Abdo pain + vomiting Flashcards
Important features to ascertain on history for child presenting with abdo pain/vomiting?
- Age of child
- Location, onset, progression
- Vomit - bilious vs. non-bilious, blood/coffee grounds
- Associated features - infective, rash, resp symptoms, UTI, DKA features, migraine features, inguinoscrotal
- Context - travel, sick contacts
- PMHx - diabetes, hernia, migraine, surgery
- FHx - pyloric stenosis (maternal esp.), diabetes
- Adolescence - menstrual and sexual history - STI, ectopic pregnancy
Important features on examination of child presenting with abdo pain/vomiting?
- General - colour, posturing, well vs. unwell, rash, temp & vitals
- Abdo - masses (pyloric mass, faeces, distention), peritonitis, visible peristalsis
- Fluid assessment
- Inguinoscrotal - scrotal swelling, hernia
What are the DDx for non-bilious vomit?
Most common causes are not surgical
Infection - sepsis most common cause of vomiting in children. UTI, meningitis, gastro
Reflux, overfeeding
Pyloric stenosis
What are the DDx for bilious vomit?
Malrotation with volvulus until proven otherwise (grassy green)
What Ix to consider in child presenting with abdo pain/vomiting?
Urine - urinanalysis, MCS, ketones, glucose, pregnancy
Blood tests - B-hCG, FBE, U&Es, LFTs, lipase, acid-base/blood gas
Imaging - CXR - pneumonia, erect AXR - obstruction (not helpful in constipation or malrotation), U/S (pyloric stenosis, intersussception, malrotation)
What are the clinical features of pyloric stenosis?
Vomiting after soon after feeding in infants (peak age 2-6 weeks of age but rarely commencing >12 weeks)
Sudden onset, progressively more forceful in nature (projectile). Copious volume, milky and sometimes blood/coffee grounds (2o gastritis)
Non-bilious
Child appears well, hungry and wants to feed again after vomiting
Eventually leads to weight loss/poor weight gain and dehydration
Examination - signs of dehydration, abnormal growth chart, palpable pyloric mass/olive (RUQ), visible peristaltic waves, rarely jaundice
What are risk factors for pyloric stenosis?
Male (5:1)
Caucasian
FHx - esp. if maternal hx
First born
Diagnosis of pyloric stenosis?
Palpable pyloric mass (olive) in RUQ sufficient for clinical diagnosis and treatment/referral
If unsure/no palpable mass - U/S to confirm (95% sensitive, visualise thickened circular muscle of pylorus)
How should pyloric stenosis be Ix?
Bloods - FBE (exclude infection, anaemia), U&Es (hydration, hypochloraemia, hypokalaemia), LFTs (bilirubin)
Acid-base/ABG - metabolic alkalosis
Urinanalysis - paradoxical urine acidosis (compensatory to preserve Na)
What are the DDx for pyloric stenosis?
Cow’s milk protein intolerance - would expect blood in stools (colitis), hx cow’s milk consumption, cow’s milk protein/soy protein formula or high maternal consumption if BF
Obstruction
Reflux
Liver disease - i.e. biliary atresia
What is the Rx for pyloric stenosis?
- Early surgical referral
- Management of dehydration & electrolyte imbalance BEFORE surgery
- NS + dextrose and add KCl once voiding if required
- NBM +/- NGT on free drainage if continue to vomit - Monitor - U&Es, acid-base (4-6 hourly) and adjust fluids as needed
What is intussusception?
Invagination/telescoping of the small bowel on it’s self
Usually in the distal ileum
Due to hyperplasia of gut lymphoid tissue
What are risk factors/associated factors of intussusception?
Male Rotavirus vaccine (peyer's patch tissue enlargement) Enteric infection - viral or bacterial Polyps** Meckel's diverticulum* HSP
What are the clinical features of intussusception?
Peak age 5 -7 months, but consider in child 3 months - 2 years
Sudden onset of vomiting
Non-bilious vomit, but can become bilious as obstruction progresses - EARLY sign
A FEW lose stools initially, constipation later (LATE sign) - helps differentiate b/w gastro
During episodes of vomiting child is pale, floppy and hikes up legs
Appears anxious and pale
Red current jelly stools - LATE sign
Abdominal distention - LATE sign
Abdo pain - intermittent/colicky initially, can become constant, variable severity
Palpable sausage-shaped abdominal mass - typically RUQ but can be LUQ
~30% have hx of recent preceding URTI/flu-like symptoms
How do you diagnose intussusception?
Clinical diagnosis
Can confirm with U/S if unsure - highly sensitive & specific
What Ix can be considered for intussusception?
U/S - very good
AXR - not good, can appear normal
FBE - infection
U&Es - fluid status
What is the Rx of intussusception?
- Fluid resuscitation and warming first
- Aim to reduce obstruction:
1st = gas enema
2nd = barium contrast enema
3rd = surgical reduction
Surgical reduction if gas enema fails or signs of necrosis/peritonitis
What are the risk factors for inguinal hernia?
Prematurity - bilateral
Male
Fhx - high familial incidence
What is the most common type of inguinal hernia?
Indirect
Also most common cause of complications in inguinal hernia
What age group most likely associated with strangulated inguinal hernia?
What is the peak age of presentation for inguinal hernia?
<6 months for strangulation
Boys 3 months
More even spread across ages in females
In boys, which is the most common side affected by inguinal hernia & why?
The right side as the right testes descends later
What are the complication of strangulated/incarcerated inguinal hernia?
Obstruction
Ischaemia/infarction
Testicular ischaemia and atrophy
What is the typical presentation of strangulated inguinal hernia?
Boy aged 3 months
Hx of intermittent non-painful groin bulge associated with irritability (i.e. noticed during nappy changes)
When strangulated - non-reducible, hard/tense, painful lump, not irreducible and no cough or cry impulse
Acute groin swelling
May have signs of peritonism if ischaemia
What is the treatment of inguinal hernia?
Reduce hernia (usually surgeon can) + analgesia and surgical management within 48 hours
What is Hirschsprung disease and what age does it present?
Congenital abnormality of the innervation of the colon
Presents in the first few days of life usually - 80% within 6 weeks
What is the presentation of Hirschsprung disease?
Failure to pass meconium (within 24hrs)
Marked but gradual abdominal distention
Bilious vomiting
Severe constipation
What is the Ix and Rx of Hirschsprung disease?
Confirm diagnosis with rectal biopsy and exclude other surgical causes (i.e. obstruction)
Supportive management initially followed by surgical
What are risk factors for Hirschsprung disease?
Male (4:1)
Down syndrome
What is malrotation with volvulus?
Congenital abnormality of the hind gut which increases risk of twisting of mysentery and subsequent volvulus
9/10 will have no problems but 1/10 will have obstruction
When does malrotation with volvulus most commonly present?
Typically within first week of life
Can occur during infancy and rarely >1 year
What are the complications of malrotation?
Obstruction - ischaemia/infarction
intersussception
Recurrent obstruction
What are common bowel symptoms <6 months?
Painful poo (dyschezia) - strain or cry Some may only pass stools once per week This is not constipation unless stools are small and hard
What is the most common cause of constipation? What are other causes?
Functional most common - painful defecation leading to avoidance
If occuring <6 weeks this is a red flag Hirschsprung Imperforate anus Obstruction Cows milk allergy Malabsorptive diseases Hypothyroidism Hypocalcaemia
What is the Rx of constipation?
1st = behavioural modifications (toilet sits, posturing, encouragement/+ve reinforcement) and diet
2nd = osmotic or softener laxatives (macrogol, lactulose, paraffin oil)
3rd (impaction) = higher dose macrogol with maintenance dosage (~6 months)
If < 6 months = coloxyl drops
If 6-12 months = coloxyl drops or lactulose
What are the clinical features of constipation?
Altered stools - infrequent passing, small, hard stools
New onset faecal incontinence
Hx painful defecation
Palpable faeces in abdomen
What is Meckel’s diverticulum?
Failure of the closure of an omental duct
What are the complications of Meckel’s diverticulum? What age are they most common?
Intusussception
Diverticulitis
Perforation
Obstruction
<2 years complications more common
What is the clinical presentation of Meckel’s diverticulum?
usually asymptomatic
Rarely PR bleeding
Later abdominal pain
May present with complications
What are the clinical features of malrotation with volvulus?
Bilious vomit - grassy green (main symptom)
Usually no other clinical findings - abdominal distention may occur later
What are the Ix and Rx of malrotation with volvulus?
Upper GI contrast study to confirm diagnosis - C shape is normal and S-shape is volvulus
U/S can be helpful
AXR not usually helpful
Rx = surgical reversal of volvulus + appendix removal (to exclude as DDx with future abdo pain presentations)
What is the Ix and Rx of Meckel’s diverticulum?
Meckel’s (technetium) scan to confirm diagnosis
Surgical resection in symptomatic
What are the diagnostic difficulties in appendicitis in kids?
Difficult to diagnose in children <5 years
They present atypically - usually minimal vomiting, diarrhoea, diffuse abdominal pain
What ages does appendicitis most commonly occur?
More common in school age + children than <5 years
What are the general clinical features?
Absent or low fever
Vomiting ++
+/- some lose stools
Localised abdo pain - McBurney’s point tenderness
What are the examination considerations in appendicitis in kids?
Rebound tenderness should not be performed - cruel + unreliable sign in kids
Should give analgesia prior to examining
Most reliable clinical sign = local tenderness with some rigidity over McBurney’s point
How do <5 with appendicitis more commonly present?
Atypical presentation - no/minimal vomiting and abdo pain, diffuse abdo pain, diarrhoea
With complications - perforation, sepsis
What are the Ix and Rx for appendicitis?
Urine - exclude UTI U/S - thickened appendix, free fluid surrounding Analgesia Prophylactic antibiotics Surgical removal
What is mesenteric adenititis?
Inflammation of the mesenteric lymph nodes
What ages does mesenteric adenititis most commonly occur?
Very common in school aged children
Peak in 10 - 12 years
What are the causes of mesenteric adenititis?
Gastroenteritis - bacterial or viral
Most commonly viral
What are the clinical features of mesenteric adenititis?
Mimics appendicitis - often RIF pain as this is location of LNs
Pain can be variable
Very high fever - main clinical differentiating factor with appendicitis
Guarding rarely present
What are the Ix and Rx for mesenteric adenititis?
U/S to exclude appendicitis and other surgical causes - LNs >10 mm and normal appendix
Supportive management - analgesia, rest, fluids and antibiotics if suspect bacterial gastro
What is HSP?
Small vessel vasculitis
What ages does HSP typically occur?
Peak presenting age 2 - 8 years
Relatively common
What is the typical clinical presentation of HSP?
Classic triad - abdominal pain, joint pain followed by non-blanching purpuric rash
May have been preceeded by URTI
Other symptoms less common - PR bleeding
What are the complications of HSP?
Abdominal - intusussception most common
Renal - haematuria and HTN - similar histology to IgA nephropathy
What are examination findings of HSP?
HTN - renal complications
Urinanalysis - haematuria - renal complications
Acute scrotal swelling
Painful subcutaneous oedema
What are other DDx for HSP?
Rash - meningoccocal disease, ITP, trauma, viral, leukaemia
Abdo pain/scrotal swelling - testicular pathology
What are the Ix and Rx for HSP?
Exclude other DDx rash and abdo pain
Urinanalysis and consider FBE, U&Es, blood culture
Admission - monitor urine and blood pressure
Supportive
Consider prednisolone - reduces duration and risk of abdo complications but not renal complications
What DDx for abdo pain/vomiting should be considered in neonates & infants?
Pyloric stenosis Hirshsprungs disease Malrotation with volvus Intusussception Incarcerated hernia Meckel's diveriticulum UTI
Gastro, viral illness
What DDx for abdo pain/vomiting should be considered in pre-school age children?
Constipation Malrotation Intusussception UTI Pneumonia Appendicitis HSP Testicular torsion
What DDx for abdo pain/vomiting should be considered in school aged children?
Mesenteric adenitis Appendicitis Constipation UTI Pneumonia Testicular torsion Ovarian pathology HSP DKA Migraine
What additional DDx should be considered for abdo pain/vomiting in adolescents?
Ectopic pregnancy STI Biliary Pancreatic Renal calculi DKA
