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Flashcards in Abdominal pain Deck (35):
1

Key components of GIT history overview

Nutrition
Vomiting
Bowel habits
Pain
Family history
GU symptoms

2

History of nutrition (11)

Infant feeding patterns- duration of breast feeding
Any breast feeding problems
Key professional support for breast feeding
If formula fed- type and volume
Review intake- typical is 150ml/kg/24 hours
Age at weaning to semi solids, any choking problems, foods taken
Detail what the child eats in a typical day
Review calorie intake and nutritional balance
Level of appetite and difficult feeding behaviours
Pattern of weight gain
Review parent hand held health record

3

Volume of one fluid oz to ml

one fluid oz is 28 ml

4

Typical infant intake of milk

100-150ml/kg/24 hours

5

History of vomiting

Vomiting frequency and colour

6

What does green, posseting, blood in vomit of small and older children

Green= bile
Posseting= vomiting milk
Blood in vomit of infant->maternal blood in milk
In older children blood may suggest esophageal bleeding due to vomiting

7

History of bowel habits

Feces->frequency, consistency, colour, mucus, blood, greasy
Diarrhea->frequency, urgency, consistency, blood, link with diet
Meconium passed
Age of potty training
Constipation->straining, pain, reduced frequency, hard faeces
Soiling of faeces in underwear
Encopresis

8

In newborns when should meconium be passed

Within the first 24 hours

9

What is encopresis

Behavioural problem of passing faeces in inappropriate places

10

Components of abdominal examination

Observation
Palpation
Percussion
Auscultation
Genitalia and anus
Rectal examination

11

Observation

Child should be relaxed
Assess nutritional status->percentiles, BMI, HC, AC
Jaundice
Pallor
Abdominal distension
Wasting of buttocks

12

Organs to be palpated on abdominal examination

Liver
Spleen
Kidneys

13

What is to be examined for on genitals in boys

Hypospadias
Epispadias
Undescended testes
Hydrocele
Hernia

14

Causes of acute abdominal pain in neonates

Hirschprung's enterocolitis
Incarcerated hernia
Intussusception
Irritable/unsettled infant
Meckel's diverticulum
UTI
Volvulus

15

Causes of acute abdominal pain in infants and preschool

Appendicitis
Gastroenteritis
Intussusception
Pneumonia
UTI
Volvulus
Constipation

16

Causes of acute abdominal pain in school aged children

Appendicitis
Gastroenteritis
DKA
Henoch-schnolein purpura
Mesenteric adenitis
Migraine
Ovarian pathology
Pneumonia
Constipation
Testicular torsion
UTI
Viral illness

17

Causes of acute abdominal pain in adolescents

Appendicitis
DKA
Ectopic
Cholecystitis
Gastroenteritis
IBD
Ovarian cyst torsion/rupture
Pancreatitis
Pelvic inflammatory disease
Renal calculi
Testicular torsion
UTI
Viral illness

18

History in acute abdomen

SOCRATES
Billous vomiting->obstruction
Pallor and lethargy->intussusception
Rash and purpura on extensor surfaces->HSP
Cough and fever->pneumonia
Dysuria and frequency->UTI
Polyuria polydipsia, loss of weight->DKA
Menstural history in post pubertal->ectopic, torsion
Loss of appetite
Blood in stool

Past medical history
-Hirschsprungs, CF complicated by enterocolitis->sudden painful abdominal distension and bloody diarrhea
-Primary bacterial peritonitis->liver disease, nephrotic syndrome, splenectomy, ascites, VP shunt.
-Pancreatitis->chemotherapy, immunosuppressants
-IBD->toxic megacolon

19

What should you suspect when acute onset of pain

Testicular/ovarian torsion
Intussusception
Perforated viscus

20

What should you suspect with episodic severe pain

Intussusception
Mesenteric adenitis
Gastroenteritis
Constipation

21

Important associated features

Billous vomiting
Pallor and lethargy
Rash and purpura on extensor surfaces
Cough and fever
Dysuria and frequency
Polyuria polydipsia, loss of weight
Menstural history in post pubertal

22

Examination in acute abdomen

Assess hydration
Assess overt signs of peritonism: not moving, not walking comfortably, tender to percussioin
Examine the abdomen
Respiratory examination
Inguinoscrotal examination
Rectal/vaginal examination avoided in children

23

Investigations that may be required in acute abdomen

FBC
Urine MCS
Glucose
UEC
LFTs
Lipase
Urine bHCG

Imaging:
AXR if obstruction suspected, dilated=obstruction, abnormal gas in intussusception, fecal loading in constipation
CXR if pneumonia suspected
USS->discuss with senior, renal tract abnormals

24

Acute management of acute abdomen

ABC
Early referral if surgery likelye
Fluid resuscitation
IV/IO access
Measure UEC and glucose if appear deH
NBM
Analgesia- morphnine/fentanyl may be required
NGT if BO suspected
IV antibiotics in surgical

25

D/C advise following acute abdomen

Many can be d/c after good H/E/urine
Clear f/u plan, with GP

26

Conditions which may present with recurrent abdominal pain only

Inflammatory bowel disease
Chronic urine infections
Parasites

27

Management of "recurrent abdominal pain"- as functional problem

Assure parents no major illness
Cause is unknown, pain is very real
Do not communicate to the parent that the child is malingering
Identify those signs and symptoms to watch for and which would suggest need for re-evaluation
Develop a schedule for re-visits to monitor symptoms. Have family keep a diary of pain episodes and related symptoms
During return visits, allow patient and parents to express concerns and stresses
Make every effort to normalise the life of the child, encourage attendance and participation in activities
Liase with school to ensure attendance

28

Psychogenic abdominal pain

Psychosomatic->related to stress at home/school
Assure parents of no major illness
Link pain with the stresses

29

Causes of recurrent abdominal pain

Idiopathic recurrent abdominal pain
Hepatic->hepatitis
Pancreatic->pancreatitis

GIT:
IBS
Esophagitis
Peptic ulcer
IBD
Constipationn
Malabsorption
Giardia
Celiac

UTI
Psychogeni, abdominal migraine, sickle cell

Gynaecological:
Dysmenorrhea
PID
Hematocolpos
Ovarian cyst

30

History in recurrent abdominal pain

SOCRATES
Affect daily activities
Constitutional symptoms/red flags->vomiting, diarrhea, weight loss, lethargy
GIT, GU, gynaecological symptoms
Psychosocial history
School

Must ask parents if they are specifically concerned that their child has a serious disease not being investigated/being missed

31

Examination in recurrent abdominal pain

Growth->++percentile
General examination: jaundice, palor, deficiencies
Abdominal examination
Anorectal->not routine

32

Investigations and significance in chronic abdominal pain->if suspect organic cause

Bloods:
FBC->anemia, eosinophils, infection
CRP->add stool test for H pylori antigen
LFTs
Celiac screen
UEC
Amylase

Urinalysis and culture
Stool for OCP
Occult blood

Imaging:
Abdominal and pelvic USS: urinary obstruction, organomegaly, abscess, pregnancy, cyst/torsion
AXR: constipation, renal calculi, lead poisening
Barium swallow->esophagitis, GORD, peptic ulcer, crohns, congenital malformations

Endoscopy: esphagitis, reflux, peptic ulcer, IBD

33

Red flags in abdominal pain

 Pain not confined to periumbilical area (the further the
pain is from the umbilicus the less likely it is to be
functional).
 Pain at night / waking from sleep
 Change in bowel habit or blood in the stools
 Vomiting
 Intermittent fever
 Weight loss
 Lethargy
 Poor growth
 Involvement of other system e.g. rash, joint pain
 Anaemia or raised acute phase reactants

34

Information to gain re school

School:
 Academic progress, any change?
 Peer relationships: does he have a good friend, any change in friends?
 Is there bullying at his school?
 Does he feel mostly happy or sad?
 How would he rate his mood on a scale of 1 – 10 where 1 is very happy and 10 is very sad

35

Abdominal masses in children

Common abdominal masses in children include faecal masses, neuroblastoma, nephroblastoma (Wilm's tumour) and lymphoma.

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