19. Abdo pain and vomiting

Question 1

What happens in malrotation and when does it typically occur?

Answer 1

Volvulus usually happens with malrotation, typically occurs in 1st wk/mth of life
Malrotation= DJ flexure stays on the right, and so does the small bowel so it’s easier for the bowel to twist

Question 2

presentation of malrotation with volvulus?

Answer 2

bile coloured vomiting.

Question 3

Why is vomited bile green?

Answer 3

bile is naturally yellow but if goes through stomach acid makes it green

Question 4

What is the best invx for malrotation with volvulus?

Answer 4

upper GI contrast study to see orientation of gut and duodenum (normal C shape- S is malrotation)

Question 5

Tx of malrotation

Answer 5

surgery- Ladd’s procedure - derotate all gut, widen mesentery, but small bowel on right side and large bowel on left.

Question 6

What happens if kids present with malrotation and volvulus late?

Answer 6

passing blood PR - indication that gut is dying

Question 7

What is the most common bowel obstruction?

Answer 7

pyloric stenosis - 1/300- most common cause of non bilious vomiting other than sepsis

Question 8

typical age, type of vomiting for pyloric stenosis

Answer 8

3-6 wks - non bilius projectile vomiting (stomach strong, peristaltic wave projects back on itself), hungry afterwards (unlike gastro)

Question 9

metabolic derangements with pyloric stenosis?

Answer 9

metabolic alkalosis, hypochloremic, hypokalemic- vomited out NaCL and K+
Not hyponatremic because Na is the most important electrolyte to have and will be conserved til the laslt moment.

Question 10

Urine in pyloric stenosis?

Answer 10

is actually acidotic cause desparately holding onto sodium- Na/H shunt - shunt out H+ and keep Na

Question 11

Fixing pyloric stenosis?

Answer 11

medical first: rehydrate, K and Cl back to normal (danger of cardiac arrest)
surgery:tear pylorus- division of hypertrophic muscle

Question 12

What is the most common obstruction outside the pyloric area?

Answer 12

intussusception- invagination of proximal into distal bowel

Question 13

age of intussusception- why?

Answer 13

3mths to 3 yrs, peak incidence 6 mths due to introduction of solid foods and increase in MALT proliferation (pushing LNs along > intussusception)

Question 14

presentation of intussusception?

Answer 14

pain, hot, pale, nausea, sweaty, look terrible- in waves as contractions come and go. pull legs up to decrease pain.
May have palpable mass, redcurrent jelly stool is a late sign

Question 15

dx intuss

Answer 15

US- see small bowel into small/big- usually on right side

Question 16

how to tx intuss

Answer 16

gas reduction enema in radiology- fluid, abx, pain> then rubber cather up bottom> pushgas up bowel- works quite well

Question 17

pathological reasons for intuss?

Answer 17

meckel's diverticulum (slight bulge in small intestine at birth due to incomplete omphalomesenteric duct obliteration)
polyp
HSP
vascular malformation
ca

Question 18

Fluid regime with pyloric stenosis

Answer 18

150ml/kg/day: 0.45% NaCl with 5% dextrose, add 20mmol KCl/L after confirming K level

Question 19

sequelae of intussusception

Answer 19

• dehydration
• bowel obstruction
• bowel ischaemia leading to perforation

Question 20

differential dx intuss

Answer 20

colic
gastroenteritis
mesenteric adenitis
meckel's 
ing hernia

Question 21

investigation of choice for intuss

Answer 21

U/s> see ‘target sign”

Question 22

peak incidence of appendicitis

Answer 22

10-12 yrs

Question 23

signs of appendicitis

Answer 23

abdo pain lasting> 4 hrs
diarrhoea 24hrs
infant who prefers to lie still

Question 24

diff dx appendicits

Answer 24

gastroenteritis
mesenteric adenitis
UTI
right lower lobe pneumonia
testicular torsion
constipation

Question 25

‘medical student’ presentation of appendicitis

Answer 25

- periumbilical pain with shift to RIF +/- vomiting, anorexia
signs:
- lying still
- pallor 
- fetor
- low grade fever
- guarding RIF

Question 26

presentation of retrocaecal appendicitis

Answer 26

vague non localising RIF pain with deep RIF tenderness - often without guarding. Differential diagnosis from mesenteric adenitis can be difficult

Question 27

presentation pelvic appendicitis

Answer 27

lower abdo pain and tenderness
urinary sxs
small vol diarrhoea

Question 28

How does perforated appendicitis present? in who is the risk of this greater?

Answer 28

generalised peritonitis

greater in young ppl - communication difficult, assumed to be viral

Question 29

imagin with appendicitis

Answer 29

US, AXR

Question 30

treatment of app

Answer 30

• Important: correct dehydrationand electrolyte disturbance first
• lap app

Question 31

What is mesenteric adenitis?

Answer 31

inflammation of mesenteric lymph nodes