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MD 3: Paeds > Abdo pain + vomiting > Flashcards

Abdo pain + vomiting Flashcards

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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
What is Hirschsprung disease and what age does it present?
Congenital abnormality of the innervation of the colon Presents in the first few days of life usually - 80% within 6 weeks
26
What is the presentation of Hirschsprung disease?
Failure to pass meconium (within 24hrs) Marked but gradual abdominal distention Bilious vomiting Severe constipation
27
What is the Ix and Rx of Hirschsprung disease?
Confirm diagnosis with rectal biopsy and exclude other surgical causes (i.e. obstruction) Supportive management initially followed by surgical
28
What are risk factors for Hirschsprung disease?
Male (4:1) | Down syndrome
29
What is malrotation with volvulus?
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
When does malrotation with volvulus most commonly present?
Typically within first week of life | Can occur during infancy and rarely >1 year
31
What are the complications of malrotation?
Obstruction - ischaemia/infarction intersussception Recurrent obstruction
32
What are common bowel symptoms <6 months?
``` 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
What is the most common cause of constipation? What are other causes?
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
What is the Rx of constipation?
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
What are the clinical features of constipation?
Altered stools - infrequent passing, small, hard stools New onset faecal incontinence Hx painful defecation Palpable faeces in abdomen
36
What is Meckel's diverticulum?
Failure of the closure of an omental duct
37
What are the complications of Meckel's diverticulum? What age are they most common?
Intusussception Diverticulitis Perforation Obstruction <2 years complications more common
38
What is the clinical presentation of Meckel's diverticulum?
usually asymptomatic Rarely PR bleeding Later abdominal pain May present with complications
39
What are the clinical features of malrotation with volvulus?
Bilious vomit - grassy green (main symptom) | Usually no other clinical findings - abdominal distention may occur later
40
What are the Ix and Rx of malrotation with volvulus?
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
What is the Ix and Rx of Meckel's diverticulum?
Meckel's (technetium) scan to confirm diagnosis | Surgical resection in symptomatic
42
What are the diagnostic difficulties in appendicitis in kids?
Difficult to diagnose in children <5 years | They present atypically - usually minimal vomiting, diarrhoea, diffuse abdominal pain
43
What ages does appendicitis most commonly occur?
More common in school age + children than <5 years
44
What are the general clinical features?
Absent or low fever Vomiting ++ +/- some lose stools Localised abdo pain - McBurney's point tenderness
45
What are the examination considerations in appendicitis in kids?
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
How do <5 with appendicitis more commonly present?
Atypical presentation - no/minimal vomiting and abdo pain, diffuse abdo pain, diarrhoea With complications - perforation, sepsis
47
What are the Ix and Rx for appendicitis?
``` Urine - exclude UTI U/S - thickened appendix, free fluid surrounding Analgesia Prophylactic antibiotics Surgical removal ```
48
What is mesenteric adenititis?
Inflammation of the mesenteric lymph nodes
49
What ages does mesenteric adenititis most commonly occur?
Very common in school aged children | Peak in 10 - 12 years
50
What are the causes of mesenteric adenititis?
Gastroenteritis - bacterial or viral | Most commonly viral
51
What are the clinical features of mesenteric adenititis?
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
What are the Ix and Rx for mesenteric adenititis?
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
What is HSP?
Small vessel vasculitis
54
What ages does HSP typically occur?
Peak presenting age 2 - 8 years | Relatively common
55
What is the typical clinical presentation of HSP?
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
What are the complications of HSP?
Abdominal - intusussception most common | Renal - haematuria and HTN - similar histology to IgA nephropathy
57
What are examination findings of HSP?
HTN - renal complications Urinanalysis - haematuria - renal complications Acute scrotal swelling Painful subcutaneous oedema
58
What are other DDx for HSP?
Rash - meningoccocal disease, ITP, trauma, viral, leukaemia Abdo pain/scrotal swelling - testicular pathology
59
What are the Ix and Rx for HSP?
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
What DDx for abdo pain/vomiting should be considered in neonates & infants?
``` Pyloric stenosis Hirshsprungs disease Malrotation with volvus Intusussception Incarcerated hernia Meckel's diveriticulum UTI ``` Gastro, viral illness
61
What DDx for abdo pain/vomiting should be considered in pre-school age children?
``` Constipation Malrotation Intusussception UTI Pneumonia Appendicitis HSP Testicular torsion ```
62
What DDx for abdo pain/vomiting should be considered in school aged children?
``` Mesenteric adenitis Appendicitis Constipation UTI Pneumonia Testicular torsion Ovarian pathology HSP DKA Migraine ```
63
What additional DDx should be considered for abdo pain/vomiting in adolescents?
``` Ectopic pregnancy STI Biliary Pancreatic Renal calculi DKA ```

MD 3: Paeds (15 decks)

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