012fstrigimas retas. \u012estrigus \u017earn\u0173 kilpoms, vystosi \u017earn\u0173 obstrukcijos simptomai [25].<\/p>\n

S\u0105aug\u0173 sukeltas \u017earn\u0173 nepraeinamumas.<\/b> Jeigu vaiko, kuriam pasirei\u0161k\u0117 pilvo skausmas ar v\u0117mimas, anamnez\u0117je yra pilvo operacija, reik\u0117t\u0173 \u012ftarti s\u0105aug\u0173 sukelt\u0105 plon\u0173j\u0173 \u017earn\u0173 obstrukcij\u0105. Retrospektyvi\u0173j\u0173 tyrim\u0173 duomenimis, ma\u017edaug 1\u20136\u00a0proc. vaik\u0173, kuriems buvo atlikta pilvo operacija, per 5 metus po operacijos susidaro s\u0105augos [26, 27]. Didesn\u0117 rizika s\u0105aug\u0173 sukeltam \u017earn\u0173 nepraeinamumui i\u0161sivystyti yra pirmaisiais metais po operacijos, jeigu buvo atlikta laparotomija, pakartotin\u0117s proced\u016bros, buv\u0119s peritonitas ir operacija klubin\u0117s \u017earnos srityje [26, 27].
Nekrotizuojantis enterokolitas (NEK).<\/b> Naujagimiams, sergantiems NEK, b\u016bdingas v\u0117mimas (da\u017eniausiai su tul\u017eimi), i\u0161p\u016bstas pilvas, skausmingumas palpuojant, pilvo sienos eritema, kraujas i\u0161matose. Taip pat gali pasireik\u0161ti sisteminiai po\u017eymiai, tokie kaip apn\u0117ja, kv\u0117pavimo nepakankamumas, letargija, nenoras valgyti ir neaugantis svoris, temperat\u016bros nestabilumas, o sunkiausiais atvejais\u00a0\u2013 hipotenzija d\u0117l sepsinio \u0161oko. Da\u017eniausiai \u0161i patologija b\u016bdinga nei\u0161ne\u0161iotiems (jie sudaro 90\u00a0proc. sergan\u010di\u0173 NEK), ta\u010diau retais atvejais gali i\u0161sivystyti ir i\u0161ne\u0161iotiems naujagimiams. Svarbiausias diagnostinis NEK tyrimas yra pilvo rentgenograma [28, 29, 30].<\/p>\n

Skrand\u017eio ir dvylikapir\u0161t\u0117s \u017earnos opalig\u0117.<\/b> Opalig\u0117 vaikams diagnozuojama re\u010diau nei suaugusiesiems, ta\u010diau gali sukelti gyvybei pavojing\u0173 komplikacij\u0173\u00a0\u2013 stiprus kraujavim\u0105, perforacij\u0105 ir peritonit\u0105 [31, 32]. Klinikiniai opalig\u0117s po\u017eymiai priklauso nuo vaiko am\u017eiaus. V\u0117mimas, kraujavimas i\u0161 vir\u0161kinimo trakto, perforacija da\u017eniau pasirei\u0161kia ma\u017eiems vaikams, o vyresniems ir paaugliams klinikiniai po\u017eymiai pana\u0161\u016bs \u012f suaugusi\u0173j\u0173\u00a0\u2013 da\u017eniausiai tai yra epigastriumo srities skausmas pra\u0117jus keletui valand\u0173 po valgio. Vaikams iki 10 met\u0173 opalig\u0117 siejama su medikament\u0173 (gliukokortikoid\u0173, nesteroidini\u0173 vaist\u0173 nuo u\u017edegimo) vartojimu ar somatin\u012f stres\u0105 organizmui sukelian\u010diais \u012fvykiais (pvz., operacija) [33, 34]. Vyresniems nei 10 met\u0173 vaikams diagnozuojamos opos paprastai b\u016bna l\u0117tin\u0117s, susijusios su H. pylori<\/i> infekcija, o da\u017enesn\u0117 j\u0173 lokalizacija\u00a0\u2013 dvylikapir\u0161t\u0117 \u017earna [33, 35].<\/span><\/p>\n

Ektopinis n\u0117\u0161tumas.<\/b> \u0160i diagnoz\u0117 turi b\u016bti apsvarstyta visoms mergait\u0117ms, kurioms jau yra menstruacijos ir kurios skund\u017eiasi pilvo skausmu, nes ektopinis n\u0117\u0161tumas gali sukelti gyvybei pavojing\u0105 kraujavim\u0105. Klasikiniai ektopinio n\u0117\u0161tumo simptomai yra pilvo skausmas, amenor\u0117ja ir kraujavimas i\u0161 mak\u0161ties [36]. Nors prie\u0161 prasidedant kraujavimui b\u016bdingas amenor\u0117jos laikotarpis, kai kurios pacient\u0117s gali klaidingai interpretuoti ektopinio n\u0117\u0161tumo sukelt\u0105 kraujavim\u0105 kaip v\u0117luojan\u010di\u0173 ar nereguliari\u0173 menstruacij\u0173 kraujavim\u0105, ir nesikreipti pagalbos, kol neatsiranda kit\u0173 ektopinio n\u0117\u0161tumo po\u017eymi\u0173.<\/p>\n

Svetimk\u016bnio prarijimas. <\/b>Ma\u017ei vaikai da\u017eniausiai praryja ma\u017eus lygaus pavir\u0161iaus nemaistin\u0117s kilm\u0117s objektus, kurie paprastai pasi\u0161alina nat\u016braliai, jeigu neu\u017estringa stempl\u0117s anatomini\u0173 susiaur\u0117jim\u0173 vietose [37, 38]. \u017dinant ar tariant, kad vaikas prarijo pavojing\u0105 objekt\u0105, galint\u012f sukelti vir\u0161kinimo trakto obstrukcij\u0105 ar perforacij\u0105, b\u016btina kuo skubiau atlikti tyrimus ir gydyti. Tokiais pavojingais objektais laikomi a\u0161tr\u016bs svetimk\u016bniai (gali sukelti \u017earnos perforacij\u0105), didesni nei 6\u00a0cm ilgio ar 2\u00a0cm skersmens objektai (gali sukelti obstrukcij\u0105), maitinimo elementai (apval\u016bs\u00a0\u2013 sukelia cheminius nudegimus, pailgi\u00a0\u2013 gali sukelti obstrukcij\u0105) bei magnetai (jeigu praryta daugiau nei vienas) [38, 39]. Literat\u016broje apra\u0161yta atvej\u0173, kai vaikams, prarijusiems ma\u017eus apvalius magnetus, i\u0161sivyst\u0117 \u017earn\u0173 u\u017esisukimas ir \u017earnos perforacija. Pa\u017eeidimas \u012fvyksta, kai magnetai pritraukia vienas kit\u0105 per \u017earnos sienel\u0119. Pasirei\u0161kia pilvo skausmas ir kiti nespecifiniai simptomai [40, 41].<\/p>\n

Diabetin\u0117 ketoacidoz\u0117.<\/b> Tai gyvybei pavojinga b\u016bkl\u0117, pasirei\u0161kianti poliurija, polidipsija, svorio netekimu, gliukozurija. B\u016bdingas pilvo skausmas, pykinimas ir v\u0117mimas. Sunkiais atvejais gali b\u016bti psichikos sutrikim\u0173, Kussmaulio kv\u0117pavimas, dehidratacijos po\u017eymi\u0173 [42].<\/p>\n

Hirschprungo liga.<\/b> Tai \u012fgimtasis parasimpatini\u0173 nervini\u0173 ganglij\u0173 nebuvimas storosios \u017earnos sienel\u0117s nerviniuose rezginiuose, pasirei\u0161kiantis \u016bmia arba l\u0117tine storosios \u017earnos obstrukcija. Enterokolitas yra reta ir staigi Hirschprungo ligos komplikacija, pasirei\u0161kianti viduriavimu, kar\u0161\u010diavimu, pilvo skausmu [43]. \u012edomu tai, kad \u0161i komplikacija gali i\u0161sivystyti dar iki chirurgin\u0117s intervencijos, ankstyvuoju pooperaciniu periodu ar net pra\u0117jus daugiau nei 2 metams po pagrindin\u0117s operacijos [44\u201346].<\/p>\n

Pirminis bakterinis peritonitas.<\/b> Tai gyvybei pavojinga infekcin\u0117 nefrozinio sindromo ar kit\u0173 b\u016bkli\u0173, kurios sukelia ascit\u0105 (pvz., kepen\u0173 ciroz\u0117s), komplikacija. I\u0161sivys\u010dius \u0161ia komplikacijai, vaiko b\u016bkl\u0117 spar\u010diai blog\u0117ja, b\u016bdingas febrilus kar\u0161\u010diavimas, skausmingas ir i\u0161sip\u016bt\u0119s pilvas, \u012fsitemp\u0119 pilvo sienos raumenys, pilvapl\u0117v\u0117s dirginimo po\u017eymiai [47, 48].<\/p>\n

Miokarditas.<\/b> Pilvo skausmas gali i\u0161sivystyti d\u0117l miokardito sukelto \u0161irdies nepakankamumo ir nepakankamos vir\u0161kinimo sistemos perfuzijos [49].<\/p>\n

Da\u017enos pilvo skausmo prie\u017eastys<\/b><\/span><\/b><\/p>\n

Viduri\u0173 u\u017ekiet\u0117jimas.<\/b> U\u017ekiet\u0117jus viduriams, vaikams gali pasireik\u0161ti stiprus pilvo skausmas. Atlikto tyrimo duomenimis, 48\u00a0proc. vaik\u0173, tirt\u0173 pirmin\u0117s sveikatos prie\u017ei\u016bros \u012fstaigose d\u0117l \u016bmaus pilvo skausmo, diagnozuotas \u016bminis arba l\u0117tinis viduri\u0173 u\u017ekiet\u0117jimas ir tai buvo da\u017eniausia pilvo skausm\u0105 nul\u0117musi prie\u017eastis [50]. Viduri\u0173 u\u017ekiet\u0117jimo diagnoz\u0119 reik\u0117t\u0173 \u012ftarti vaikams, kuriems b\u016bdingi bent 2 i\u0161 \u0161i\u0173 po\u017eymi\u0173\u00a0\u2013 tu\u0161tinimasis ma\u017eiau nei 3 kartus per savait\u0119, i\u0161mat\u0173 nelaikymas, tiesioji \u017earna prisipild\u017eiusi kiet\u0173 i\u0161mat\u0173 ir tai patvirtina rektalinis digitalinis tyrimas (atliekamas retai) arba ap\u010diuopiamos i\u0161mat\u0173 mas\u0117s palpuojant pilv\u0105, \u00a0didel\u0117s mas\u0117s i\u0161matos, skausmas tu\u0161tinantis, tipi\u0161ka i\u0161mat\u0173 sulaikymo poza [50].<\/p>\n

Vir\u0161kinimo trakto infekcija<\/b>. Vaikams, sergantiems \u016bminiu gastroenteritu, gali pasireik\u0161ti kar\u0161\u010diavimas, v\u0117mimas, spazminis pilvo skausmas, pilvo jautrumas palpuojant dar prie\u0161 prasidedant viduriavimui [51]. \u012esid\u0117m\u0117tina, kad Yersinia enterocolitica<\/i> sukeltam gastroenteritui b\u016bdingas de\u0161iniojo apatinio pilvo kvadranto srities skausmas ir pilvapl\u0117v\u0117s dirginimo po\u017eymiai, kurie gali b\u016bti klini\u0161kai neatskiriami nuo apendicito [52].<\/p>\n

\u0160lapimo tak\u0173 infekcija.<\/b> 2\u20135 met\u0173 vaikams pilvo skausmas ir kar\u0161\u010diavimas yra da\u017eniausi simptomai, kuriais pasirei\u0161kia \u0161lapimo tak\u0173 infekcijos [53]. K\u016bdikiams gali pasireik\u0161ti v\u0117mimas, apetito stoka, o vyresniems nei 5 met\u0173 vaikams da\u017eniau pasitaiko tipiniai simptomai, tokie kaip dizurija, da\u017enas \u0161lapinimasis, \u0161ono skausmas [54].<\/p>\n

Faringitas.<\/b> Vaikai, sergantys faringitu, gali sk\u0173stis pilvo skausmu. I\u0161tyrus vaikus, kuriems \u012ftartas A grup\u0117s beta hemolizinio streptokoko (AGBHS) sukeltas faringitas, paai\u0161k\u0117jo, kad 25\u00a0proc. vaik\u0173, kuriems nustatytas \u0161is suk\u0117l\u0117jas, ir 34\u00a0proc. vaik\u0173, kuriems AGBHS nenustatytas, skund\u0117si pilvo skausmu [55].<\/p>\n

Pneumonija.<\/b> Vaikai, sergantys pneumonija (ypa\u010d apatini\u0173 skil\u010di\u0173), gali taip pat sk\u0173stis pilvo skausmu [56]. Kiti simptomai, leid\u017eiantys \u012ftarti pneumonijos diagnoz\u0119, da\u017eniausiai yra kar\u0161\u010diavimas, tachipn\u0117ja (i\u0161liekanti nukritus temperat\u016brai). Daugelis kit\u0173 pneumonijos klinikini\u0173 po\u017eymi\u0173, toki\u0173 kaip kosulys, auskultaciniai ir radiologiniai plau\u010di\u0173 poky\u010diai, gali i\u0161sivystyti v\u0117liau arba visai nei\u0161sivystyti, tod\u0117l j\u0173 nebuvimas pneumonijos diagnoz\u0117s nepaneigia [57].<\/p>\n

Dubens u\u017edegimin\u0117 liga (DUL).<\/b> Tai yra \u016bmi moteri\u0161k\u0173j\u0173 vir\u0161utini\u0173 lytini\u0173 tak\u0173 infekcija, galinti pasireik\u0161ti apatin\u0117s pilvo dalies skausmu. DUL sukeltas pilvo skausmas da\u017enai prasideda per m\u0117nesines ar i\u0161 karto po j\u0173. Taip pat gali varginti gausesn\u0117s i\u0161skyros i\u0161 mak\u0161ties, pacient\u0117 gali kar\u0161\u010diuoti [58]. Retais atvejais DUL gali sukelti gyvybei pavojing\u0173 b\u016bkli\u0173\u00a0\u2013 peritonit\u0105 ar tuboovarin\u012f absces\u0105 [59].<\/p>\n

Mezadenitas.<\/b> Tai \u017earn\u0173 pasaito limfmazgi\u0173 u\u017edegimas, kuris gali pasireik\u0161ti \u016bmiu ar l\u0117tiniu pilvo skausmu. \u0160ie limfmazgiai lokalizuojasi aplink bamb\u0105 ir de\u0161iniau jos, tod\u0117l klinikinis vaizdas gali b\u016bti pana\u0161us \u012f apendicito ar invaginato [60]. Atlikto tyrimo duomenimis, i\u0161tyrus 70 vaik\u0173, kuriems klini\u0161kai \u012ftartas \u016bminis apendicitas, paai\u0161k\u0117jo, kad 16 pacient\u0173 sirgo mezadenitu [61]. D\u0117l tobul\u0117jan\u010dios radiologin\u0117s diagnostikos mezadenitas nustatomas gerokai da\u017eniau. \u0160iai patologijai diagnozuoti naudojamas ultragarsinis tyrimas\u00a0\u2013 matomi padid\u0117j\u0119 pilvo limfmazgiai [60, 62]. Pa\u017eym\u0117tina, kad padid\u0117jusi\u0173 mezenterini\u0173 limfmazgi\u0173 nustatymas nepaneigia apendicito diagnoz\u0117s\u00a0\u2013 norint tai padaryti, reikia b\u016btinai vizualizuoti ir nepakitus\u012f apendiks\u0105 [63, 64]. Taip pat b\u016bdingas kar\u0161\u010diavimas, v\u0117mimas, tu\u0161tinimosi da\u017enio ir konsistencijos poky\u010diai [60]. Mezadenitu gali pasireik\u0161ti virusiniai ar bakteriniai gastroenteritai (pvz., Yersinia enterocolitica<\/i>), u\u017edegimin\u0117s \u017earn\u0173 ligos, limfoma. Mezadenitas da\u017eniau i\u0161sivysto sergant arba persirgus infekcine kv\u0117pavimo tak\u0173 liga [60]. Mezadenito sukeltas pilvo skausmas gali b\u016bti \u012fvairaus stiprumo. Paprastai jis praeina savaime per 1\u20134 savaites, ta\u010diau retais atvejais simptomai gali i\u0161likti net iki 10 savai\u010di\u0173 [64]. Jei simptomai i\u0161lieka ilgiau, kartu pasirei\u0161kia svorio kritimas ar kiti sisteminiai po\u017eymiai, rekomenduojamas i\u0161tyrimas d\u0117l u\u017edegimini\u0173 \u017earn\u0173 lig\u0173, tuberkulioz\u0117s ar onkologinio proceso.<\/p>\n

Ply\u0161usi kiau\u0161id\u0117s cista.<\/b> Skausmas, kil\u0119s ply\u0161us kiau\u0161id\u0117s cistai, gali b\u016bti labai pana\u0161us \u012f apendicito ar peritonito sukelt\u0105 skausm\u0105. Retais atvejais gali i\u0161sivystyti vidinis kraujavimas [65].
K\u016bdiki\u0173 pilvo diegliai.<\/b> K\u016bdikiai, kuriuos vargina pilvo diegliai, b\u016bna irzl\u016bs, neram\u016bs, verkia. Remiantis Veselio kriterijais, k\u016bdiki\u0173 pilvo dieglius galima diagnozuoti, jei tokie epizodai t\u0119siasi 3 ar daugiau valand\u0173 per dien\u0105, 3 ar daugiau dien\u0173 per savait\u0119 ir t\u0119siasi jau 3 ar daugiau savai\u010di\u0173 (trejet\u0173 taisykl\u0117) be ai\u0161kios prie\u017easties. Taip pat turi b\u016bti ekskliuduota organin\u0117 vir\u0161kinimo organ\u0173 patologija, i\u0161spr\u0119stos maitinimo problemos [66].<\/p>\n

Kitos prie\u017eastys<\/b><\/span><\/b><\/p>\n

Vir\u0161kinimo trakto prie\u017eastys<\/b><\/span><\/span><\/p>\n

U\u017edegimin\u0117s \u017earn\u0173 ligos.<\/b> U\u017edegimin\u0117s \u017earn\u0173 ligos (Crohno liga da\u017eniau nei opinis kolitas) gali pasireik\u0161ti epizodiniu pilvo skausmu. Kiti b\u016bdingi klasikiniai Crohno ligos simptomai yra viduriavimas ir svorio kritimas, o opinio kolito\u00a0\u2013 viduriavimas su krauju. Nors da\u017eniausiai opinis kolitas vaikams prasideda po\u016bme eiga, gali pasitaikyti ir sunki \u017eaibin\u0117 forma, kai b\u016bdingas \u016bmus pilvo skausmas, kraujingas viduriavimas, tenezmai ir sisteminiai po\u017eymiai (pvz., tachikardija)\u00a0[67, 68].
\u016aminis pankreatitas.<\/b> Pankreatitui b\u016bdingas \u016bminis vir\u0161utin\u0117s pilvo dalies skausmas, paprastai stipresnis epigastriumo ar de\u0161iniojo vir\u0161utinio pilvo kvadranto zonoje, da\u017enai iradijuojantis \u012f nugar\u0105. Neretai pasirei\u0161kia v\u0117mimas (gali b\u016bti su tul\u017eies priemai\u0161a) ir kar\u0161\u010diavimas. Da\u017eniausios pankreatito prie\u017eastys vaikams yra trauma, infekcija, strukt\u016brin\u0117s kasos anomalijos, kai kurie medikamentai (pvz., tetraciklinas, L-asparaginaz\u0117, valproin\u0117 r\u016bg\u0161tis, steroidai) [69, 70].<\/p>\n

\u016aminis cholecistitas.<\/b> \u016aminis cholecistitas pasirei\u0161kia skausmu de\u0161iniojo vir\u0161utinio pilvo kvadranto arba epigastriumo srityje. Skausmas gali iradijuoti \u012f pet\u012f ar nugar\u0105. Pacientai skund\u017eiasi apetito stoka, pykinimu, vemia [71]. Vaikams, skirtingai nuo suaugusi\u0173j\u0173, da\u017enesn\u0117 cholecistito forma be akmen\u0173 (tyrim\u0173 duomenimis, sudaro 50\u201370\u00a0proc. vis\u0173 atvej\u0173) [72]. Literat\u016broje apra\u0161yta, kad toks cholecistitas da\u017eniau i\u0161sivysto pacientams (vaikams ir suaugusiems), kurie serga terminalin\u0117mis b\u016bkl\u0117mis arba yra po operacijos. Vaikams b\u016bdinga ir tai, kad cholecistitas be akmen\u0173 da\u017eniau i\u0161sivysto sergant bakterij\u0173, parazit\u0173 ar virus\u0173 sukeltomis infekcin\u0117mis ligomis [72]. Kalkuliozinis cholecistitas vaikyst\u0117je pasirei\u0161kia re\u010diau ir yra siejamas su ligomis, kurioms b\u016bdinga hemoliz\u0117 arba enterohepatin\u0117s cirkuliacijos pa\u017eeidimas [72].<\/p>\n

Intraabdominalinis abscesas.<\/b> B\u016bdingas febrilus kar\u0161\u010diavimas, ankstesn\u0117 intraabdominalin\u0117 patologija arba pilvo operacija anamnez\u0117je [73].<\/p>\n

Mekelio divertikulas.<\/b> Mekelio divertikulas pasirei\u0161kia rektaliniu kraujavimu be skausmo. Kraujavimas paprastai i\u0161sivyto d\u0117l divertikule esan\u010dio ektopinio skrand\u017eio audinio produkuojamos r\u016bg\u0161ties sukeliamo gleivin\u0117s i\u0161op\u0117jimo [74]. Pilv\u0105 skauda jau pasirei\u0161kus Mekelio divertikulo komplikacijoms\u00a0\u2013 obstrukcijai, perforacijai, divertikulitui, invaginacijai [75]. Tyrim\u0173 duomenimis, 60\u00a0proc. vaik\u0173, kuriems kyla Mekelio divertikulo komplikacijos, yra jaunesni nei 2 met\u0173\u00a0[74].
Pilvo migrena.<\/b> Pilvo migrena (vienas periodini\u0173 vaikyst\u0117s sindrom\u0173) da\u017enai pasirei\u0161kia \u016bminiu periumbilikalin\u0117s srities arba difuziniu pilvo skausmu [76, 77]. \u0160i liga da\u017eniausiai diagnozuojama 3\u201310 met\u0173 vaikams. Skausmas da\u017enai yra stiprus, d\u0117l jo vaikai turi apriboti kasdien\u0119 veikl\u0105, kartu gali b\u016bti v\u0117mimas, galvos skausmas. Da\u017enai yra teigiama \u0161eimin\u0117 migrenos anamnez\u0117. Pilvo migrenos ataka trunka iki 72\u00a0val. ir epizodai paprastai pasikartoja bent kart\u0105 per 12 m\u0117nesi\u0173. Pirmasis epizodas turi b\u016bti kruop\u0161\u010diai diferencijuojamas su kitomis gastrointestinalin\u0117mis ir ne gastrointestinalin\u0117mis \u016bmaus pilvo sindromo prie\u017eastimis [76].<\/p>\n

Klajojanti arba prid\u0117tin\u0117 blu\u017enis.<\/b> Klajojanti (ektopin\u0117) blu\u017enis susidaro d\u0117l \u012fgytosios ar \u012fgimtosios pirmini\u0173 blu\u017enies rai\u0161\u010di\u0173 prisitvirtinimo patologijos [78]. D\u0117l to i\u0161sivysto per didelis blu\u017enies mobilumas ir dislokacija. Manoma, kad vaikams diagnozuojami klajojan\u010dios blu\u017enies atvejai yra i\u0161sivyst\u0119 d\u0117l \u012fgimtosios blu\u017enies rai\u0161\u010di\u0173 malformacijos ir yra siejami su pilvo sienos raumen\u0173 defektais, pavyzd\u017eiui, \u012fgimt\u0105ja diafragmos i\u0161var\u017ea, vadinamosios d\u017eiovintos slyvos pilvo (angl. <\/span>prune belly<\/em>) <\/span>sindromu. Simptomai pasirei\u0161kia tik i\u0161sivys\u010dius komplikacijoms, kuri\u0173 pagrindin\u0117 yra blu\u017enies apsisukimas ir d\u0117l to besivystantis blu\u017enies infarktas. Blu\u017enies apsisukimas, tyrim\u0173 duomenimis, stebimas apie 64\u00a0proc. vaik\u0173, kuriems b\u016bdinga klajojanti blu\u017enis. Pacientai gali jausti nestipr\u0173 intermituojan\u010dio pob\u016bd\u017eio pilvo skausm\u0105 d\u0117l blu\u017enies apsisukimo ir spontaninio atsik\u016brimo, o tipin\u0117 \u016bmaus pilvo klinika pasirei\u0161kia, jei d\u0117l apsisukimo pradeda vystytis blu\u017enies infarktas, tempiama blu\u017enies kapsul\u0117 [79]. Taip pat gali b\u016bti ap\u010diuopiamas darinys pilve, paprastai mobilus \u012f vir\u0161utin\u012f kair\u012fj\u012f pilvo kvadrant\u0105 [80].<\/em><\/p>\n

Prid\u0117tin\u0117 blu\u017enis i\u0161sivysto d\u0117l blu\u017enies element\u0173 susijungimo sutrikimo embriogenez\u0117s metu. Tyrim\u0173 duomenimis, prid\u0117tin\u0117 blu\u017enis b\u016bdinga 10\u201330\u00a0proc. \u017emoni\u0173 [81]. Prid\u0117tin\u0117 blu\u017enis simptom\u0173 nesukelia ir yra diagnozuojama atsitiktinai tiriant d\u0117l kitos patologijos, ta\u010diau jos apsisukimas ir d\u0117l to kylantis kraujotakos sutrikimas gali b\u016bti siejamas su \u016bmiu, \u016bmiu epizodiniu arba l\u0117tiniu pilvo skausmu [82].<\/p>\n

Ne vir\u0161kinimo trakto prie\u017eastys<\/b><\/span><\/b><\/p>\n

Imunoglobulino\u00a0A vaskulitas (Henocho-Schonleino purpura).<\/b> Tai sisteminis vaskulitas, pa\u017eeid\u017eiantis smulki\u0105sias odos, \u017earn\u0173, inkst\u0173 glomerul\u0173 kraujagysles. Da\u017eniausiai diagnozuojamas 2\u20136 met\u0173 vaikams. Difuzinis pilvo skausmas pasirei\u0161kia tada, kai jau matomas charakteringas purpuros tipo b\u0117rimas, dominuojantis apatini\u0173 gal\u016bni\u0173 ir s\u0117dmen\u0173 srityje. Atlikus i\u0161mat\u0173 tyrim\u0105, stebimas akimi matomas arba slaptas kraujavimas. Taip pat b\u016bdingas artritas arba artralgijos, inkst\u0173 pa\u017eeidimo simptomai. Kai kurios retos \u0161io vaskulito komplikacijos gali sukelti pilvo skausm\u0105 (pvz., invaginacija, pankreatitas) [83].<\/p>\n

\u0160lapimo tak\u0173 akmenlig\u0117.<\/b> Pilvo skausmas\u00a0\u2013 da\u017enas, ta\u010diau nespecifi\u0161kas \u0161lapimo tak\u0173 akmenlig\u0117s po\u017eymis ma\u017eiems vaikams. Vyresniems vaikams ir suaugusiesiems b\u016bdingesnis kolikos tipo skausmas \u0161ono srityje. Kiti da\u017enesni vaik\u0173 urolitiaz\u0117s po\u017eymiai yra hematurija ir \u0161lapimo tak\u0173 infekcijos simptomai [84].<\/p>\n

S\u0117klid\u0117s apsisukimas.<\/b> S\u0117klid\u0117s apsisukimas sukelia staig\u0173 ir stipr\u0173 kap\u0161elio srities skausm\u0105. Kartais s\u0117klid\u0117s apsisukimas i\u0161 prad\u017ei\u0173 gali pasireik\u0161ti pilvo skausmu, tod\u0117l berniukams visada reikia atlikti i\u0161sami\u0105 ap\u017ei\u016br\u0105. Pa\u017eeista s\u0117klid\u0117 paprastai yra skausminga, patinusi ir \u0161iek tiek pakilusi, nes d\u0117l apsisukimo sutrump\u0117ja vir\u017eelis. S\u0117klid\u0117 gali b\u016bti pasisukusi horizontaliai, prielipas taip pat dislokav\u0119sis i\u0161 normalios posterolateralin\u0117s pozicijos, i\u0161nyk\u0119s s\u0117klid\u0117s keliamojo raumens refleksas. Da\u017enai kartu b\u016bna pykinimas ir v\u0117mimas [85].<\/p>\n

Kiau\u0161id\u0117s apsisukimas.<\/b> Kiau\u0161id\u0117s apsisukimas da\u017eniausiai i\u0161sivysto esant patologi\u0161kai padid\u0117jusiai kiau\u0161idei d\u0117l kiau\u0161id\u0117s darinio ar cistos. D\u0117l apsisukimo sutrikdoma kiau\u0161id\u0117s kraujotaka ir gresia kiau\u0161id\u0117s nekroz\u0117 [86]. Da\u017enai kartu b\u016bna pykinimas ir v\u0117mimas [87].<\/p>\n

Intoksikacija<\/b>. Intoksikacijos \u0161vinu ar gele\u017eimi yra siejamos su pilvo skausmu. Apsinuodijimas \u0161vinu paprastai kyla d\u0117l l\u0117tinio \u0161vino patekimo \u012f vir\u0161kinimo trakt\u0105 ir sukelia pasikartojan\u010dius pilvo skausmus [88]. Apsinuodijimas gele\u017eimi paprastai yra \u016bminis per didelio gele\u017eies kiekio prarijimo padarinys ir pasirei\u0161kia v\u0117mimu, viduriavimu, kitais vir\u0161kinimo trakto pa\u017eeidimo simptomais [89].
\u0160eimin\u0117 Vidur\u017eemio j\u016bros kar\u0161tin\u0117 (\u0160VK).<\/b> Tai genetin\u0117 liga, apib\u016bdinama epizodiniu kar\u0161\u010diavimu, kuris t\u0119siasi 1\u20133 dienas. Kartu da\u017enai pasirei\u0161kia pilvo skausmas, pleuritas, artralgija ar artritas. Da\u017eniausiai serga \u017emon\u0117s, gyvenantys apie Vidur\u017eemio j\u016br\u0105 ir Vidurio Rytuose, t.\u00a0y. \u017eydai, turkai, arabai, arm\u0117nai. \u0160VK 90\u00a0proc. atvej\u0173 susergama iki 20 met\u0173. Nuolatinis u\u017edegimas gali paskatinti antrin\u0117s amiloidoz\u0117s i\u0161sivystym\u0105 [90].<\/p>\n

Apibendrinimas
<\/b>\u016amus pilvo skausmas\u00a0\u2013 viena da\u017eniausi\u0173 vaik\u0173 sveikatos problem\u0173. Da\u017eniausios vaik\u0173 \u016bmaus pilvo skausmo prie\u017eastys yra gyvybei nepavojingos ir ilgalaiki\u0173 sveikatos sutrikim\u0173 nesukelian\u010dios b\u016bkl\u0117s, tokios kaip viduri\u0173 u\u017ekiet\u0117jimas, vir\u0161kinimo trakto, \u0161lapimo tak\u0173 ir kit\u0173 lokalizacij\u0173 infekcijos, mezadenitas, k\u016bdiki\u0173 pilvo diegliai. Gydytojui svarbu kuo grei\u010diau identifikuoti pacientus, kuriems pilvo skausm\u0105 suk\u0117lusi prie\u017eastis yra sud\u0117tinga ar net gyvybei pavojinga b\u016bkl\u0117, kai reikia skubi\u0173 sprendim\u0173 d\u0117l gydymo taktikos (pvz., organ\u0173 pa\u017eeidimas d\u0117l traumos, apendicitas, \u017earn\u0173 invaginacija, \u012fstrigusi i\u0161var\u017ea ar kitos \u017earn\u0173 nepraeinamum\u0105 sukelian\u010dios prie\u017eastys, nekrotizuojantis enterokolitas, opalig\u0117s komplikacijos, pavojing\u0173 svetimk\u016bni\u0173 prarijimas). Tiriant pacient\u0105, svarbu \u017einoti, kokios patologijos yra tik\u0117tiniausios atsi\u017evelgiant \u012f jo am\u017eiaus grup\u0119, ta\u010diau nepamir\u0161ti ir retai pasitaikan\u010di\u0173 prie\u017eas\u010di\u0173.<\/span><\/p>\n

STRAIPSNIO AUTORIUS – <\/b>Viktorija Laukaitien\u0117<\/b><\/span><\/p>\n

Lietuvos sveikatos moksl\u0173 universiteto ligonin\u0117s Kauno klinik\u0173 Vaik\u0173 lig\u0173 klinika<\/b><\/span><\/b><\/span><\/p>\n

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      <\/p>\n

      <\/span><\/p>\n

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