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MD 3: Paeds > Abdo pain + vomiting > Flashcards

Abdo pain + vomiting Flashcards

1
Q

Important features to ascertain on history for child presenting with abdo pain/vomiting?

A
  1. Age of child
  2. Location, onset, progression
  3. Vomit - bilious vs. non-bilious, blood/coffee grounds
  4. Associated features - infective, rash, resp symptoms, UTI, DKA features, migraine features, inguinoscrotal
  5. Context - travel, sick contacts
  6. PMHx - diabetes, hernia, migraine, surgery
  7. FHx - pyloric stenosis (maternal esp.), diabetes
  8. Adolescence - menstrual and sexual history - STI, ectopic pregnancy
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2
Q

Important features on examination of child presenting with abdo pain/vomiting?

A
  1. General - colour, posturing, well vs. unwell, rash, temp & vitals
  2. Abdo - masses (pyloric mass, faeces, distention), peritonitis, visible peristalsis
  3. Fluid assessment
  4. Inguinoscrotal - scrotal swelling, hernia
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3
Q

What are the DDx for non-bilious vomit?

A

Most common causes are not surgical

Infection - sepsis most common cause of vomiting in children. UTI, meningitis, gastro

Reflux, overfeeding

Pyloric stenosis

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4
Q

What are the DDx for bilious vomit?

A

Malrotation with volvulus until proven otherwise (grassy green)

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5
Q

What Ix to consider in child presenting with abdo pain/vomiting?

A

Urine - urinanalysis, MCS, ketones, glucose, pregnancy

Blood tests - B-hCG, FBE, U&Es, LFTs, lipase, acid-base/blood gas

Imaging - CXR - pneumonia, erect AXR - obstruction (not helpful in constipation or malrotation), U/S (pyloric stenosis, intersussception, malrotation)

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6
Q

What are the clinical features of pyloric stenosis?

A

Vomiting after soon after feeding in infants (peak age 2-6 weeks of age but rarely commencing >12 weeks)

Sudden onset, progressively more forceful in nature (projectile). Copious volume, milky and sometimes blood/coffee grounds (2o gastritis)

Non-bilious

Child appears well, hungry and wants to feed again after vomiting

Eventually leads to weight loss/poor weight gain and dehydration

Examination - signs of dehydration, abnormal growth chart, palpable pyloric mass/olive (RUQ), visible peristaltic waves, rarely jaundice

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7
Q

What are risk factors for pyloric stenosis?

A

Male (5:1)
Caucasian
FHx - esp. if maternal hx
First born

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8
Q

Diagnosis of pyloric stenosis?

A

Palpable pyloric mass (olive) in RUQ sufficient for clinical diagnosis and treatment/referral

If unsure/no palpable mass - U/S to confirm (95% sensitive, visualise thickened circular muscle of pylorus)

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9
Q

How should pyloric stenosis be Ix?

A

Bloods - FBE (exclude infection, anaemia), U&Es (hydration, hypochloraemia, hypokalaemia), LFTs (bilirubin)

Acid-base/ABG - metabolic alkalosis

Urinanalysis - paradoxical urine acidosis (compensatory to preserve Na)

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10
Q

What are the DDx for pyloric stenosis?

A

Cow’s milk protein intolerance - would expect blood in stools (colitis), hx cow’s milk consumption, cow’s milk protein/soy protein formula or high maternal consumption if BF

Obstruction

Reflux

Liver disease - i.e. biliary atresia

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11
Q

What is the Rx for pyloric stenosis?

A
  1. Early surgical referral
  2. Management of dehydration & electrolyte imbalance BEFORE surgery
    - NS + dextrose and add KCl once voiding if required
    - NBM +/- NGT on free drainage if continue to vomit
  3. Monitor - U&Es, acid-base (4-6 hourly) and adjust fluids as needed
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12
Q

What is intussusception?

A

Invagination/telescoping of the small bowel on it’s self

Usually in the distal ileum

Due to hyperplasia of gut lymphoid tissue

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13
Q

What are risk factors/associated factors of intussusception?

A 
Male 
Rotavirus vaccine (peyer's patch tissue enlargement)
Enteric infection - viral or bacterial
Polyps**
Meckel's diverticulum*
HSP
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14
Q

What are the clinical features of intussusception?

A

Peak age 5 -7 months, but consider in child 3 months - 2 years

Sudden onset of vomiting

Non-bilious vomit, but can become bilious as obstruction progresses - EARLY sign

A FEW lose stools initially, constipation later (LATE sign) - helps differentiate b/w gastro

During episodes of vomiting child is pale, floppy and hikes up legs

Appears anxious and pale

Red current jelly stools - LATE sign

Abdominal distention - LATE sign

Abdo pain - intermittent/colicky initially, can become constant, variable severity

Palpable sausage-shaped abdominal mass - typically RUQ but can be LUQ

~30% have hx of recent preceding URTI/flu-like symptoms

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15
Q

How do you diagnose intussusception?

A

Clinical diagnosis

Can confirm with U/S if unsure - highly sensitive & specific

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16
Q

What Ix can be considered for intussusception?

A

U/S - very good
AXR - not good, can appear normal
FBE - infection
U&Es - fluid status

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17
Q

What is the Rx of intussusception?

A
  1. Fluid resuscitation and warming first
  2. Aim to reduce obstruction:
    1st = gas enema
    2nd = barium contrast enema
    3rd = surgical reduction

Surgical reduction if gas enema fails or signs of necrosis/peritonitis

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18
Q

What are the risk factors for inguinal hernia?

A

Prematurity - bilateral
Male
Fhx - high familial incidence

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19
Q

What is the most common type of inguinal hernia?

A

Indirect

Also most common cause of complications in inguinal hernia

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20
Q

What age group most likely associated with strangulated inguinal hernia?

What is the peak age of presentation for inguinal hernia?

A

<6 months for strangulation

Boys 3 months
More even spread across ages in females

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21
Q

In boys, which is the most common side affected by inguinal hernia & why?

A

The right side as the right testes descends later

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22
Q

What are the complication of strangulated/incarcerated inguinal hernia?

A

Obstruction
Ischaemia/infarction
Testicular ischaemia and atrophy

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23
Q

What is the typical presentation of strangulated inguinal hernia?

A

Boy aged 3 months

Hx of intermittent non-painful groin bulge associated with irritability (i.e. noticed during nappy changes)

When strangulated - non-reducible, hard/tense, painful lump, not irreducible and no cough or cry impulse

Acute groin swelling

May have signs of peritonism if ischaemia

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24
Q

What is the treatment of inguinal hernia?

A

Reduce hernia (usually surgeon can) + analgesia and surgical management within 48 hours

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25
Q

What is Hirschsprung disease and what age does it present?

A

Congenital abnormality of the innervation of the colon

Presents in the first few days of life usually - 80% within 6 weeks

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26
Q

What is the presentation of Hirschsprung disease?

A

Failure to pass meconium (within 24hrs)
Marked but gradual abdominal distention
Bilious vomiting
Severe constipation

27
Q

What is the Ix and Rx of Hirschsprung disease?

A

Confirm diagnosis with rectal biopsy and exclude other surgical causes (i.e. obstruction)
Supportive management initially followed by surgical

28
Q

What are risk factors for Hirschsprung disease?

A

Male (4:1)

Down syndrome

29
Q

What is malrotation with volvulus?

A

Congenital abnormality of the hind gut which increases risk of twisting of mysentery and subsequent volvulus

9/10 will have no problems but 1/10 will have obstruction

30
Q

When does malrotation with volvulus most commonly present?

A

Typically within first week of life

Can occur during infancy and rarely >1 year

31
Q

What are the complications of malrotation?

A

Obstruction - ischaemia/infarction
intersussception
Recurrent obstruction

32
Q

What are common bowel symptoms <6 months?

A 
Painful poo (dyschezia) - strain or cry
Some may only pass stools once per week  
This is not constipation unless stools are small and hard
33
Q

What is the most common cause of constipation? What are other causes?

A

Functional most common - painful defecation leading to avoidance

If occuring <6 weeks this is a red flag
Hirschsprung 
Imperforate anus 
Obstruction 
Cows milk allergy 
Malabsorptive diseases
Hypothyroidism 
Hypocalcaemia
34
Q

What is the Rx of constipation?

A

1st = behavioural modifications (toilet sits, posturing, encouragement/+ve reinforcement) and diet

2nd = osmotic or softener laxatives (macrogol, lactulose, paraffin oil)

3rd (impaction) = higher dose macrogol with maintenance dosage (~6 months)

If < 6 months = coloxyl drops
If 6-12 months = coloxyl drops or lactulose

35
Q

What are the clinical features of constipation?

A

Altered stools - infrequent passing, small, hard stools
New onset faecal incontinence
Hx painful defecation
Palpable faeces in abdomen

36
Q

What is Meckel’s diverticulum?

A

Failure of the closure of an omental duct

37
Q

What are the complications of Meckel’s diverticulum? What age are they most common?

A

Intusussception
Diverticulitis
Perforation
Obstruction

<2 years complications more common

38
Q

What is the clinical presentation of Meckel’s diverticulum?

A

usually asymptomatic
Rarely PR bleeding
Later abdominal pain
May present with complications

39
Q

What are the clinical features of malrotation with volvulus?

A

Bilious vomit - grassy green (main symptom)

Usually no other clinical findings - abdominal distention may occur later

40
Q

What are the Ix and Rx of malrotation with volvulus?

A

Upper GI contrast study to confirm diagnosis - C shape is normal and S-shape is volvulus
U/S can be helpful
AXR not usually helpful

Rx = surgical reversal of volvulus + appendix removal (to exclude as DDx with future abdo pain presentations)

41
Q

What is the Ix and Rx of Meckel’s diverticulum?

A

Meckel’s (technetium) scan to confirm diagnosis

Surgical resection in symptomatic

42
Q

What are the diagnostic difficulties in appendicitis in kids?

A

Difficult to diagnose in children <5 years

They present atypically - usually minimal vomiting, diarrhoea, diffuse abdominal pain

43
Q

What ages does appendicitis most commonly occur?

A

More common in school age + children than <5 years

44
Q

What are the general clinical features?

A

Absent or low fever
Vomiting ++
+/- some lose stools
Localised abdo pain - McBurney’s point tenderness

45
Q

What are the examination considerations in appendicitis in kids?

A

Rebound tenderness should not be performed - cruel + unreliable sign in kids

Should give analgesia prior to examining

Most reliable clinical sign = local tenderness with some rigidity over McBurney’s point

46
Q

How do <5 with appendicitis more commonly present?

A

Atypical presentation - no/minimal vomiting and abdo pain, diffuse abdo pain, diarrhoea

With complications - perforation, sepsis

47
Q

What are the Ix and Rx for appendicitis?

A 
Urine - exclude UTI 
U/S - thickened appendix, free fluid surrounding 
Analgesia 
Prophylactic antibiotics
Surgical removal
48
Q

What is mesenteric adenititis?

A

Inflammation of the mesenteric lymph nodes

49
Q

What ages does mesenteric adenititis most commonly occur?

A

Very common in school aged children

Peak in 10 - 12 years

50
Q

What are the causes of mesenteric adenititis?

A

Gastroenteritis - bacterial or viral

Most commonly viral

51
Q

What are the clinical features of mesenteric adenititis?

A

Mimics appendicitis - often RIF pain as this is location of LNs
Pain can be variable

Very high fever - main clinical differentiating factor with appendicitis

Guarding rarely present

52
Q

What are the Ix and Rx for mesenteric adenititis?

A

U/S to exclude appendicitis and other surgical causes - LNs >10 mm and normal appendix

Supportive management - analgesia, rest, fluids and antibiotics if suspect bacterial gastro

53
Q

What is HSP?

A

Small vessel vasculitis

54
Q

What ages does HSP typically occur?

A

Peak presenting age 2 - 8 years

Relatively common

55
Q

What is the typical clinical presentation of HSP?

A

Classic triad - abdominal pain, joint pain followed by non-blanching purpuric rash

May have been preceeded by URTI

Other symptoms less common - PR bleeding

56
Q

What are the complications of HSP?

A

Abdominal - intusussception most common

Renal - haematuria and HTN - similar histology to IgA nephropathy

57
Q

What are examination findings of HSP?

A

HTN - renal complications
Urinanalysis - haematuria - renal complications
Acute scrotal swelling
Painful subcutaneous oedema

58
Q

What are other DDx for HSP?

A

Rash - meningoccocal disease, ITP, trauma, viral, leukaemia

Abdo pain/scrotal swelling - testicular pathology

59
Q

What are the Ix and Rx for HSP?

A

Exclude other DDx rash and abdo pain

Urinanalysis and consider FBE, U&Es, blood culture

Admission - monitor urine and blood pressure
Supportive
Consider prednisolone - reduces duration and risk of abdo complications but not renal complications

60
Q

What DDx for abdo pain/vomiting should be considered in neonates & infants?

A 
Pyloric stenosis
Hirshsprungs disease
Malrotation with volvus 
Intusussception 
Incarcerated hernia 
Meckel's diveriticulum
UTI

Gastro, viral illness

61
Q

What DDx for abdo pain/vomiting should be considered in pre-school age children?

A 
Constipation 
Malrotation 
Intusussception 
UTI
Pneumonia 
Appendicitis
HSP
Testicular torsion
62
Q

What DDx for abdo pain/vomiting should be considered in school aged children?

A 
Mesenteric adenitis 
Appendicitis 
Constipation
UTI
Pneumonia 
Testicular torsion 
Ovarian pathology 
HSP 
DKA 
Migraine
63
Q

What additional DDx should be considered for abdo pain/vomiting in adolescents?

A 
Ectopic pregnancy 
STI 
Biliary 
Pancreatic 
Renal calculi 
DKA

MD 3: Paeds (15 decks)

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