Flashcards in Abdominal pain Deck (66):
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.
Important questions to ask on history for acute abdomen pain
Description of pain
Relations to meals
Nausea, vomiting, diarrhoea, fever.
What to look for on examination of acute abdomen pain
Abdominal exam , peritoneal signs, bowel sounds, rectal exam, rash.
Ix for acute abdominal pain
FBC, Differential, urinalysis to rule out UTI.
Most common cause of acute abdomen in children
Clinical features of appendicitis
Low grade fever
N/V after onset of pain
Peritoneal signs - generalised peritonitis is common in infants and young children.
Who get Intussusception
CF or gastrojejunostomy
Children between 3 months to 2 yrs.
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
Dx of intussusception
US, air enema
Tx of Intussusception
Air enema or surgery
Clinical features of gastroenteritis
diarrhoea with or without vomiting or cramping abdominal pain
Check dehydration level
Red flags for abdominal symptoms
Severe abdominal pain or abdominal signs
Persistent diarrhoea >10 d
Blood in stool
Very unwell appearance
vomiting without diarrhoea
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.
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
How to calculate fluids
Maintenance = 4:2:1 upper limit is 100ml/hr
Deficit = % of dehydration X wt x 10
Define chronic abdominal pain
3 episodes of severe pain
Child >3yr old
Over 3 month period
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
- Intermittent fever
- Wt loss
- poor growth
- Involvement of other system e.g. rash, joint pain
- Anaemia or raised acute phase reactants
DDX of chronic abdominal pain
GIT - constipation, IBD, esophitis, peptic ulcer disease, lactose intolerance, anatomic anomalies, masses,Pancreatic, oesophagitis, IBS, Malabsorption, Giardiasis
Genitourinary - recurrent urinary tract infection, nephrolitiasis, chronic PID, Mittelschmerz, dysmenorrhoea, ovarian cysts,
Sickle cell disease
Non Organic - Function recurrent abdominal pain
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
Ix for function/recurrent abdominal pain
FBC, ESR, urinalysis, stools for O&P, Occult blood.
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.
who get appendicitis
commonest in post pubertal,
uncommon in under 5 yr
Clinical features of appendicitis
Periumbilical pain that become localised over RLQ when peritoneum becomes involved
lay very still
worse on movement
Vomiting - bile stained
occasional diarrhoea & vomiting
low grade fever
Ix for appendicitis
Urine to exclude infection
USS if unsure of Dx
DDX for pain in Iliac fossa
Urinary tract infection
Inflammatory bowel disease
Mx of appendicitis
Perforation is commoner in children
If peritonitis = severe illness and adhesions may lead to bowel obstruction.
Blood - G&H, cross hold, FBC, U&E, CRP, B
Antibiotics - cefuroxime, metronidazole
Reassess - ABC and vital signs
Ix - Abdo Xray - stones, SBO or servere constipation.
Urinalysis +/- microscopy
refer to paediatric surgery for Appendicectomy Laparoscopically
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.
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
Presentation of Inflammatory bowel disease
Blood/mucus in stools
Family Hx of diarrhoea
Wt less and poor growth
Presentation of Mesenteric adenitis
Recent viral infection
No peritonism or guarding
Pain can mimic appendicitis
Presentation of peptic ulcer
Pain at night
Relief with milk
Prevention intestinal obstruction
Bile stained vomiting
Consider a volvulus
Presentation of constipation
Hard or infrequent stools
Mass in left iliac fossa
Faecal loading on radiograph
Presentation of UTI
Evidence of infection on urinalysis or microscopy.
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
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
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.
DDX for blood in stools
inflammatory bowel disease
Henoch Schonlein purpura
Some types of gastroenteritis.
Surgical causes of abdominal pain
Renal, ureteric and biliary stones
Non surgical causes of abdominal pain
Gastroenteritis - common, colicky, V&D
Lower lobe pneumonia
Henoch Schonlein purpura
Mx of mesenteric adenitis
Diagnosis of exclusion
tx if simple analgesia
Hx and Examination finding for chronic abdominal pain
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
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.
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
Tx of IBS
Smooth muscle relaxants eg mebeverine for spasms
Presentation of gastritis and peptic ulcer
Relieved by food
May be family hx
A – anorexia
L – loss of weight
A – anemia
R – recent onset/ progressive symptoms
M – melaena/ haematemesis
S – swallowing difficulty
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
- PPI - Ezomerprazole
- ABx - Amoxicillin, clarithroycin
Causes of constipation
- Fluid depletion
- low fibre diet
- lack of mobility & exercise
- Hirschsprung's disease
- anal disease - infection, stenosis, ectopic, fissure, hypertonic sphincter)
- Bowel obstruction
- food hypersensitivity
- Coeliac disease
- Neurological disease e.g. spinal disease
- Chronic dehydration eg diabetes insipidus
- Drugs e.g. opiate and anticholinergics
- sexual abuse
Clinical features of constipation
Mx of constipation
- soften retained stool e.g. movicol
- Colonic stimulant eg Senna.
Continue until bowel pattern regular and then decrease
- 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
- 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
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.
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
Medication eg codeine, cough medicine, some anticonvulsants, antihistamines.
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.
how to calculate likelihood of appendicitis
Alvarado score uses the Acromin MANTRELS
Migration of pain 1
Tenderness in RLQ 2
Rebound pain 1
Elevated temperature 1
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%
Presentation of Oesphagitis
difficult feeding with crying
Causes of UTI
90% Escherichia coli - important
recurrence UTI - 40% - very common
Rarely - 10%
Ureaplasma - rare
underlying causes for Paediatric UTI
Obstructed urinary system
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
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
Clinical features for UTI in paediatric patients
Distal system - Dysuria, Low grade fever, frequency, urgency,
Pyelonephritis. Flank pain, high fever,
often non-specific e.g. fever, irritability, poor feeding and vomiting, failure to thrive, septic
loin or abdominal pain, frequency and dysuria but are often absent in younger patients
varies from children looking well to appearing very unwell.
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.
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
Blood: Leukocytosis – neutrophilia
Midstream clean catch Urine specimen*
Dipstick: Leukocyte esterase (only in neutrophils) & nitrite +ve.
Urine: pyuria, neutrophils, bacteria, cloudy
Urinanalysis - blood, nitrates, leucocytes esterase, screening test only.
bHCG - confirm that they are not pregnant - changes treatment
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
indications - Don’t have time to wait for a clean catch e.g. septic and need to give antibiotics
in a child
Tx of UTI in kids
If unwell or
presentation of DKA
Kussmaul breathing (deep and laboured breathing),
Hypotension - postural or supine
Cold extremities/peripheral cyanosis
smell of acetone
confusion, drowsiness, coma
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
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
Management of DKA
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
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
Things to look for when treating DKA