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Flashcards in Abdominal pain Deck (66):
1

Causes of acute abdominal pain in infantsand children

GIT - Gastroenteritis, Appendicitis, Meckel's diverticulum, Mesenteric adenitis, Ileus, Intestinal obstruction (Incarcerated hernia, intussusception, volvulus), Malabsorption, IBS, Constipation.
Hepatobillary tract - Cholecystitis, Pancreatitis
Genitourinary -UTI, Nephrolithiasis, testicular torsion, Ovarian torsion, ectopic pregnancy, PID, Endometriosis Menstruation.
Hematologic - Henoch-Schonlein Purpura, Sickle cell crisis
Other - DKA, pneumonia, somatisation.

2

Important questions to ask on history for acute abdomen pain

Description of pain
Relations to meals
Associated sysmtpoms
Nausea, vomiting, diarrhoea, fever.

3

What to look for on examination of acute abdomen pain

Abdominal exam , peritoneal signs, bowel sounds, rectal exam, rash.

4

Ix for acute abdominal pain

FBC, Differential, urinalysis to rule out UTI.

5

Most common cause of acute abdomen in children

Appendicitis

6

Clinical features of appendicitis

Low grade fever
Abdominal pain
Anorexia
N/V after onset of pain
Peritoneal signs - generalised peritonitis is common in infants and young children.

7

Who get Intussusception

CF or gastrojejunostomy
Children between 3 months to 2 yrs.

8

Clinical features of intussusception

Classic triad (abdo pain, palpable mass(Sausage shape), red current jelly)
Sudden onset of recurrent , paroxysmal, severe periumbilical pain with pain-free intervals (episodic screaming)
Later vomiting may be bilious
Rectal bleeding (late
Shock and dehydration

9

Dx of intussusception

US, air enema

10

Tx of Intussusception

Air enema or surgery

11

Clinical features of gastroenteritis

diarrhoea with or without vomiting or cramping abdominal pain
Check dehydration level

12

Red flags for abdominal symptoms

Severe abdominal pain or abdominal signs
Persistent diarrhoea >10 d
Blood in stool
Very unwell appearance
Billions vomit
vomiting without diarrhoea

13

Ix for gastroenteritis

None unless the following
Stool sample if >7 days, suspect septicaemia, blood or mucus or immunocompromised
Blood test if - Severe dehydration, renal disease, ALOC, Hypernataemia, Profuse or prolonged losses, ileostomy.

14

Mx of gastroenteritis

Simple cases - Oral rehydration
Shocked - resus
discuss with consultant
No/Mild dehydration - Trail of fluids, advice, arrange follow up and D/C
Moderate dehydration - trail of fluids, NGT if needed
ORS = 10-20mls/kg over 1hour. NGTR Rapid 25l/kg/hr for 4 hours. Slower if

15

How to calculate fluids

Maintenance = 4:2:1 upper limit is 100ml/hr
Deficit = % of dehydration X wt x 10
Ongoing loss

16

Define chronic abdominal pain

3 episodes of severe pain
Child >3yr old
Over 3 month period

17

Red flags for chronic or recurrent abdominal pain

Any of the following make functional chronic or recurrent abdominal pain unlikely
- Pain not confined to periumbilical area
- Pain at night/waking from sleep
- Change in bowel habit or blood in stool
- vomiting
- Intermittent fever
- Wt loss
- lethargy
- poor growth
- Involvement of other system e.g. rash, joint pain
- Anaemia or raised acute phase reactants

18

DDX of chronic abdominal pain

Organic (105)
GIT - constipation, IBD, esophitis, peptic ulcer disease, lactose intolerance, anatomic anomalies, masses,Pancreatic, oesophagitis, IBS, Malabsorption, Giardiasis
hepatobiliary- hepatitis
Genitourinary - recurrent urinary tract infection, nephrolitiasis, chronic PID, Mittelschmerz, dysmenorrhoea, ovarian cysts,
Neoplastic
Abdominal migraine
Sickle cell disease
Non Organic - Function recurrent abdominal pain

19

Clinical features of function/recurrent abdominal pain

Clustering episodes of vague, crapy periubilical/epigastric pain, vivid pain description.
Seldom, awakens child from sleep, less common on weekends
aggravated by exercise, alleviated by rest
Psychological factors related to onset and or maintenance of pain, school avoidance
Psychiatric coorbidity - anxiety, somatoform, mood, learning disorder, sexual abuse, eating disorders, elimination disorders
Diagnosis of exclusion

20

Ix for function/recurrent abdominal pain

FBC, ESR, urinalysis, stools for O&P, Occult blood.

21

Mx for function/recurrent abdominal pain

Continue to attend to school
Manage any emotional or family problems, counselling
Trail of high fibre diet, trail of lactose free diet
Reassurance that it is real but not pathological problem
Education on red flags
Follow up - for review and expression of stresses

Prognosis - resolves in 30-50% of kids 2-6 wks after dx. 30-50% have functional pain as adults e.g. IBS.

22

who get appendicitis

commonest in post pubertal,
uncommon in under 5 yr

23

Clinical features of appendicitis

Periumbilical pain that become localised over RLQ when peritoneum becomes involved
lay very still
worse on movement
Nausea
Vomiting - bile stained
anorexia
Tachycardia
constipation
occasional diarrhoea & vomiting
low grade fever

24

Ix for appendicitis

leucocytosis
Neutrophilic
Urine to exclude infection
USS if unsure of Dx

25

DDX for pain in Iliac fossa

mesenteric adenitis
Gastroenteritis
Constipation
Urinary tract infection
Hence-schonlein purpura
Inflammatory bowel disease
Ovarian pain
Ectopic pregnancy
Pyelonephritis

26

Mx of appendicitis

Appendicectomy
Laparoscopically
Excellent prognosis
Perforation is commoner in children
If peritonitis = severe illness and adhesions may lead to bowel obstruction.
Other
Resus
IV
Blood - G&H, cross hold, FBC, U&E, CRP, B
Fluid bolus
Antibiotics - cefuroxime, metronidazole
Hx
Reassess - ABC and vital signs
Examination
Reassess
Ix - Abdo Xray - stones, SBO or servere constipation.
Urinalysis +/- microscopy
RBC/CRP/UE/BCs
USS -
Reassess
surgery
refer to paediatric surgery for Appendicectomy Laparoscopically

27

Cause of intussusception

Enlarged lymphatic may form the leading edge of the intussusception. This is often following a viral infection.
Adenovirus or rotavirus
Very rarely due to pathological lesion such as polyp or lymphoma or complication of HSP.

28

Ix of intussusception

AXR - rounded edge of intussusception against gas filled lumen of the distal bowel with signs of proximal bowel obstruction
USS - Doughnut sign

29

Presentation of Inflammatory bowel disease

Blood/mucus in stools
Family Hx of diarrhoea
Wt less and poor growth

30

Presentation of Mesenteric adenitis

Recent viral infection
No peritonism or guarding
Pain can mimic appendicitis

31

Presentation of peptic ulcer

Pain at night
Relief with milk
Think Helicobacterpylori

32

Prevention intestinal obstruction

Bile stained vomiting
Abdominal distension
Consider a volvulus

33

Presentation of constipation

Hard or infrequent stools
Mass in left iliac fossa
Faecal loading on radiograph

34

Presentation of UTI

Dysuria, frequency
Bedwetting
Back pain
vomiting
Evidence of infection on urinalysis or microscopy.

35

Presentation of Henoch-Schonlein purpura

palpable purpuric rash on lower half of body (buttocks and extensor surfaces). disappears on pressure, due to signifying intradermal bleeding
- Joint pain and Arthritis - Usually main compliant and most pain resolves in 24-48 hrs.
+/-Swelling - eg scrotum, hands, feet and sacrum - can be very painful.
Abdominal pain due to GI vasculitis risk of +/- intussusception. Blood in stool and acute abdomen
If uncomplicated - resolves spontaneously 72 hr
Complications - intussusception, blood stools, haematemesis, spontaneous bowel perforation, pancreatitis
Renal
+/- Glomerulonephritis
haematuria (90%),
Less common proteinuria, hypertension, nephrotic syndrome and rarely Renal failure
Can present as abdominal pain or arthralgia before rash.
Commonly 2-8 yrs
Hx of URTI

36

Mx of Henoch schonlein purpura

Consult senior staff
Steroids helpful in abdominal & joint pain - prednisolone 1mg/kg
Look for complications e.g. Intussusception, Perforation, pancreatitis, stone,
Admit if Cx presentation or severe pain from joint, abdomen or subcutaneous oedema.
when DC follow up with GP for BP and urine
Education - on need for follow up and rash being the last to go. Worsen in child is active.

37

DDX for blood in stools

Intussusception
inflammatory bowel disease
Henoch Schonlein purpura
Some types of gastroenteritis.

38

Surgical causes of abdominal pain

Acute appendicitis
Intussusception
Ovarian cysts
Volvulus
Renal, ureteric and biliary stones

39

Non surgical causes of abdominal pain

Gastroenteritis - common, colicky, V&D
PID
Ectopic
UTI
DKA
Lower lobe pneumonia
Henoch Schonlein purpura
Anxiety
Mesenteric adenitis

40

Mx of mesenteric adenitis

Diagnosis of exclusion
tx if simple analgesia

41

Hx and Examination finding for chronic abdominal pain

Hx
where it is worse
when it is worse
Does the pain affect daily activities
Constitutional symptoms - wt loss, anorexia, fever
emotional, anxiety or daily problem
Ex
Growth - wt loss or fall off in growth indicated serious pathology
GI - look for pallor, jaundice and clubbing
Abdo - hepatomegaly, splenomegaly, enlarged kidneys or distended bladder.
PR - not routine in children.

42

Presentation of IBS

functional condition associated with recurrent abode pain and minor GI symptoms such as bloating and altered bowel habit e.g. ranging from pellets to unformed stools. Gas.
Hx of colic as infant.
Acute symptoms resolve with time but relapse occur.
Red flags are change in symptoms e.g. wt loss, bleeding or anaemia

43

Tx of IBS

Reassurance
Diet education
Low FODMAP
Smooth muscle relaxants eg mebeverine for spasms

44

Presentation of gastritis and peptic ulcer

epigastric pain
Relieved by food
May be family hx
ALARM Symptoms:
A – anorexia
L – loss of weight
A – anemia
R – recent onset/ progressive symptoms
M – melaena/ haematemesis
S – swallowing difficulty

45

Work up and Mx for peptic ulcer

Ix - stool examination for helicobacter antigen, Hydrogen breath test or endoscopy
H2 receptor eg ranitidine
PPI eg ezomerprazole
Helicobactor pylori
- PPI - Ezomerprazole
- ABx - Amoxicillin, clarithroycin

46

Causes of constipation

Idiopathic
- Fluid depletion
- low fibre diet
- lack of mobility & exercise
Gastrointestinal
- Hirschsprung's disease
- anal disease - infection, stenosis, ectopic, fissure, hypertonic sphincter)
- Bowel obstruction
- food hypersensitivity
- Coeliac disease
Non-gastrointestinal
- Hypothyroidism
- Hypercalcaemia
- Neurological disease e.g. spinal disease
- Chronic dehydration eg diabetes insipidus
- Drugs e.g. opiate and anticholinergics
- sexual abuse

47

Clinical features of constipation

Infrequent stool

48

Mx of constipation

Short term
- soften retained stool e.g. movicol
- Colonic stimulant eg Senna.
Continue until bowel pattern regular and then decrease
Long term
- Soften retained stool for at least a week
- Oral colonic stimulant eg senna
- if failure then try oral bowel evacuation preparation, enema, manual evacuation under general sedation
Maintenance tx
- Increase dietary fibre and fluid
- Regular bulk laxative
- Reg colonic stimulant
- Persist with medication for at least 6 months.
- Behaviour management - establish toilet routine
- Assessment by a clinical psychologist and therapist if there is a degree of family discord

49

Presentation of Hirschprung's disease

in newborn period with delayed passage of meconium and abdominal distention.
If only small segment then may present later with constipation and FTT.
Commoner in boys then girl
Dx by barium enema and then rectal biopsy
Mx resection of abnormal section of bowel.

50

risk factors for constipation

Diet - not drinking enough fluid or high fibre foods
Holding of stools - e.g. not liking public toilet
Change in routine - e.g. holiday, moving house, or school or even changing of formula
Lack of exercise
Genetic
Medication eg codeine, cough medicine, some anticonvulsants, antihistamines.

51

how to differentiate organic causes of abdominal pain to non organic causes

Non organic - periodic pain with intervening good health, often periumbilical, may be related to school hours
Organic pain- pain occurring at night, wt loss, reduced appetite, lack of energy, recurrent fever, organ-specific symptoms e.g. change in bowel habit, polyuria, menstrual problems, vomiting, occult or frank bleeding
Ill appearance, growth failure, swollen joint.

52

how to calculate likelihood of appendicitis

Alvarado score uses the Acromin MANTRELS
Migration of pain 1
Anorexia 1
Nausea 1
Tenderness in RLQ 2
Rebound pain 1
Elevated temperature 1
Leucocytosis 2
Shift of WBC count to the left 1
Score 1-4 D/C (30%)
Score 5-6 Observation/admission (66%)
Score 7-10 Surgery 93%

53

Presentation of Oesphagitis

heartburn,
difficult feeding with crying
Painful swallowing
haematemesis

54

Causes of UTI

90% Escherichia coli - important
recurrence UTI - 40% - very common
Rarely - 10%
Staph
Saprophyticus
Proteus
Klebs
Entero
Ureaplasma - rare

55

underlying causes for Paediatric UTI

Obstructed urinary system
Pelviureteric obstruction
Urinary stones
Posterior urethral valves 0 in boys with poor urinary stream)
Duplex kidney with obstructed pole
Horse shoe kidney
Organism - E.coli most of the time
Gram -ve - E.coli, Klebsiella, proteus, enterobacter, pseudomonas
Gram +ve - S.saprophyticus, enterococcus

56

Paediatrics risk factors for UTI

Non modifiable - female, caucasian, previous UTIs, FmHx
Modifiable - Urinary tract abnormalities (vesicoureteral reflux, neurogenic bladder catheterisation, uncircumcised males, labial adhesions, sexually active, constipation, toilet training
Increase chance of spread to kidney in

57

Clinical features for UTI in paediatric patients

Distal system - Dysuria, Low grade fever, frequency, urgency,
Pyelonephritis. Flank pain, high fever,
Paediatrics
Hx
often non-specific e.g. fever, irritability, poor feeding and vomiting, failure to thrive, septic
May have
loin or abdominal pain, frequency and dysuria but are often absent in younger patients
varies from children looking well to appearing very unwell.
NICE
3 months Preverbal - Most common - Fever
Less common - Abdominal pain, loin tenderness, vomiting, poor feeding
Least common - Lethargy, irritability, Haematuria, offensive urine, failure to thrive
> 3 months Verbal - Most common - frequency, Dysuria
Less common - Dysfunctional voiding, changes to continence, abdominal pain, loin tenderness
Least common - Fever, Malaise, Vomiting, Haematuria, Offensive urine, cloudy urine.

O/E
Often normal other then fever
May have Loin or supra-pubic tenderness
Toxic vs non toxic, FTT, Jaundice, look for external genitalia abnormalities (Phimosis, labial adhesions), Lower back signs of occult myelodysplasia (eg hair tufts), which may be associated with neurogenic bladder.
Old child - febrile, suprapubic and/or CVA tenderness, abdominal mass (enlarged bladder or kidney); may present with short stature, FTT or hypertension secondary to renal scarring from previously unrecognised or recurrent UTIs

58

IX UTI

Blood: Leukocytosis – neutrophilia
Midstream clean catch Urine specimen*
Dipstick: Leukocyte esterase (only in neutrophils) & nitrite +ve.
Urine: pyuria, neutrophils, bacteria, cloudy
MCS
Urinanalysis - blood, nitrates, leucocytes esterase, screening test only.
bHCG - confirm that they are not pregnant - changes treatment

59

Methods for getting a urine samples in kids

Clean catch - sterile around and give the parents a jar and ask them to watch and wait
SPA -
indications - Don’t have time to wait for a clean catch e.g. septic and need to give antibiotics
in a child

60

Tx of UTI in kids

If unwell or

61

presentation of DKA

Symptoms
PolyUria
polydipsia
weight loss
weakness
Nausea
vomiting
leg cramps
blurred vision
abdominal pain
Sign
Kussmaul breathing (deep and laboured breathing),
dehydration
Hypotension - postural or supine
Cold extremities/peripheral cyanosis
tachycardia
smell of acetone
hypothermia
confusion, drowsiness, coma

62

criteria for DKA

combination of hyperglycemia, metabolic acidosis, and ketonaemia
BGL >/= 11.1 mol/L
bed side Blood ketone >0.6 mol/L or urinanlysis
vBG pH

63

Work up for DKA

1 degree of dehydration: None/mild (7%): poor perfusion, rapid pulse, reduced blood pressure e.g. shock
2 level of consciousness
3 Investigations: VGB, FBC, Blood glucose, urea, electrolytes, blood ketones. investigations for cause.
if new diabetic: Insulin antibodies, GAD antibodies, coeliac seen (total IgA, anti gliadin Ab, tissue transglutaminase Ab) and TFT
Urine - ketones and culture

64

Management of DKA

DRSABCDEFG
IV
O2
cardiac monitor - signs of hyperkaleia (Peaked T waves, widened QRS) or hypokalemia (flattened or inverted T waves, ST depression, wide PR interval.
Blood cultures if febrile
Catheterise and fluid control
Fluid requirements - if hypo perfusion - give 0.9% NS at 10ml/Kg
initial fluid replacement
- NS + potassium
Insulin 0.1units/kg/hr
- Glucose
Nil by mouth

Ongoing monitoring and management
- Strict fluid balance
- Hourly observation - HR, BP, RR, GCS, neuro signs:pupillary responses, assess for change e.g. restlessness, irritability, headache.
Hourly glucose and ketones
recheck K+ within 1 hr of commencing insulin infusion
VBG and lab glucose 2 hourly for initial 6 hrs and then 2-4 hourly there after.
Serum U&E 2-4 hourly for initial 12-24hr
2-4 hourly temp
nursed head up

65

Things to look for when treating DKA

Hyper/hyponatraeia
Hypoglycaemia
Cerebral oedema

66

How to describe an enlarged liver

5S
Site
Size
Shape
Surface,
Skin
Consistency - hard, soft
Young liver is 4-6cm big. Starts at 5th rib.