What are the clinical features of appendicitis? (How common and Symptoms)
Very uncommon <3 years, otherwise commonest childhood abdo pain that requires surgical intervention. Can occur from 1-100 year olds
Symptoms
Anorexia
Vomiting (few times)
Abdo pain, initially central and colicky, then localising to right iliac fossa
What are the signs of acute appendicitis?
Flushed face with oral fetor
Low-grade fever (37.2-38°C)
Abdo pain aggravated by movement (walk, cough, bumps on the road during car journey)
Persistent tenderness with guarding in the right iliac fossa (McBurney’s point)
Signs are easy to underestimate in pre-school age group
Why may appendicitis present with white blood cells or organisms in the urine and thus lead to a misdiagnosis of UTI?
Inflamed appendix may be adjacent to the ureter or bladder
Which clinical examination and investigatins are required in acute abdominal pain?
Full examination
Includes gynae examination in girls
Testicular examination in boys (referred)
Investigations depend on age and presentation: Capillary blood glucose FBC CRP LFTs Urine dipstick U&Es Renal function Amylase Stool sample with diarrhoea Blood cultures Imaging (AXR/US of abdo/testis, erect CXR - gas) may be required, but not always
Laparoscopy
Which are very common causes of acute abdominal pain? At which age are they common?
UTI Acute appendicitis (>3 years) Mesenteric adenitis Gastro-enteritis Constipation
Which are less common causes of acute abdo pain?
Lower lobe pneumonia Strangulated hernia Diabetic ketoacidosis Intussusception Intestinal obstruction Henoch Schönlein Purpura Pancreatitis
What are the causes of acute abdominal pain in <1 year olds?
Medical:
gastroenteritis
Constipation
UTI
Surgical:
intussusception
volvulus
incarcerated hernia
Other:
Hirschprung’s disease
What are the causes of acute abdominal pain in 2-5 year olds?
Medical:
gastroenteritis
constipation
UTI
Surgical: Appendicitis Intussusception Volvulus Trauma
Other: Henoch-schonlein purpura DKA Mesenteric lymphadenitis Sickle cell crisis
What are the causes of acute abdominal pain in 6-11 year olds?
Medical:
gastroenteritis
constipation
UTI
Surgical:
appendicitis
trauma
Other: Mesenteric adenitis Abdominal migraine Henoch schonlein purpura DKA Sickle cell crisis Lower lobe pneumonia
What are the causes of acute abdominal pain in 12-18 year olds?
Medical:
gastroenteritis
constipation
Surgical: appendicitis trauma testicular torsion ovarian torsion
Other: Dysmenorrhoea Ectopic pregnancy Mittelschmerz (ovulation) PID Threatened abortion DKA IBD Adrenal crisis
In which cases can acute appendicitis be easily misdiagnosed?
Can present atypically with diarrhoea/tender RIF - misdiagnosed as gastroenteritis
Can present atypically with tender RIF/ abnormal urine dipstick - misdiagnosed as UTI
List differentials for paediatric acute appendicitis (vague symptoms)
Ovarian cyst/torsion (12-18) PID (12-18) Pregnancy (12-18) Ectopic pregnancy (12-18) Testicular torsion
Renal calculi Mesenteric adenitis Right LL pneumonia Volvulus Intussusception Constipation Gastroenteritis UTI Pyelonephritis
Hirschprungs disease in infants
HSP (henoch schonlein purpura)
HUS (haemolytic uraemic syndrome)
What are the differentials for acute appendiceal abscess or mass?
Meckel’s diverticulum
Crohn’s disease
How is the late presentation of appendicitis explained and how is it managed?
Appendicular mass. (Retroceacal appendicitis can also present late)
Managed with immediate laparoscopic appendicectomy
OR - since this is still researched
Conservative management with antibiotics and ultrasound guided percutaneous drainage. Depending on the recurrence rate after this (which is still controversial), patients may need interval surgery. In patients, conservative is SAFER
What are the symptoms and signs of intestinal obstruction?
Abdominal pain
Persistent vomiting
Signs:
Bile-stained vomit
Jaundice if high intestinal obstruction
Abdominal distension
Auscultation - increased bowel sounds
In suspected intestinal obstruction (infant), how can malrotation volvulus be diagnosed?
Imaging is the mainstay. Always if bilious vomiting.
Malrotation with volvulus:
Upper GI series
Absence of splenic and hepatic flexures
If abdominal distension and tenderness, barium enema is better - distinguishes malrotation from Hirschprung’s enterocolitis
What is the age group and the clinical features of intussusception?
0-6 years
Peak 3 months - 2 years
Refuse feeds
Signs: Acutely unwell (pallor - around mouth) Increasingly lethargic Waves of abdominal pain Often a palpable mass in RUQ (sausage shape) Redcurrant jelly stool - blodd-stained mucus (DRE) Bilious vomit (late) Abdo distension Shock
Why does upper intestinal obstruction cause bilious vomiting?
Enzymes secreted by gall bladder go up into the gallbladder and digest it
What has to always be assessed for in intussusception, malrotation, and strangulated inguinal hernia?
Dehydration and shock (vomiting)
What is intussusception?
Invagination of proximal bowel into distal segment
Most commonly ileum into caecum (through ileocaecal valve)
Why is prompt diagnosis and immediate treatment of intusussception necessary?
To avoid life-threatening complications:
Stretching and constriction of the mesentery can result in venous obstruction. Causes engorgement and bleeding from bowel mucosa. FLuid loss
Bowel perforation
Peritonitis
Gut necrosis
What is the management of intussusception?
Fluid resuscitation, first, then
Air enema reduction (75% success)
there needs to be a paediatric surgeon, in case of failure, or if bowel perforation occurs.
Operative reduction is by manual squeezing of the colon to reduce intussusception
How is intussusception diagnosed?
Investigations needed if bilious vomit
AXR may show distented small intestine and absence of air in distal colon/rectum
Sometimes the outline of intussusception can be seen
Abdo US can help
Which investigation is required in bilious vomiting?
Ugent upper GI contrast study to assess intestinal rotation
Unless there are signs of vascular compromise - requires urgent laparotomy
What is the management of volvulus?
Surgery recommended within 2 days of diagnosis OR immediately if severely twisted or blood supply cut off. In case of infarction, resection is required with reattachment.
Sigmoid: decompression with sigmoidoscope + flatus tube (allows rapid decompression of distended bowel)
Surgery:
Sigmoidectomy
Untwist duodenum (rotate anti-clockwise) Mobilise duodenum and place bowel in unrotated position with duodeno-jejunal flexure on the right and the caecum and appendix on left
For cecal:
Cecoplexy or intestinal resection
What are the types of volvulus? What are their features?
Volvulus is obstruction caused by rotation of bowel with its mesentery.
Sigmoid volvulus
Caecal volvulus Midgut volvulus (small intestine - duodenum)
What are the features of sigmoid volvulus?
Occurs with chronic constipation, such as in Hirschprung’s
Sudden onset colicky, lower abdo PAIN. Gross abdo distension (palpable mass, non-tender)
Constipation/blood in stools
Vomiting occurs late.
Signs of shock
AXR shows massively distended sigmoid, reaching the xiphisternum
What are the features of cecal volvulus?
Usually young adults. Undeveloped mesentery.
Adhesions are main pathological cause
Often intermittent chronic symptoms:
Abdominal cramping/swelling
Nausea + vomiting
Slowly develop constipation
What are the clinical features of midgut volvulus?
Mostly babies. Twisting of bowel around mesentery
ACUTE:
Usually 1st year of life (most significant to paeds)
Sudden onset bilious emesis
Diffuse abdominal tenderness (out of proportion to examination)
CHRONIC:
Recurrent abdominal pain
Malabsorption syndrome
What are signs of worsening intestinal ischaemia?
Signs of shock: Decreased urine output Hypotension Elevated lactate Base deficit
Peritonitis
Discolouration of skin
What are the symptoms and signs of acute and chronic duodenal obstruction?
Acute: (usually infants) Forceful biliary/nonbiliary emesis Abdominal distension possible There can be passage of stool/meconium Usually no signs of peritonitis or shock, unless volvulus further down
Chronic: (infancy to pre-school) Usually bilious vomiting May have failure to thrive May have intermittent abdominal pain Physical findings may be completely normal There may be distension and tenderness
What is the epidemiology of necrotising enterocolitis?
Mainly pre-term infants
Occurs in first few weeks of life
Pre-term infants fed cow’s milk formula are at higher risk
How does necrotising enterocolitis present?
Poor feeding
Milk aspirated from stomach
Bilious/non-bilious emesis (possible)
Distended abdomen
Blood in stool/explosive diarrhoea
Rapidly becomes shocked/Respiratory distress with acidosis
What are the feautes of necrotising enterocolitis on AXR? (mainstay)
Distended loops of bowel
Thickening of bowel wall with INTRAMURAL air (thumb printing)!
There may be gas in the portal tract
What is the treatment of NEC? Indications for surgery?
Stop oral feed
Broad-spectrum antibiotics (cefotaxime)
Parenteral nutrition
Artificial ventilation Circulatory support (often)
If bowel perforation: surgery
Resection of clearly necrotic bowel and creating proximal enterostomy
Also if there is air in the portal circulation on AXR
What are the different types of bowel atresias in the newborn?
Oesophageal. Usually associated with tracheo-oesophageal fistulas.
Pyloric atresia (familial)
Duodenal atresia. Associated with Trisomy 21. Recanalisation of bowel by 9 weeks gestation fails.
Jejunal ileal and colon atresia: are not from a failure of recanalisation, but ischaemic injury (all supplied by superior mesenteric artery - SMA)
How is oesophageal artresia diagnosed?
If suspected, a wide-calibre feeding tube is passed and checked by X-ray to see if it reaches the stomach
What are the features on AXR of duodenal atresia (eg. in gestation). Clinical features?
“Double Bubble”
Swallowing of amniotic fluid which cannot pass through leads to inflation of stomach and duodenum. Mother may have polyhydramnios due to blockage.
Also seen on US.
There may be bilious vomiting in first few days of life. Swollen but soft abdomen.
May not pass meconium.
What are the clinical features of pyloric atresia?
AXR - air filled stomach (distended), but no air in the rest of the abdomen
Vomiting
Distended abdomen
What are the clinical features of jejuno-ileal atresia
Bilious emesis within first 24 hours of life.
Distended abdomen.
No bowel movements within first day.
AXR shows distension and air above atresia + distension
What are the clinical features and complications of Meckel’s diverticulum?
Most asymptomatic
May have severe rectal bleeding (lower GI)
This may cause symptoms of anaemia (lethargy, pallor, failure to thrive)
Intussusception
Volvulus around a band
Diverticulitis (mimics appendicitis)