12- Paediatric Gastroenterology Flashcards
Abdominal pain Background
Very common and split into:
- Non-organic causes/ functional
o very common in >5 years
- medical causes
- surgical causes
abdominal pain causes
Medical causes
- Constipation is also very
common (ALWAYS CONSIDER) -> often coincides with eating - Urinary tract infection
- Coeliac disease
- Inflammatory bowel disease
- Irritable bowel syndrome
- Mesenteric adenitis
- Abdominal migraine
- Pyelonephritis
- Henoch-Schonlein purpura
- Tonsilitis
- Diabetic ketoacidosis
- Infantile colic
There are addition causes in adolescent girls: - Dysmenorrhea (period pain)
- Mittelschmerz (ovulation pain)
- Ectopic pregnancy
- Pelvic inflammatory disease
- Ovarian torsion
- Pregnancy
surgical causes of abdominal pain
- Appendicitis causes central abdominal pain spreading to the right iliac fossa
- Intussusception causes colicky non-specific abdominal pain with redcurrant jelly stools
- Bowel obstruction causes pain, distention, absolute constipation and vomiting
- Testicular torsion causes sudden onset, unilateral testicular pain, nausea and vomiting
Red flags for abdominal pain
- Persistent or bilious vomiting
- Severe chronic diarrhoea
- Fever
- Rectal bleeding
- Weight loss or faltering growth
- Dysphagia (difficulty swallowing)
- Nightime pain
- Abdominal tenderness
investigations for abdominal pain
- Anaemia can indicate inflammatory bowel disease or coeliac disease
- Raised inflammatory markers (ESR and CRP) can indicate inflammatory bowel disease
- Raised anti-TTG or anti-EMA antibodies indicates coeliac disease
- Raised faecal calprotectin indicates inflammatory bowel disease
- Positive urine dipstick indicates a urinary tract infection
Functional abdominal pain
Examples
e.g. Recurrent abdominal pain syndrome
e.g. Abdominal migraine
A child presenting with repeated episodes of abdominal pain without identified underlying cause
- Psychosocial problems- e.g. missed days at school and parental anxiety
functional abdominal causes
- Non-organic o/ functional
- Often corresponds to stressful life events such as bullying
pathophysiology of functional abdominal pain
Leading theory for the cause is increased sensitivity and inappropriate pain signals from the visceral nerves (the nerves in the gut) in response to normal stimuli.
Management of functional constipation
Careful explanation and reassurance
- Distracting the child from the pain with other activities
- Encourage parents not to ask about or focus on the pain
- Advice about sleep, regular meals, healthy balanced diet, staying hydrated, exercise and reducing stress
- Probiotic supplements may help symptoms of irritable bowel syndrome
- Avoid NSAIDs such as ibuprofen
- Address psychosocial triggers and exacerbating factors
- Support from a school counsellor or child psychologist
abdominal migraine background
This may occur in young children before they develop traditional migraines as they get older. Abdominal migraine presents with episodes of central abdominal pain lasting more than 1 hour.
presentation of abdominal migraine
Examination will be normal.
- Signs
o Nausea and vomiting
o Anorexia
o Pallor
o Headache
o Photophobia
o Aura
management of abdominal migraine
Management of abdominal migraine is similar to migraine in adults. Careful explanation and education is important. It involves treating acute attacks and preventative measures. Preventative medications are initiated by a specialist.
abdominal migraine treating an attack
o Low stimulus environment (quiet, dark room)
o Paracetamol
o Ibuprofen
o Sumatriptan
preventative medications
- Pizotifen, a serotonin agonist
Main preventative medication to rmemeber for abdominal migraine - Propranolol, a non-selective beta blocker
- Cyproheptadine, an antihistamine
- Flunarazine, a calcium channel blocker
Pizotifen
MOA: Serotonin agonist
Needs to be withdrawn slowly when stopping due to withdrawal
* Depression
* Anxiety
* Poor sleep
* Tremor
coeliac disease background
Autoimmune condition where exposure to gluten causes an immune reaction that creates inflammation in the small intestine
- Usually develops early childhood
pathophysiology of coeliac disease
- Autoantibodies are created response to gluten (gliadin)
–> IgA Anti-tissue transglutaminase (anti-TTG) and anti-endomysial (anti-EMA)
–> These antibodies rise and fall with disease activity - These antibodies target the epithelial cells of the intestine and lead to inflammation
- Location: small bowel (jejunum particularly)
–> Causes atrophy of intestinal villi
–> Villi important for absorbing nutrient malabsorption and symptoms
RF of coeliac disease
- Female
- T1DM
- Hereditary: HLA-DQ2 gene (90%) and HLA-DQ8 gene
- DS
- Autoimmune thyroid disease
Coeliac disease presentation
is often asymptomatic, so have a low threshold for testing for coeliac disease in patients where it is suspected. Symptoms can include:
* Failure to thrive in young children
* Diarrhoea
* Fatigue
* Weight loss
* Mouth ulcers
* Anaemia secondary to iron, B12 or folate deficiency
* Dermatitis herpetiformis is an itchy blistering skin rash that typically appears on the abdomen
Rarely coeliac disease can present with neurological symptoms:
due to vitamin E deficiency
* Peripheral neuropathy
* Cerebellar ataxia
* Epilepsy
coeliac disease investigation
- Patient must remain on gluten diet when investigations are happening (otherwise inflammation and antibodies may be missing)
- TEST: total immunoglobulin A levels to exclude IgA deficiency before checking for coeliac disease specific antibodies
o Raised anti-TTG antibodies (first choice)
o Raised anti-endomysial antibodies
coeliac disease: why check IgA first
total immunoglobulin A levels to exclude IgA deficiency before checking for coeliac disease specific antibodies
pathophysiology of Hirschsprungs
- Nerve cells of myenteric plexus (Auerbach’s) are absent in the distal bowel and rectum
o Auerbach’s forms the enteric nervous system – brain of the gut - Auerbach’s runs all the way along the bowel in the bowel war and is a complex network of neurones, ganglion cells, receptors, synapses and NT
o Causes peristalsis of the large bowel
o Without this stimulation -> bowel loses motility and food cannot pass food along - Key pathology: absence of parasympathetic ganglion cells – responsible for peristalsis
- Foetal development of the parasympathetic ganglion cells
o During fetal development these start in the upper GI tract and gradually migrate down the distal colon and rectum -> in Hirschsprung’s these cells do not travel all the way down the colon- therefore a section of the colon is left without these parasympathetic ganglion cells
o Aganglionic sections of the colon cannot relax-> therefore become constricted
o Proximal bowel will become distended and full
