abdominal pain Flashcards
Signs of peritonitis
severe inflammation within the peritoneal cavity of the abdomen and usually means that surgery is needed
- widespread guarding
- involuntary tenderness
- dehydration
- sepsis
most common cause is perforated appendix.
signs of intussusception
It is important to recognise this life-threatening condition.
The pain is characteristically colicky, and the child will settle in-between bouts of this pain. A mass may be felt in the abdomen, usually on the right-hand side. As time goes on the child will become dehydrated.
what is intussusception
Intussusception usually affects infants and toddlers.
It is caused by invagination of intestine into itself, like a telescope, leading to bowel obstruction.
It can be associated with extra-abdominal infections (for example tonsillitis or an ear infection) because these make lymph nodes (called Peyer’s patches) in the bowel wall swell, these act as a lead point for the bowel to fold on.
investigation and management on intussusception
It is important to put up intravenous fluids, send blood tests, and get an ultrasound scan. An x-ray may be useful but an ultrasound is better. The child will need to be treated by a radiologist, who may be able to reduce the intussusception with contrast liquid, or they may need a paediatric surgeon to operate.
abdominal mass causes
cancer - neuroblastoma or willm’s tuour
appendicitis can present late as appendix abscess
constipation
what causes bile vomitting
bowel obstruction
could be empty stomach, rule out obstruction first
Colour - green
Ix: abdominal xray, blood test, surgical review
what is testicular torsion
Testicular torsion is a surgical emergency and requires prompt diagnosis and treatment to save the testicle. Fertility in the testicle concerned may be lost within 4 to 6 hours of interrupted blood flow to the organ.
Signs of testicular torsion
It is more common over twelve years but need to be considered in any age group. The child will have abdominal pain. Usually there is a history of testicular pain but it can present as just abdominal pain. Equally in a pre-verbal child, the child will just be crying and unsettled. In all of these circumstances you should always check the scrotum for signs of swelling, tenderness or discolouration.
management of suspected testicular torsion
Any suspicion of testicular torsion should prompt an immediate referral to a paediatric surgical unit for examination and possible surgical exploration.
Examination of abdominal pain
assess simple things
- the way they are behaving
- whether they can walk and move comfortably
- whether they can comfortably lie down or climb on and off the examination couch.
After your general observations you need to ensure you’ve made note of physiological parameters to pick up the signs of dehydration such as tachycardia or delayed capillary refill time or signs of sepsis such as in surgical causes like a perforated appendix, such as tachycardia or a fever. This is part of your breathing and circulation assessment, B and C on the 3 minute toolkit. It is important to look at the respiratory system properly as lower lobe pneumonias can present as abdominal pain.
When you’re examining a child’s abdomen, you want the child to be as calm as possible. You sometimes have to spend time gaining the child’s trust first. Talking about other things also helps distract the child so you can see if the tenderness is genuine. Once you have gained the child’s trust, ask them to show you where it hurts. Children will generally point to their umbilicus or all over when describing the pain. This does not automatically mean that the pain is not from a serious cause but if a child points away from the umbilicus you should note this as unusual and more significant. With careful palpation of the left iliac fossa in a constipated child you will usually feel hard faeces. Go back over the history to check that you are right. Children usually have soft stomach muscles so palpation should be easy. Palpation is often enough to detect any masses, unless they are overweight. You need to be able to pick up the surgical signs of tenderness, guarding and peritonism. Always watch the child’s face to see if there is true tenderness. Pain is a symptom, tenderness is what you find when you press on something. Tenderness therefore localises the cause of the pain to the abdomen. If the cause of the pain is inflammation such as appendicitis, inflammatory cells are relased into the peritoneum, and this is called peritonitis. Inside the whole of the abdomen, inflammatory fluid is washing around, and so anywhere you press will be tender with guarding. Any movement of the abdomen will cause pain. You can also ask the patient to suck in and blow out their abdomen. Children usually enjoy sticking out their tummies, but peritonitis stops them doing that.
It is important to dip test the urine in all cases of abdominal pain. Firstly it may show you a urinary tract infection, which may be the cause, or it may show glucose and ketones, which mean diabetic ketoacidosis (this can present with abdominal pain). Or it can show just ketones, which means the child has been not eating for a day or two and means the illness is more serious. The diagnosis of a UTI can only be eliminated by obtaining a suitable urine sample for Dipstick testing. If a child is not toilet trained the best way of getting an uncontaminated sample is a clean catch as shown.
A final point is that a full rectal examination is invasive and may be distressing for the child or their parents, so if it is carried out at all, should only be done by the surgeon who will be ultimately looking after the child.
Causes of abdominal pain
Abdominal conditions
- Colic
- Intussusception
- Mesenteric adenitis
- Constipation
- Inflammatory bowel disease
- Coeliac disease
Extra-abdominal conditions
- Migraine
- Diabetic ketoacidosis
- Infection elsewhere
- Pneumonia
- Urinary tract infection
- Stress
Some causes are rare but serious enough not to be forgotten:
Malignancy
- Neuroblastoma
- Wilms tumour
Testicular torsion
Bowel obstruction
- Incarcerated hernia
- Malrotation
- Meckel’s diverticulum
abdominal pain examination
General observations – what is the child’s behaviour:
- Whilst lying down?
- Whilst climbing on and off the couch?
Physiological observations – are there signs of dehydration or sepsis:
- Fever
- Capillary refill
- Heart rate
- Respiratory rate
Gather the child’s trust:
- Use distraction techniques
- Ask the child to show you where it hurts
- Away from or near the umbilicus?
Examine the abdomen for:
- Tenderness
- Guarding
- Peritonism
- Masses
- Organomegaly
Perform urinalysis for:
- Infection
- Glucose
- Ketones
Examine genitalia in all boys
Consider rectal examination by a surgeon
