10. Abdominal Pain in Pediatrics Flashcards
1
Q
Describe: Visceral (splanchnic) pain (4)
A
- due to noxious stimuli (usually stretch) stimulating receptors of the visceral peritoneum, mesentery, or the muscle or mucosa of hollow organs.
- The associated afferent autonomic nerves have few nerve endings, innervate targets in a bilaterally symmetric fashion, are unmyelinated, and enter spinal cord at multiple levels.
- Thus, visceral pain is dull, poorly localized, and associated with the midline.
- Pain generally sensed in areas corresponding to embryonic origin of affected structure:
- Foregut (esophagus to duodenum at major duodenal papilla, liver, gallblad- der, pancreas)—epigastric
- Midgut (distal 2nd part of duodenum to proximal two-third of transverse colon)—periumbilical
- Hindgut (distal one-third of transverse colon to rectum)—suprapubic/ hypogastric
2
Q
Describe: Parietal (somatic) pain (3)
A
- due to noxious stimuli (stretch, inflammation/irritation, tearing) stimulating receptors of the parietal peritoneum, skin, or skeletal muscle.
- Associated somatic afferent nerves are numerous, myelinated, and transmit to a specific dorsal root ganglion.
- Thus, somatic pain is relatively more intense and localized, on the same side and dermatomal region as origin of pain.
3
Q
Describe: Referred pain (2)
A
- due to convergence/shared projections of somatic and/or visceral pain pathways in the CNS.
- For example, pneumonia may present as abdo pain due to parietal pleural pain referred to abdo wall.
4
Q
Name causal conditions of acute abdominal pain in pediatrics: Upper/Epigastric (6)
A
- Hepatobiliary/pancreatic: acute hepatitis, cholecystitis, cholelithiasis, cholangitis,* acute pancreatitis
- Esophagus: foreign body ingestion, esophagitis (reflux, chemical, infective, traumatic)
- Stomach: gastritis, reactive gastropathy, or peptic ulcer (infectious, medications, autoimmune, stress, trauma), foreign body ingestion/bezoar, pyloric stenosis
- Small intestine: duodenal ulcer, small bowel volvulus*
- Spleen: infarction, rupture*
- Functional dyspepsia
5
Q
Name causal conditions of acute abdominal pain in pediatrics: Lower/Hypogastric (5)
A
- Intestinal: gastroenteritis, constipation, appendicitis/Meckel diverticulitis causing focal peritonitis,* IBD
- Mesenteric lymphadenitis
- Urinary tract: UTI/pyelonephritis, urolithiasis
- Male genital: incarcerated inguinal hernia,* testicular torsion*
- Gynecologic: ectopic pregnancy,* threatened abortion, pelvic inflammatory disease, ovarian torsion,* endometriosis, dysmenorrhea, Mittelschmerz, hematocolpos
6
Q
Name causal conditions of acute abdominal pain in pediatrics: Generalized or Periumbilical (8)
A
- Intestinal
- Inflammatory: infectious gastroenteritis, appendicitis,* Meckel diverticulitis,* allergy, IBD, Henoch-Schonlein Purpura (HSP), Hirschsprung, or necrotizing enterocolitis*
- Obstruction*/dysmotility: constipation, Hirschsprung disease (HD), intussusception, malrotation with volvulus, meconium ileus, distal intestinal obstruction syndrome (DIOS), appendicitis, Meckel diverticulitis, adhesions, duodenal/intes- tinal atresia, bezoar/foreign body, strictures
- Malabsorption: secondary lactase deficiency, dietary protein-induced enteropathy/ enterocolitis
- Peritoneal*: abdo trauma, ruptured viscus, primary/secondary bacterial peritonitis, autoinflammatory disease (e.g., Familial Mediterranean fever)
- Metabolic*: diabetic ketoacidosis, hypoglycemia, adrenal insufficiency
- Hematologic: sickle cell acute pain crisis, hemolytic uremic syndrome
- Drugs/toxins*:many (e.g.,consider lead/iron poisoning, salicylates, acetaminophen)
- Referred: pneumonia, pharyngitis, myocarditis/pericarditis
- Infantile colic
- Functional abdo pain, irritable bowel syndrome, abdo migraine
7
Q
Name causal conditions of CHRONIC abdominal pain in pediatrics: Upper/Epigastric (6)
A
- Esophagus: esophagitis (reflux, immunologic, infectious, systemic disease associated)
- Stomach: gastritis, reactive gastropathy, peptic ulcer (infections, medications, eosinophilic, immune-mediated), bezoar or foreign body
- Duodenum: peptic ulcer, inflammation (celiac disease, eosinophilic gastroenteritis)
- Hepatobiliary: biliary dyskinesia, chronic hepatitis, cholelithiasis, choledochal cyst
- Pancreatic: chronic pancreatitis, pancreatic pseudocyst
- Functional dyspepsia
8
Q
Name causal conditions of CHRONIC abdominal pain in pediatrics: Lower/Hypogastric (4)
A
- Intestinal: gastroenteritis, constipation, IBD, malabsorption, polyps
- Functional abdo pain, irritable bowel syndrome
- Gynecologic: pelvic inflammatory disease, endometriosis
- Urinary tract: ureter pelvic junction obstruction, hydronephrosis, nephrolithiasis
9
Q
Name causal conditions of CHRONIC abdominal pain in pediatrics: Generalized or Periumbilical (7)
A
- Inflammatory: IBD, infectious gastroenteritis (parasites, bacteria, viruses), celiac disease, allergy (eosinophilic gastroenteritis, food protein intolerance), collagen
- Intestinal vascular disease
- Obstruction/dysmotility: functional constipation, secondary constipation (HD, anorectal malformation, spinal cord abnormalities, etc.), strictures, malrotation (intermittent volvulus), intussusception
- Malabsorption: carbohydrate intolerance (primary lactase deficiency, overfeed- ing or dietary excess of fermentable oligosaccharides, fructose, sorbitol, etc.), cystic fibrosis
- Metabolic: adrenal insufficiency, diabetes mellitus, thyroid disease
- Hematologic: hereditary angioedema, porphyria
- MSK: muscle strain
- Neoplastic/anatomic: abdo mass (nephroblastoma, neuroblastoma, germ cell tumor, etc.), GI duplication, polyps, hernias (diaphragmatic, internal, umbilical, inguinal), malrotation (Ladd bands)
- Functional abdo pain, irritable bowel syndrome, abdo migraine
10
Q
Describe HX: Abdominal Pain in Pediatrics (10)
A
- ID: Age, PMHx, presenting symptoms
- History of Present Illness: Tailor to age of presentation, acuity, and whether appears stable or unstable
- Features of pain: OPQRST
- Provocation by: movement (peritoneal irritation), meal (pancreatitis, cholecystitis, gastric ulcer, GERD)
- Palliation by: emesis (small bowel involvement), defecation (colonic condition), meal (duodenal ulcer)
- Associated symptoms: fever, weight loss
- GI: anorexia, dysphagia, heartburn, vomiting (coffee ground), early satiety, diarrhoea or constipation, last BM, melena, hematochezia, urgency/tenesmus, flatus/ bloating/distension, jaundice
- GU: dysuria, hematuria, polyuria, frequency/nocturia, scrotal pain, vaginal discharge/bleeding, and last menstrual period (normal/abnormal)
- Recent trauma, infections, treatments (and effects)
- Infectious risks: travel Hx, infectious contacts/animal exposures, uncooked food, untreated water
- Past Medical History/PSHx
- If presentation in newborn/infancy—antenatal/perinatal/neonatal Hx, including age (hours/days) of first meconium
- Chronic medical conditions (e.g., sickle cell disease, diabetes mellitus, cystic fibrosis)
- Previous abdo surgeries (risk for adhesions, anastomotic complications)
- Medications/Allergies/Immunizations
- Including OTC medications, alternative medicine
- Nutrition
- Acute pain: time of last meal, relation to pain
- Chronic pain: variety, quantity, maladaptive eating habits, relation to pain (food diary)
- FHx /SHx
- FHx of IBD, celiac disease, functional bowel disorders, etc.
- Adolescents—HEEADDSSS Hx (Home, Education, Employment, Activities, Drugs, Diet, Sexuality, Safety, Suicidal ideation/mood)
- Impacts on daily function (school absenteeism, activities, etc.) and family unit
- Review of Systems: Extraintestinal symptoms of organic disease
11
Q
Name causal conditions of abdominal pain in paediatrics according to the age of onset (Figure)
A
12
Q
Name redflags for an organic pathology (4)
A
- Pain features: progressive, localized (nonumbilical), wakes from sleep, radiates to shoulder, back, or groin
- GI sx: dysphagia/odynophagia, anorexia, emesis (bilious, bloody, persis- tent), jaundice, absence of flatus/bowel movements, diarrhea (especially chronic and nocturnal), hematochezia/melena
- Extraintestinal sx: unexplained fevers, weight loss/failure to thrive, decelerated linear growth velocity, oral ulcers, perirectal disease, arthritis, cough/dyspnea, dysuria/hematuria, vaginal discharge/bleeding, scrotal/ pelvic pain
- FHx: IBD, celiac disease, peptic ulcer disease
13
Q
Describe physical exam: Abdominal pain (9)
A
- General appearance: comfort, positioning, level of consciousness, ill-appearance, malnutrition
- Vitals/anthropometrics: abnormal growth parameters (failure to thrive), fever, tachypnea/desaturation, hypotension, or unexplained tachycardia
- Skin: bruising, petechiae/purpura, jaundice, erythema nodosum, dermatitis her- petiformis, etc.
- HEENT/respiratory: conjunctivitis/episcleritis, oral lesions, cheilitis/glossitis, pharyngeal erythema/exudate, lymphadenopathy, thyromegaly, findings consistent with respiratory infection
- Cardiovascular: delayed capillary refill, diminished peripheral pulses, muffled/ additional heart sounds
- Abdo exam: surgical scars, distention, visible bowel loops, altered bowel sounds, focal tenderness, peritoneal irritation (percussive or rebound tenderness, involun- tary guarding), masses, hepatosplenomegaly, ascites
- DRE: local tenderness, mass, hard stool, blood
- Perianal/GU: perianal skin tag/abscess, hemorrhoids, anal fissure, imperforate anus, scrotal swelling, incarcerated hernia
- Pelvic exam: in sexually active females with lower abdo pain
14
Q
Describe ROUTINE investigations: Abdominal pain (1)
A
No additional evaluation required for children with abdo pain who are otherwise healthy, with normal physical exam and absence of “red flags” for organic disease
15
Q
Name LAB tests: Abdominal pain (11)
A
- CBC/differential: high WBC/Plt (infectious/inflammatory), anemia (MAHA, hemoglobinopathy)
- Serum electrolytes, glucose, creatinine, BUN (metabolic acidosis, DKA, renal pathology, or hypovolemia)
- Total/direct bilirubin, transaminases, GGT, ALP, amylase, lipase (hepatic, biliary, pancreatic pathology)
- Antitissue transglutaminase and IgA level (celiac disease screen)
- Serum/urine b-hCG (if postmenarcheal female)
- Stool for O&P × 3, C&S, C. difficile PCR, viral culture/electron microscopy
- Consider stool for fecal fat, occult blood, WBC, reducing substances
- Urine R+ M , C+ S if indicated
- Throat swab for culture (streptococcal pharyngitis)
- Urea breath test or stool H. pylori antigen assay (H. pylori screen)
- Consider vaginal swabs or urine testing for chlamydia, gonorrhea, trichomonas (if microscopy available)
16
Q
Name imaging tests: Abdominal pain (6)
A
- CXR: pulmonary disease, cardiomegaly (myocarditis), foreign body
- AXR (three views include upright view with visible diaphragms): free air under diaphragm (pneumoperitoneum with ruptured viscus), bowel obstruction/volvulus, nephrolithiasis, constipation, foreign body
- CT abdo (appendicitis, pancreatitis, intra-abdo abscess, mesenteric ischemia, Abdo mass)
- U/S abdo (cholelithiasis, cholecystitis, intussusception, appendicitis, hydronephrosis, obstruction)
- U/S bowel wall or MR enterography (if suspect IBD with small bowel involvement—unable to be determined on upper endoscopy or colonoscopy)
- U/S pelvis/scrotum (testicular torsion, gynecologic pathology)
17
Q
Name mainly clinical dx (6)
A
- Henoch-Schönlein Purpura
- Appendicitis
- Infantile colic
- Incarcerated hernia,
- Gastroenteritis
- GERD
18
Q
Describe HX and Physical exam: Hirschsprung Disease (6)
A
- HX:
- Delayed meconium
- Failure to Thrive
- Bilious vomiting
- Chronic constipation since birth
- Physical exam:
- Abdo distension
- Digital Rectal Exam: tight anal sphincter, empty ampulla, blast sign (expulsion of gas and stool after DRE)
19
Q
Describe investigations: Hirschsprung Disease (2)
A
- Barium enema:
- narrow/normal rectum
- dilated colon proximal to aganglionic segment
- with transition zone
- Definitive Dx by rectal biopsy: absence of ganglion cells
20
Q
Describe HX (4) and physical exam (2): Pyloric stenosis
A
- HX:
- Symptom onset 3–8 wk old
- Failure to Thrive, “hungry vomiter”
- M>F
- Projectile nonbilious vomiting, immediately postprandial
- Physical exam:
- ± Visible peristalsis
- Possible palpable epigastric mass (“olive sign”)
21
Q
Describe investigations: Pyloric stenosis (2)
A
- U/S: hypertrophied pylorus (increased muscle thickness and length)
- Lytes/blood gas: hypochloremic, hypokalemic metabolic alkalosis
22
Q
Describe HX (1) and physical exam (2): Duodenal atresia
A
- HX: Bilious vomiting within hours of birth (later if stenosis)
- Physical exam:
- Epigastric distension
- 1⁄4 have trisomy 21
23
Q
Describe investigations: Duodenal atresia (2)
A
- AXR: “double bubble” sign, absent distal abdo gas
- Upper GI series: duodenal obstruction
24
Q
Describe HX (3) and physical exam (1): Infantile colic
A
- HX:
- Unexplained paroxysms of irritability, fussiness, or crying starting/ stopping without obvious cause, in < 4 mo old
- episodes of ≥ 3 h/d, ≥ 3 d/wk, for ≥ 1 wk
- No failure to thrive
- Physical exam: Healthy appearing infant
25
Describe investigations: Infantile colic (1)
Clinical Dx (Rome III criteria)
26
Describe HX (9) and physical exam (2): Gastroesophageal reflux/GERD
* HX:
* Regurgitation/emesis
* feeding aversion
* “colicky baby,”
* irritable
* Apnea
* stridor
* aspiration
* wheeze
* Sandifer syndrome: back arching, chin lifting, neck contortions due to discomfort
* Physical exam:
* ± FTT (in GERD)
* ± Hoarseness/stridor/wheeze
27
Describe investigations: Gastroesophageal reflux/GERD (4)
* Empiric trial of acid suppressant
* Endoscopy: esophagitis
* 24- ph probe/impedanc study: acidic/nonacidic reflux, strength of association with suspected signs/ symptoms
* ± Upper GI series: R/O obstruction/stenosis, malrotation
28
Describe HX (4) and physical exam (4): Incarcerated inguinal hernia
* HX: Classic Hx
* swelling in inguinal area during crying/straining
* Irritable and crying
* Vomiting, abdo distension
* Groin pain
* Physical exam:
* Firm, tender, often edematous inguinal mass
* ± Surrounding erythema
* ± Abdo distension/tenderness
* ± Scrotum appear blue due to testicular venous congestion
29
Describe investigations: Incarcerated inguinal hernia (3)
* Clinical
* AXR (may see lower GI obstruction or air bubble in groin)
* U/S
30
Describe HX (6) and physical exam (3): Intussusception
* HX:
* 3 mo to 3 y.o. (up to 6 y.o.)
* Paroxysmal, severe, crampy abdo pain, inconsolable crying, drawing up legs
* Episodes progress in frequency
* ± Vomiting
* Currant jelly stool (blood/ mucous)
* Initially comfortable/normal behavior between episodes; progressive lethargy
* Physical exam:
* Abdo may be benign vs. variable abdo distension and tenderness
* ± Palpable sausage-shaped RUQ or epigastric mass
* ± Bloody mucus on DRE
31
Describe investigations: Intussusception (2)
* Air contrast enema: obstruction (filling defect), air fluid levels, absence of gas in RLQ
* U/S: target sign (bowel within bowel), tubular mass
32
Describe HX (3) and physical exam (2): Malrotation with mid-gut volvulus
* HX:
* Sudden onset bilious emesis, abdo distension, melena
* Septic shock (necrotic bowel and 3rd spacing)
* Children may have episodic abdo pain with vomiting for weeks to years before detection
* Physical exam:
* Abdo distension/tenderness
* ± Peritonitis/shock
33
Describe investigations: Malrotation with mid- gut volvulus (2)
* AXR: upper GI obstruction (dilated proximal loops with fairly gasless abdo), pneumoperitoneum
* Upper GI series: failure of duodenum to cross midline (malrotation), duo- denal obstruction (volvulus)
34
Describe HX (8) and physical exam (4): UTI
* HX:
* Dysuria
* urgency
* frequency
* Irritability
* fever
* poor feeding
* Vomiting or diarrhea
* Flank or abdo pain
* Physical exam:
* Tender abdo (suprapubic)
* ± Costovertebral angle tendernes
* Murphy punch sign (in pyelonephritis)
* ± Fever
35
Describe investigations: UTI (3)
* Urine R&M (WBC, nitrites, leukocyte esterase)
* C&S
* Controversy in workup after 1st UTI: renal U/S ± Voiding Cystourethrogram
36
Describe HX (4) and physical exam (3): Constipation
* HX:
* BMs: 2 or less per week, large diameter, difficult/incomplete evacuation
* Colicky abdo pain, painful defecation
* ± fecal incontinence
* ± Retentive posturing
* Physical exam:
* Abdo palpation of hard fecal mass
* Dilated rectum filled with stool
* ± Anal fissure
37
Describe investigations: Constipation (2)
* Clinical (Rome criteria for functional constipation)
* AXR: fecal impaction (excessive stool in colon)
38
Describe HX (4) and physical exam (2): Gastroenteritis
* HX:
* Fever, cramping abdo pain
* Diarrhea, ± minimal bright red blood per rectum (BRBPR)
* Vomiting, anorexia
* H/A, myalgia
* Physical exam:
* Soft, tender abdo
* Fever possible
39
Describe HX and physical exam:
* HX:
* Physical exam:
40
Describe investigations:
41
Describe HX and physical exam:
* HX:
* Physical exam:
42
Describe investigations:
43
Describe investigations:
44
Describe HX and physical exam:
* HX:
* Physical exam:
45
Describe HX (4) and physical exam (2): Gastroenteritis
* HX:
* Fever, cramping abdo pain
* Diarrhea, ± minimal bright red blood per rectum (BRBPR)
* Vomiting, anorexia
* H/A, myalgia
* Physical exam:
* Soft, tender abdo
* Fever possible
46
Describe HX (2) and physical exam (8): Pneumonia
* HX:
* Respiratory tract symptoms N/V
* Chest and/or upper abdo pain
* Physical exam:
* Tachypnea
* hypoxia
* increased work of breathing
* fever
* Percussion dullness
* increased tactile fremitus
* decreased air entry
* bronchial breath sounds
47
Describe investigations: Pneumonia (2)
* CXR: focal consolidation, pleural effusion (atypical pneumonia w/ patchy diffuse opacifications)
* Possible ↑ WBC
48
Describe HX (5) and physical exam (3): Hemolytic Uremic Syndrome
* HX:
* Preceding gastroenteritis
* fever, bloody diarrhea (5–10 d)
* Abrupt onset of irritability, lethargy
* edema
* pallor (usually without purpura)
* Physical exam:
* Toxic, ± uremic encephalopathy
* Tender abdo
* Hypertension
49
Describe investigations: Hemolytic Uremic Syndrome (4)
* CBCD, blood smear, haptoglobin & bilirubin: MAHA, thrombocytopenia
* Cr:↑(ARF)
* U/A: proteinuria, hematuria
* Stool C&S: infection
50
Describe HX (5) and physical exam (3): Henoch-Schönlein Purpura
* HX:
* Colicky abdo pain associated with vomiting (within 8 d of purpuric rash)
* Melena/hematochezia
* Arthralgias
* Hematuria
* Rare GI complications: intussusception, pancreatitis, protein- losing enteropathy
* Physical exam:
* Palpable purpura on lower extremities/gravity dependent areas)
* Oligoarthritis
* ± Hypertension
51
Describe investigations: Henoch-Schönlein Purpura (5)
* No lab findings diagnostic
* Common: increased ESR, CRP, WBC, platelets; anemia
* IgA: elevated in 50%–70%
* INR/PTT: no coagulopathy
* ± Hematuria, proteinuria, ↑ Cr Biopsy skin/kidney (rarely needed); IgA deposition, leukocytoclastic vasculitis
52
Describe HX (3) and physical exam (2): Urolithiasis
* HX:
* Colicky abdo/flank pain, radiating to testes or labia
* N/V, chills, ileus
* Gross hematuria, dysuria, urgency
* Physical exam:
* Fever
* Abdo ± costovertebral angle tendernes
53
Describe investigations: Urolithiasis (3)
* Radiopaque stones on AXR
* Non-contras CT gold standard
* U/S: obstruction of GU system, Hydronephrosis
54
Describe investigations:
55
Describe HX (4) and physical exam (3): Diabetic Ketoacidosis
* HX:
* N/V, anorexia
* Dehydration, weight loss
* Fatigue
* Polyuria, polydipsia, polyphagia
* Physical exam:
* Dehydration
* Diffuse abdo tenderness
* Kussmaul breathing
56
Describe investigations: Diabetic Ketoacidosis (3)
* ↑ Blood glucose (\> 11.1 mM)
* ABG: WAG metabolic acidosis (Hco3 \<15,pH\<7.3)
* Positive urine/serum ketones ± ↑ WBC, Cr, and BUN (hemoconcentration)
57
Describe HX (2) and physical exam (3): Appendicitis
* HX:
* Periumbilical pain, migrating to RLQ (worse with cough, walking, jumping)
* Anorexia, nausea, vomiting
* Physical exam:
* Fever
* RLQ tenderness (percussion andpalpation)—often focal at McBurney point
* ± Peritonism: rebound tenderness, involuntary guarding, Rovsing sign, Obturator sign, Iliopsoas sign
58
Describe investigations: Appendicitis (3)
* U/S: thick-walled/dilated appendix ± appendicolith
* CT: enlarged appendix, appendicolith, associated mesenteric fat stranding
* ± ↑ WBC, ↑ neutrophils
59
Describe investigations: Appendicitis (3)
* U/S: thick-walled/dilated appendix ± appendicolith
* CT: enlarged appendix, appendicolith, associated mesenteric fat stranding
* ± ↑ WBC, ↑ neutrophils
60
Describe HX (3) and physical exam (2): Pancreatitis
* HX:
* Severe persistent epigastric/LUQ pain radiating to back, alleviated by bending forward
* Anorexia, vomiting
* Restlessness, agitation
* Physical exam:
* Fever, tachycardia
* Tender ± distended abdo Periumbilical or flank bruising (hemorrhage)—very rare in pediatrics
61
Describe investigations: Pancreatitis (3)
* ↑ lipase , ↑ WBC
* U/S: hypoechoic enlarged pancreas ± gallstones
* CT: edema, necrosis, hemorrhage, peripancreatic fat stranding, pseudocyst
62
Describe HX (3) and physical exam (4): Cholecystitis
* HX:
* Epigastric/RUQ pain steady, severe ± radiation to shoulder/back, worse with motion
* Preceded by/associated with fatty meal
* Anorexia, N/V
* Physical exam:
* Fever, tachycardia
* Tender abdo
* ± guarding
* ± Murphy sign
63
Describe investigations: Cholecystitis (4)
* U/S: thick wall, gallstones, dilated gallbladder
* ↑ WBC
* Bili, ALP, GGT usually normal
* hIDA: nonvisualized gallbladder
64
Describe HX (7) and physical exam (2): IBD
* HX:
* FTT/weight loss, fatigue
* Growth failure, pubertal delay
* Red eyes, mouth ulcers
* Abdo pain
* Perianal disease
* Diarrhea ± blood, mucus/pus, urgency, tenesmus
* Arthralgia, rashes
* Physical exam:
* Tender abdo ± RLQ mass
* Extraintestinal: fever, episcleritis, oral ulcers, pallor, digital clubbing, erythema nodosum, pyoderma gangrenosum, arthritis/sacroiliitis, perianal disease
65
Describe investigations: IBD (5)
* Anemia (iron deficiency and chronic inflammation)
* ↑ WBC and Plts, ↑ ESR/CRP
* Low albumin, vitamin D
* Stool positive for blood, WBC
* Upper endoscopy/colonoscopy, small bowel imaging
66
Describe HX (3) and physical exam (2): Testicular torsion
* HX:
* Severe sudden onset testicular or scrotal pain, ± inguinal/lower
* Abdo pain
* Nausea, vomiting ± fever
* Physical exam:
* Tender, swollen testicle, elevated ± horizontal lie
* Absent ipsilateral cremasteric reflex
67
Describe investigations: Testicular torsion
Scrotal doppler U/S: compromised testicular perfusion
68
Describe HX (3) and physical exam (2): Ectopic pregnancy
* HX:
* Sexually active
* Missed period
* Vaginal bleeding, pelvic pain
* Physical exam:
* Painful internal pelvic exam
* ± Peritonitis
69
Describe investigations: Ectopic pregnancy (2)
* serum b-HCG (slow rise)
* Pelvic U/S: absent intrauterine fetus ± visible ectopic pregnancy
70
Describe HX (5) and physical exam (3): Endometriosis
* HX:
* Dysmenorrhea
* ± Acyclic pelvic pain
* Abnormal vaginal bleeding
* Urgency, dysuria
* Dyschezia, constipation
* Physical exam:
* General pelvic tenderness
* ± Tender uterosacral ligaments, posterior uterus
* ± Fixed uterine retroversion
71
Describe investigations: Endometriosis (3)
* Pregnancy test negative
* Pelvic U/S: excludes other pathology, may see endometrioma
* Laparoscopy
72
Describe HX (2) and physical exam (2): Ovarian torsion
* HX:
* Sudden unilateral abdo/pelvic pain
* ± N/V
* Physical exam:
* Painful unilateral adnexa
* ± Peritonitis
73
Describe investigations: Ovarian torsion (2)
* Pregnancy test negative
* Pelvic U/S: ovarian torsion
74
Describe: Rome III Criteria for Functional Chronic Abdo pain disorders (7)
* All functional disorders→ no evidence of inflammatory, anatomic, metabolic, or neoplastic process to otherwise explain symptoms
* Functional dyspepsia: persistent/recurrentupper abdopain/discomfort, ≥1×/wk for ≥ 2 mo
* Irritable bowel syndrome: abdo pain/discomfort with ≥ 2 of 3 (pain improved by defecation, associated with change in frequency of stool or form of stool) for ≥ 25% of the time, ≥ 1× /wk for ≥ 2 mo
* Childhood functional abdopain: episodic/continuous abdo pain, ≥1×/wk for ≥ 2 mo
* Childhood functional Abdo pain syndrome: functional Abdo pain ≥ 25% of the time, with some loss of daily activity, headache, limb pain, or difficulty sleeping
* Abdo migraine: intense periumbilical pain for ≥1h, interferes with normal activities, associated with ≥ 2 of 6 (headache, photophobia, nausea, vomiting, pallor, anorexia), intervening usual health
* “Recurrent abdo pain” (RomeII): ≥ 3 episodes of pain severe enough to affect daily activities over ≥ 3 mo
75
Describe: Pediatric Appendicitis Score (PAS) (8)
* 1 point for each of:
* (1)Anorexia
* (2) nausea or vomiting
* (3) migration of pain
* (4)fever \> 38°C
* (5) WBC \> 10× 106/L
* (6) neutrophils + band forms \> 7.5 × 106 cells/L
* 2 points for each of:
* (7) RLQ tenderness
* (8) pain with cough or percussion
* PAS ≤2: low risk; PAS 3 to 6: intermediate risk → consider surgical consultation, serial exams; PAS ≥ 7: high risk → surgical consultation warranted
76
Describe: Hemolytic uremic syndrome (HUS) (3)
1. Acute kidney injury
2. Thrombocytopenia
3. Microangiopathic hemolytic anemia
77
Name: Diabetic ketoacidosis (DKA) Precipitants (4)
* Insulin deficiency (new Dx or missed insulin dose)
* Infection
* Ischemia
* Intoxication
78
Describe management: Constipation (4)
* Diet modification
* bowel routine
* increased fluids
* behavior modification
79
Describe management: Gastroenteritis (1)
Oral/IV rehydration; treat etiology
80
Describe management: UTI (1)
Antibiotics
81
Describe management: Functional/infantile colic (3)
* Patient/parent education, reassurance
* Address psychosocial issues
* Consider: allergy, probiotics
82
Describe management: Pancreatitis (6)
* Aggressive fluid resuscitation
* Monitor/correct electrolyte/metabolic disturbances
* Pancreatic rest (NPO vs. low-fat semi-elemental feeds) if pain limiting intake
* Pain management
* Broad-spectrum antibiotics if necrosis
* Treat etiology
83
Describe management: Henoch-Schönlein Purpura (2)
* Supportive: rest, hydration, nutritional support, analgesia PRN
* Systemic corticosteroids for severe GI involvement (controversial)
84
Describe management: Hemolytic Uremic Syndrome (3)
* Monitor/correct fluids and lytes
* Red cell and Plt transfusions PRN
* Strict control of hypertension and nutrition; possible dialysis
85
Describe management: Acute intestinal obstruction (6)
* Stabilize ABCs
* IV fluid resuscitation
* Broad-spectrum antibiotics if suspect necrosis/ perforation
* NPO/NG tube decompression
* Treat etiology
* Surgical:
* If necrosis/perforation
* If no improvement within ~24 h
* If “ de novo” or closed-loop obstruction
86
Describe management: Appendicitis (2)
* IV antibiotics if perforated
* Appendectomy
87
Describe management: Intussusception (2)
* IV resuscitation, NG decompression Reduction with air contrast enema
* Surgical: If symptoms \>24 h or signs of peritonitis
88
Describe management: Incarcerated hernia (2)
* Nonoperative reduction with sedation/analgesia if nonstrangulating
* Surgical: If unable to reduce or signs of peritonitis
89
Describe management: IBD (2)
* Immunosuppressive therapy (induction agent) once exclude active infection
* Surgical: Bowel resection/stricturoplasty if obstruction refractory to medical management
90
Describe management: Pyloric stenosis (2)
* IV resuscitation and correction of electrolyte derangements if present
* Pyloromyotomy
91
Describe management: Malrotation with midgut volvulus (2)
* Fluid resuscitation if hemodynamically unstable
* Laparotomy with Ladd procedure
92
Describe management: Duodenal atresia/stenosis (1)
Surgical: Duodenoduodenostomy or duodenojejunostomy
93
Describe management: Testicular torsion (2)
* Attempt at manual detorsion with sedation/ analgesia
* Surgical: Detorsion with orchiopexy or testicular removal (if necrotic)
