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Essentials - Pediatrics > 10. Abdominal Pain in Pediatrics > Flashcards

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
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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.
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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.
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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
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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
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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
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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
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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
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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
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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
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11
Q

Name causal conditions of abdominal pain in paediatrics according to the age of onset (Figure)

A
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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
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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
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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

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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)
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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)
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17
Q

Name mainly clinical dx (6)

A
  • Henoch-Schönlein Purpura
  • Appendicitis
  • Infantile colic
  • Incarcerated hernia,
  • Gastroenteritis
  • GERD
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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)
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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
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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”)
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21
Q

Describe investigations: Pyloric stenosis (2)

A
  • U/S: hypertrophied pylorus (increased muscle thickness and length)
  • Lytes/blood gas: hypochloremic, hypokalemic metabolic alkalosis
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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
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23
Q

Describe investigations: Duodenal atresia (2)

A
  • AXR: “double bubble” sign, absent distal abdo gas
  • Upper GI series: duodenal obstruction
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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
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25
Q

Describe investigations: Infantile colic (1)

A

Clinical Dx (Rome III criteria)

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26
Q

Describe HX (9) and physical exam (2): Gastroesophageal reflux/GERD

A
  • 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
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27
Q

Describe investigations: Gastroesophageal reflux/GERD (4)

A
  • 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
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28
Q

Describe HX (4) and physical exam (4): Incarcerated inguinal hernia

A
  • 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
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29
Q

Describe investigations: Incarcerated inguinal hernia (3)

A
  • Clinical
  • AXR (may see lower GI obstruction or air bubble in groin)
  • U/S
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30
Q

Describe HX (6) and physical exam (3): Intussusception

A
  • 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
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31
Q

Describe investigations: Intussusception (2)

A
  • Air contrast enema: obstruction (filling defect), air fluid levels, absence of gas in RLQ
  • U/S: target sign (bowel within bowel), tubular mass
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32
Q

Describe HX (3) and physical exam (2): Malrotation with mid-gut volvulus

A
  • 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
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33
Q

Describe investigations: Malrotation with mid- gut volvulus (2)

A
  • 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)
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34
Q

Describe HX (8) and physical exam (4): UTI

A
  • 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
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35
Q

Describe investigations: UTI (3)

A
  • Urine R&M (WBC, nitrites, leukocyte esterase)
  • C&S
  • Controversy in workup after 1st UTI: renal U/S ± Voiding Cystourethrogram
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36
Q

Describe HX (4) and physical exam (3): Constipation

A
  • 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
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37
Q

Describe investigations: Constipation (2)

A
  • Clinical (Rome criteria for functional constipation)
  • AXR: fecal impaction (excessive stool in colon)
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38
Q

Describe HX (4) and physical exam (2): Gastroenteritis

A
  • 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
Q

Describe HX and physical exam:

A
  • HX:
  • Physical exam:
40
Q

Describe investigations:

A
41
Q

Describe HX and physical exam:

A
  • HX:
  • Physical exam:
42
Q

Describe investigations:

A
43
Q

Describe investigations:

A
44
Q

Describe HX and physical exam:

A
  • HX:
  • Physical exam:
45
Q

Describe HX (4) and physical exam (2): Gastroenteritis

A
  • 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
Q

Describe HX (2) and physical exam (8): Pneumonia

A
  • 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
Q

Describe investigations: Pneumonia (2)

A
  • CXR: focal consolidation, pleural effusion (atypical pneumonia w/ patchy diffuse opacifications)
  • Possible ↑ WBC
48
Q

Describe HX (5) and physical exam (3): Hemolytic Uremic Syndrome

A
  • 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
Q

Describe investigations: Hemolytic Uremic Syndrome (4)

A
  • CBCD, blood smear, haptoglobin & bilirubin: MAHA, thrombocytopenia
  • Cr:↑(ARF)
  • U/A: proteinuria, hematuria
  • Stool C&S: infection
50
Q

Describe HX (5) and physical exam (3): Henoch-Schönlein Purpura

A
  • 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
Q

Describe investigations: Henoch-Schönlein Purpura (5)

A
  • 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
Q

Describe HX (3) and physical exam (2): Urolithiasis

A
  • 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
Q

Describe investigations: Urolithiasis (3)

A
  • Radiopaque stones on AXR
  • Non-contras CT gold standard
  • U/S: obstruction of GU system, Hydronephrosis
54
Q

Describe investigations:

A
55
Q

Describe HX (4) and physical exam (3): Diabetic Ketoacidosis

A
  • HX:
    • N/V, anorexia
    • Dehydration, weight loss
    • Fatigue
    • Polyuria, polydipsia, polyphagia
  • Physical exam:
    • Dehydration
    • Diffuse abdo tenderness
    • Kussmaul breathing
56
Q

Describe investigations: Diabetic Ketoacidosis (3)

A
  • ↑ Blood glucose (> 11.1 mM)
  • ABG: WAG metabolic acidosis (Hco3 <15,pH<7.3)
  • Positive urine/serum ketones ± ↑ WBC, Cr, and BUN (hemoconcentration)
57
Q

Describe HX (2) and physical exam (3): Appendicitis

A
  • 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
Q

Describe investigations: Appendicitis (3)

A
  • U/S: thick-walled/dilated appendix ± appendicolith
  • CT: enlarged appendix, appendicolith, associated mesenteric fat stranding
  • ± ↑ WBC, ↑ neutrophils
59
Q

Describe investigations: Appendicitis (3)

A
  • U/S: thick-walled/dilated appendix ± appendicolith
  • CT: enlarged appendix, appendicolith, associated mesenteric fat stranding
  • ± ↑ WBC, ↑ neutrophils
60
Q

Describe HX (3) and physical exam (2): Pancreatitis

A
  • 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
Q

Describe investigations: Pancreatitis (3)

A
  • ↑ lipase , ↑ WBC
  • U/S: hypoechoic enlarged pancreas ± gallstones
  • CT: edema, necrosis, hemorrhage, peripancreatic fat stranding, pseudocyst
62
Q

Describe HX (3) and physical exam (4): Cholecystitis

A
  • 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
Q

Describe investigations: Cholecystitis (4)

A
  • U/S: thick wall, gallstones, dilated gallbladder
  • ↑ WBC
  • Bili, ALP, GGT usually normal
  • hIDA: nonvisualized gallbladder
64
Q

Describe HX (7) and physical exam (2): IBD

A
  • 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
Q

Describe investigations: IBD (5)

A
  • 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
Q

Describe HX (3) and physical exam (2): Testicular torsion

A
  • 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
Q

Describe investigations: Testicular torsion

A

Scrotal doppler U/S: compromised testicular perfusion

68
Q

Describe HX (3) and physical exam (2): Ectopic pregnancy

A
  • HX:
    • Sexually active
    • Missed period
    • Vaginal bleeding, pelvic pain
  • Physical exam:
    • Painful internal pelvic exam
    • ± Peritonitis
69
Q

Describe investigations: Ectopic pregnancy (2)

A
  • serum b-HCG (slow rise)
  • Pelvic U/S: absent intrauterine fetus ± visible ectopic pregnancy
70
Q

Describe HX (5) and physical exam (3): Endometriosis

A
  • 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
Q

Describe investigations: Endometriosis (3)

A
  • Pregnancy test negative
  • Pelvic U/S: excludes other pathology, may see endometrioma
  • Laparoscopy
72
Q

Describe HX (2) and physical exam (2): Ovarian torsion

A
  • HX:
    • Sudden unilateral abdo/pelvic pain
    • ± N/V
  • Physical exam:
    • Painful unilateral adnexa
    • ± Peritonitis
73
Q

Describe investigations: Ovarian torsion (2)

A
  • Pregnancy test negative
  • Pelvic U/S: ovarian torsion
74
Q

Describe: Rome III Criteria for Functional Chronic Abdo pain disorders (7)

A
  • 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
Q

Describe: Pediatric Appendicitis Score (PAS) (8)

A
  • 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
Q

Describe: Hemolytic uremic syndrome (HUS) (3)

A
  1. Acute kidney injury
  2. Thrombocytopenia
  3. Microangiopathic hemolytic anemia
77
Q

Name: Diabetic ketoacidosis (DKA) Precipitants (4)

A
  • Insulin deficiency (new Dx or missed insulin dose)
  • Infection
  • Ischemia
  • Intoxication
78
Q

Describe management: Constipation (4)

A
  • Diet modification
  • bowel routine
  • increased fluids
  • behavior modification
79
Q

Describe management: Gastroenteritis (1)

A

Oral/IV rehydration; treat etiology

80
Q

Describe management: UTI (1)

A

Antibiotics

81
Q

Describe management: Functional/infantile colic (3)

A
  • Patient/parent education, reassurance
  • Address psychosocial issues
  • Consider: allergy, probiotics
82
Q

Describe management: Pancreatitis (6)

A
  • 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
Q

Describe management: Henoch-Schönlein Purpura (2)

A
  • Supportive: rest, hydration, nutritional support, analgesia PRN
  • Systemic corticosteroids for severe GI involvement (controversial)
84
Q

Describe management: Hemolytic Uremic Syndrome (3)

A
  • Monitor/correct fluids and lytes
  • Red cell and Plt transfusions PRN
  • Strict control of hypertension and nutrition; possible dialysis
85
Q

Describe management: Acute intestinal obstruction (6)

A
  • 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
Q

Describe management: Appendicitis (2)

A
  • IV antibiotics if perforated
  • Appendectomy
87
Q

Describe management: Intussusception (2)

A
  • IV resuscitation, NG decompression Reduction with air contrast enema
  • Surgical: If symptoms >24 h or signs of peritonitis
88
Q

Describe management: Incarcerated hernia (2)

A
  • Nonoperative reduction with sedation/analgesia if nonstrangulating
  • Surgical: If unable to reduce or signs of peritonitis
89
Q

Describe management: IBD (2)

A
  • Immunosuppressive therapy (induction agent) once exclude active infection
  • Surgical: Bowel resection/stricturoplasty if obstruction refractory to medical management
90
Q

Describe management: Pyloric stenosis (2)

A
  • IV resuscitation and correction of electrolyte derangements if present
  • Pyloromyotomy
91
Q

Describe management: Malrotation with midgut volvulus (2)

A
  • Fluid resuscitation if hemodynamically unstable
  • Laparotomy with Ladd procedure
92
Q

Describe management: Duodenal atresia/stenosis (1)

A

Surgical: Duodenoduodenostomy or duodenojejunostomy

93
Q

Describe management: Testicular torsion (2)

A
  • Attempt at manual detorsion with sedation/ analgesia
  • Surgical: Detorsion with orchiopexy or testicular removal (if necrotic)

Essentials - Pediatrics (20 decks)

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