Abdomen Flashcards
Normal liver span children? (3)
Neonate: 5 cm
Prepubescent boy: 8 cm
Prepubescent girl: 7 cm
Therafter: <15cm
Describe the abdominal examination (14)
- Introduce, orientate, expose, position, consent
- General appearance: acute/chronic, syndromic features, equipment
- vitals
- anthropometry
- limbs: jaccold, koilonychia, leukonychia, palmar erythema
- face: sclera icterus, aniridia, kaiser Fleischer rings, neuroblastoma, corneal arcus, angular stomatitis, glossitis, aphthous ulcers, dental carries, macroglossia, pigmentation/polyps
- inspection: distension, striae, kaput medusae, spider naevi, hernia, drains/tubes/access, scars
- Palpate: light (rigidity, tender, guarding, masses)
- deep palpation: liver edge, gallbladder, spleen, kidney, descending aorta, fluid thrill
- percussion: shifting dullness, liver, suprapubic
- auscultate: normal / tinkling / absent bowel sounds, renal artery and aortic bruits
- genital examination (penile abnormalities, descended testes, scrotal swelling, external Genitalia )
- rectal: perforate, skin tags (Chrons), prolapse, underwear staining)
- summarise and differential
What is and causes picture 10? (4)
Palmar erythema
- chronic liver disease
- polycythaemia (excessive rbc)
- Kawasaki disease (mucocutaneous lymph node syndrome)
- Thyrotoxicosis
Name 5 broad causes of oedema and how differentiate
With proteinuria
- renal disease
Without proteinuria
- increased vascular permeability (capillary leak)
- increased hydrostatic pressure
- decreased oncotic (colloid osmotic) pressure
- iatrogenic
Name 3 causes oedema with proteinuria
- Glomerulonephritis
- nephrotic syndrome
- acute kidney injury
Name 14 causes oedema without proteinuria
Increased vascular permeability (capillary leak)
- sepsis
- allergy: histamine mediated , anaphylaxis
- Premature
- post op, burns
- CCF, cor pulmonale
Increased hydrostatic pressure
- Ht and drugs
- heart failure
Decreased oncotic (colloid osmotic) pressure:
- nutritional: PEM: SAM (decreased intake protein)
- liver: cirrhosis (decreased production)
- git: protein losing enteropathy (increased loss)
- short bowel
- nephrotic syndrome (increased loss)
Iatrogenic
- drugs
- fluid overload: Na cl
What is and causes picture 11
Aniridia (partial/complete absence iris )
- wilms tumour
- WAGR syndrome
Name 5 causes abdominal distension
- Constipation
- Hirchsprung’s disease
- ascites
- organonegaly
- malignancy
Identify and name cause of picture 16
Caput medusae
- portal ht
Identify and name cause of picture 17 a
Spider naevi
Chronic liver disease
Name 2 causes generalised abdominal tenderness
- Mesenteric adenitis
- peritonitis
Describe the usual character of Wilm’s tumour (3)
- renal mass
- sometimes visible
- does not cross midline
Describe the usual character of abdominal neuroblastoma (3)
- Irregular firm
- may cross midline
- child very unwell
Most common site intussusception?
RUQ
Name 8 red flags constipation <1 year
- no meconium > 24 hours
- abdominal distention
- vomiting
- Failure to thrive
- bloody stools
- neurodevelopmental delay
- anal/sacral abnormalities
- any signs of other organic causes
Management difficult or rare ( < 1/3 days formula fed, < 1/7 breastfed) defecation (constipation) for at least 2 weeks in infants (10)
Check for red flags; if present transfer
child exclusively breastfed and 2 or more weeks old
→ assure, family education, probably normal, follow up
Formula feeding with or without solid food, or <2 weeks old.
→ functional constipation. Reassure,educate, verify proper formula preparation
> good response, maintenance therapy and close follow up
> partial or bad response
- reconsider diagnosis
- < 6 months: lactulose
- > 6 months: lactulose or peg
- Consider switching formula to pHf or eHf
- Rectal treatment for acute relief (glycerine suppository)
- If partial/bad response, transfer. If good, maintenance therapy and close follow up
Define troublesome regurgitation (3)
- 4 or more regurgitations per day
- 2 or more weeks
- age of onset 3 weeks - 6 months
Define infantile colic (5)
- 3 months age or less
- fussy, irritable or frequent crying
- 3 or more hours per day
- 3 or more days per week
- at least 1 week
How differentiate vomiting and regurgitation (3)
- Prodromal period with nausea, autonomic symptoms vs none
- Retching and muscle contraction vs none
- forceful expulsion stomach contents vs effortless passive reflex
Name 6 causes vomiting in first week of life
Common
- gastric irritation: ingestion blood, mucus
- under/over feeding
Other
- infections: sepsis, meningitis, NEC, UTI, oral thrush
- raised intracranial pressure: hydrocephalus, ich
- intestinal malformation and obstruction: intestinal atresia, hiatus hernia, malrotation, meconium ileus, volvulus
- Toxic and metabolic disorders
Name 6 causes vomiting in early infancy
Common
- gord
- feeding faults
- infection: URTI, oral thrush, gastroenteritis
Other
- Intestinal malformation and obstruction: hypertrophic pyloric stenosis, malrotation, volvulus
- intracranial pathology: hydrocephalus
- toxic and metabolic: inborn errors metabolism, uremia, drugs
Name 5 causes vomiting in late infancy
Common
- infections: gastro-enteritis, respiratory tract infection, UTI
Less common
- intestinal malformation and obstruction: intussusception, malrotation
- food intolerance: celiac, CMPA
- toxic and metabolic disorders: poisoning, drugs, uremia
- infections: meningitis, hepatitis
Name 7 causes vomiting in childhood
Common
- acute: gastro-enteritis, resp tract infection, food poisoning
- acute dietary indiscretion
Other
- Digestive tract disorders: peptic ulcers, appendicitis
- Raised ICP: ht, tumor, hydrocephalus
- infection: UTI, meningitis, encephalitis, hepatitis
- Toxic and metabolic: drugs, poisons, DM
- psychogenic / other: migraine, bulimia, cyclic vomiting syndrome
Significance of vomit containing undigested food?
Gastric outlet obstruction
Significance of vomit containing bile?
Intestinal obstruction
Significance of vomit containing blood,? (5)
- Esophagitis
- esophageal varices
- Gastritis
- peptic ulcer
- secondary swallowing nasopharyngeal blood
Significance increased bowel sounds? (2)
- Gastro-enteritis
- obstruction
Significance decreased bowel sounds?
Ileus
What derangement is seen on blood gas after vomiting
Hyponatremic hypochloremic metabolic alkalosis
Regurgitation vs gord?
Regurg = effortless, gastric contents via oesophagus to orophanynx
Gord = effortless passing of gastric contents to oesophagus, doesn’t have to present at mouth
Name 5 anatomical anti-reflux mechanisms
Extrinsic
- Crura
- angle of his
Intrinsic
- Lower oesophageal sphincter,
- increased tone 10 - 40 mm
- fluctuations “normal” reflux
Name 3 predispositions for gor
- Cerebral palsy
- Tubes in seriously ill patients
- sliding hiatus hernia
How does milk scan work and what is it indicated for?
Consists of 4 parts:
- oesophageal transit
- reflux
- gastric emptying
- pulmonary aspiration
Tests functioning of oesophagus: motility, emptying, esophagitis, aspiration
Non invasive, low radiation
Mix radio pharmaceutical with milk, then picked up on gamma camera
To diagnose gor
Management gor? (5)
- Feeding and post feeding position: prone, elevate
- change feeding pattern: frequent small feeds, thicken feeds with nestargel/gelatine
Gord:
- H2 receptor antagonists, PpI, antacid
- prokinetics: domperidone or metoclopromide before meals, erythromycin
- surgery: nissen fundoplication
Define functional constipation criteria (6)
Two or more in the last 1-2 months:
- 2 or less defecations in toilet each week
- at least 1 episode faecal incontinence each week
- history retentive posturing or excessive volitional stool retention
- history painful/hard bowel movements
- presence large faecal mass in rectum
- history large diameter stools that may obstruct toilet
Name 10 causes constipation in infants and toddlers
From history
- genetic predisposition
- Nutritional Change eg from breastfeeding to cow’s milk
- cow’s milk protein allergy
- lack fibre in diet
- stool withholding behaviour
- retentive posturing
- coeliac disease
From examination
- anal fissures
- anorectal malformations
- spina bifida
- Hirschprung’s
Name 9 causes constipation for school children and adolescents
From history
- inadequate food intake
- toilet training coerced
- attention deficit disorders
- developmental handicaps
- toilet phobia, school bathroom avoidance
- excessive anal interventions
From examination
- Anorexia nervosa
- depression
- slow transit constipation
Name 6 organic causes of constipation
- Neurogenic constipation: Hirchprung’s, spinal dysraphisms, tumor, cp, chronic intestinal pseudo-obstruction
- anal lesions: fissure, anterior location, stenosis, atresia
- endocrine and metabolic: hypothyroid, renal acidosis, di, hypercalcaemia, Cf
- neuromuscular disorders:muscular dystrophy
- abnormal abdominal musculature: prune belly syndrome, downs, gastroschisis
- drugs: methylphenidate, morphine, codeine, antacids, phenytoin
Definition and management infant dyschezia?
- Young healthy infants with 10 minutes straining and crying before successful defecation,
- complex defecation process is a learned practice: immature, failure to coordinate abdominal muscle contraction with pelvic floor relaxation
- reassure
Definition and management non retentive fecal incontinence
- Repeated socially inappropriate stool passage in absence of fecal retention or predisposing medical condition
- > 4 years old
- no evidence constipation
- educate family, vigorous toilet training, caution against intensive use stool softeners
Name 8 red flags of constipation in children by history
- Onset <12 months
- delayed passage meconium
- not stool with holding
- no soiling
- intermittent diarrhoea and explosive stools
- No response to conventional treatment
- bladder disease
- extra intestinal symptoms
Name 7 red flags of constipation in children by examination
- Failure to thrive
- empty rectal ampulla
- tight anal sphincter
- gushing of stool with rectal exam
- abnormal neurological exam
- pigmentary abnormalities
- heme positive stools
Constipation disimpaction and maintenance therapy? (5)
Disimpaction
- Oral: mineral oil 15 - 30 ml /year of age until 240ml or peg 1,5 g/kg/day
- phosphate enema
- glycerine suppository
Maintenance, At least 6 months
- Osmotic laxatives: lactose or polyethylene glycol 3350
- mineral oil: lubricant and hydroxy fatty acids
- stimulant laxatives
- behavioural modification: gastrocolic reflex,
- dietary measures: high fibre, good floods
Which supplement can prevent diarrhoea
Vitamin A
Which supplement can treat diarrhoea
Zinc
Name 2 common viral causes diarrhoea in children
- Rotavirus
- adenovirus
Name the 8 management principles for diarrhoea
- Hydration assessment
- fluid management
- metabolic and electrolyte disturbances
- feeding,
- anti emetic
- anti diarrhoeal
- antibiotics
- probiotics
Moderate vs severe dehydration? (3)
Moderate
- sunken eyes
- slow skin pinch <2 seconds
- drinks eagerly
- irritable/restless
Severe
- sunken eyes
- very slow skin pinch >2 seconds
- drinking poorly