22 Flashcards
Diff dx for abdominal pain and vomiting 12
Appendicitis
Always consider in a child or adolescent with acute abdominal pain.
Classic pattern (60% of the time) is periumbilical pain followed by generalized RLQ abdominal pain.
Vomiting is very common; while diarrhea is uncommon (typically patients have had no bowel movements in the past several hours).
Cholecystitis
Pain, most often in the RUQ, is steady, and may radiate to the shoulder.
Pain is usually constant and worse after eating, especially fatty foods.
Episodes may be intermittent (colicky) and accompanied by decreased appetite, nausea, and vomiting.
Cholecystitis is less common in children than in adults, but does occur.
Ectopic pregnancy
Strongly consider in any sexually active female patient with abdominal pain (it is an emergency).
Ectopic pregnancy classically presents with lower abdominal pain, vaginal bleeding, and abnormal menstrual history.
Fever and diffuse abdominal pain are uncommon
A history of vomiting without diarrhea suggests extra-intestinal pathology.
Hepatitis
Usually presents with fever, malaise, diffuse or RUQ abdominal pain, nausea, and vomiting without diarrhea.
Patients will often comment on jaundice and a change in the color of their urine.
Onset of symptoms depends on the etiology of the hepatitis
Alcohol use may either directly cause hepatitis or predispose an individual to increased risk-taking behavior and the acquisition of infectious hepatitis.
Pancreatitis
May present with diffuse abdominal pain, but other patterns (such as epigastric or RUQ) are more common; band-like pain radiating to the back is highly suggestive.
Pain is constant and usually severe.
Nausea and vomiting are almost always present.
Causes of pancreatitis include gallbladder disease, infection, alcohol use, injury, certain medications, and inherited conditions.
Pelvic inflammatory disease
Presents with abdominal pain in almost all cases, more typically in the lower abdomen; RUQ pain can occur with perihepatitis—Fitz-Hugh-Curtis syndrome—an occasional complication (5% of cases) of PID caused by N. gonorrhoeae or C. trachomatis (this pain is of sudden onset and may refer to the right shoulder).
Vomiting is seen in some but not all cases of PID.
While a history of sexual activity makes PID much more likely (the highest rates of PID are in sexually active girls 15-19 years of age), PID must be considered in a young woman with acute abdominal pain, even if there is no history of sexual activity.
Urinary tract infection (UTI)
UTIs in older children usually present with dysuria, frequency, and urgency.
Poorly localized abdominal pain occasionally occurs with a UTI; fever or back pain suggests pyelonephritis.
Previous history of UTIs may suggest underlying structural abnormalities that would increase the risk of infection.
More common in sexually active women.
Acute gastroenteritis
Though vomiting is a common presenting complaint in acute gastroenteritis.
After a couple of days, diarrhea typically becomes the most pronounced symptom.
May reveal history of sick contacts.
Incarcerated hernia
A hernia that can no longer be reduced to its usual position with manipulation.
Rates of incarceration vary, but most present before one year of age.
Occur slightly more often in girls, and an ovary may be in the hernia instead of intestine.
Incarcerated hernias are painful, and irritability is a common symptom.
Vomiting and abdominal distention might occur if intestinal obstruction has occurred as a result of the incarceration.
On physical examination, you will find a tender mass in the groin or labia majora if the hernia is in the inguinal region.
Mesenteric adenitis
Inflammation of the mesenteric lymph nodes.
Has many causes and often presents like appendicitis.
Typical presentation is of RLQ pain with fever, vomiting, and diarrhea.
Ovarian torsion
Can happen in any age group but is more common in post-menarchal women.
Abdominal pain is a common symptom, often described as stabbing.
Most typically occurs in the lower abdomen or pelvic region.
Nausea and vomiting are also seen in the majority of patients.
Pneumonia
An uncommon but important case of abdominal pain in young children.
Irritation of the pleura by a lower lobe infection causes pain.
Cough, difficulty breathing, rhinorrhea, and chest pain are common.
Testicular torsion
Presentation
Intervention
Testicular torsion is a urologic emergency in which the goal is to save the affected testis.
Presentation
Usually occurs in early adolescence and presents with acute onset of severe hemi-scrotal pain, nausea, and vomiting.
Physical examination reveals an enlarged tender testis, scrotal edema, and absence of the cremasteric muscle reflex.
Prompt Intervention
If torsion is suspected, an emergent urology consult is indicated.
The diagnosis is made mainly by clinical suspicion.
Color Doppler ultrasound or nuclear testicular scan may be useful but should not delay treatment if the diagnosis is evident.
Surgical exploration and detorsion must occur promptly, because irreversible changes in the testis can occur within four hours.
Appendicitis acute in children
Rare in children under 2
Presents atypically so is often missed
Teenage F with abdominal pain - 2 things to do after Hx and PE
A pelvic examination (C) should be performed in any sexually active adolescent girl with abdominal pain. You need to perform a rectal exam (E) as well.
Pelvic inflammatory disease SXS
What cause RUQ pain PID
Documenting the presence of cervical motion tenderness (C) or adnexal or uterine tenderness is important when making the diagnosis of PID. PID is a clinical diagnosis.
Also purulent cervical discharge
Fitz-Hugh-Curtis syndrome is characterized by RUQ pain in association with PID typically caused by Neisseria gonorrhoeae or Chlamydia trachomatis. Infectious material may spill from the uterus and track along the paracolic gutter and cause inflammation of the hepatic capsule and diaphragm. This results in RUQ pain and referred scapular pain.
Physical exam findings for some abdominal conditions 7
Appendicitis
Although fever is often seen with appendicitis, it is a non-specific finding.
Tenderness over McBurney’s point is commonly seen in adults, but less frequently found in children.
Diffuse abdominal tenderness is possible (as in the case of peritonitis due to a ruptured appendix).
Cholecystitis
RUQ tenderness is usually seen with cholecystitis.
Murphy’s sign (increased pain upon palpation of the area when the patient takes a deep breath) is a finding specific for cholecystitis.
Ectopic pregnancy
Physical examination may be completely normal in an early, unruptured ectopic pregnancy
More rarely, diffuse abdominal tenderness, adnexal or cervical motion tenderness may also be seen.
Mild enlargement of the uterus may be present.
Fever is not a usual characteristic of an uncomplicated ectopic pregnancy.
Hepatitis
RUQ pain, jaundice, and hepatomegaly are common findings.
Pancreatitis
Low-grade fevers are common.
May have diffuse abdominal tenderness or pain more localized to the epigastric region.
PID
Fever and diffuse abdominal pain are both consistent with PID
Pain localized to the RUQ may also be seen, especially in some forms.
Cervical motion tenderness is highly suggestive (if not almost diagnostic!).
Purulent cervical discharge is also highly suggestive of PID.
UTI
CVA tenderness may be seen, but is not a constant finding at any age.
PID Epidemiology Microbiology Dx Complications
Epidemiology
Sexually active females ages 15 to 19 years are at highest risk because of both biological and behavioral factors:
At this age, there are fewer protective antibodies in the vagina (compared to those in older women).
Another reason is the cervical ectropion which represents the transitional zone between the columnar and the squamous epithelium is not fully matured; cells in this zone are particularly susceptible to STDs, and the cervix is therefore easier to infect.
Behavioral factors include intercourse during menses, infrequent or no condom use, and multiple sexual partners.
Microbiology
The most common organisms to cause PID (> 50% of cases) are Neisseria gonorrheoea or Chlamydia trachomatis
Lower-tract infection with these pathogens leads to an alteration of the normal vaginal flora and allows bacteria such as E. coli, Bacteroides species, other anaerobes, Mycoplasma hominis or Ureaplasma urealyticum access to the uterus and fallopian tubes.
Diagnosis
Diagnosis of PID is based on a combination of clinical findings:
Cervical motion tenderness
Abdominal pain
Cervical discharge
and laboratory tests:
Culture for bacteria
Molecular diagnostic tests (e.g., NAAT) on urine or cervical discharge for Chlamydia and N. gonorrhea.
(Although a gram stain was ordered for Mandy, most practitioners no longer obtain a gram stain.)
Complications
The most worrisome long-term morbidity is increased rates of infertility. Other complications with PID include:
Sepsis
Tubo-ovarian abscess, or
Other intra-abdominal abscesses.
Hospitalization of patient wth PID 5
The decision to hospitalize a patient diagnosed with pelvic inflammatory disease should be individualized. Reasons to hospitalize a patient include:
Pregnancy
Previous noncompliance
High fever
Intractable vomiting
Inability to exclude a surgical emergency
STIs that have to be reported 4
All states require reporting of STIs, including chlamydia, gonorrhea, syphilis, and chancroid.
