Abdo pain + vomiting Flashcards Preview

MD 3: Paeds > Abdo pain + vomiting > Flashcards

Flashcards in Abdo pain + vomiting Deck (63):
1

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

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

2

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

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

3

What are the DDx for non-bilious vomit?

Most common causes are not surgical

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

Reflux, overfeeding

Pyloric stenosis

4

What are the DDx for bilious vomit?

Malrotation with volvulus until proven otherwise (grassy green)

5

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

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)

6

What are the clinical features of pyloric stenosis?

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

7

What are risk factors for pyloric stenosis?

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

8

Diagnosis of pyloric stenosis?

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)

9

How should pyloric stenosis be Ix?

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)

10

What are the DDx for pyloric stenosis?

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

11

What is the Rx for pyloric stenosis?

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

12

What is intussusception?

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

Usually in the distal ileum

Due to hyperplasia of gut lymphoid tissue

13

What are risk factors/associated factors of intussusception?

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

14

What are the clinical features of intussusception?

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

15

How do you diagnose intussusception?

Clinical diagnosis

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

16

What Ix can be considered for intussusception?

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

17

What is the Rx of intussusception?

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

18

What are the risk factors for inguinal hernia?

Prematurity - bilateral
Male
Fhx - high familial incidence

19

What is the most common type of inguinal hernia?

Indirect
Also most common cause of complications in inguinal hernia

20

What age group most likely associated with strangulated inguinal hernia?

What is the peak age of presentation for inguinal hernia?

<6 months for strangulation

Boys 3 months
More even spread across ages in females

21

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

The right side as the right testes descends later

22

What are the complication of strangulated/incarcerated inguinal hernia?

Obstruction
Ischaemia/infarction
Testicular ischaemia and atrophy

23

What is the typical presentation of strangulated inguinal hernia?

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

24

What is the treatment of inguinal hernia?

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

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