Abdomen Flashcards
Localizing Pain (3)
- 1-finger test: show me where the pain is with 1 finger
- If pain is all over, the cause is more functional
- The closer the pain is to the umbilicus = the more likely it is to be functional EXCEPT for in the first hours of the initiation of appendicitis (which will localize to RLQ later)
Anatomy Review (4)
- LUQ: pancreas, spleen
- RUQ: Gallbladder, liver
- LLQ: Colon, intestine, L ovary
- RLQ: Intestine appendix, R ovary
Kidney Palpation (5 steps)
1st: Place left hand posteriorly just below the right 12th rib. Lift upwards trying to displace the right kidney anteriorly.
2nd: Palpate deeply with right hand on anterior abdominal wall.
3rd: Have the patient take a deep breath.
4th: Feel for lower pole of kidney as it descends and try to capture it between your hands.
5th: Have the patient release breath. Slowly release the kidney and feel it slide back into place.
* Try the same on the left kidney, but is seldom palpable.
How to palpate for CVA tenderness
With patient seated upright, place palm of left hand over each CVA and strike back left hand with ulnar surface or right fist
What does CVA tenderness indicate?
Suggests kidney infection such as pyelonephritis or perinephric abscess.
- pyelonephritis: Inflammation of kidney substance and pelvis.
- perinephric abscess: Abscess formation in the peritoneal membrane surrounding the kidney
Guarding may indicate…(3)
- Peritonitis
- Appendicitis
- Cholecystitis
Point tenderness may indicate (2)
- Appendicitis
- Cholecystitis
Point tenderness: mcburney’s point at right lower quadrant below inguinal fold)
Asymmetry indicates (2)
- Appendiceal abscess
2. Tumor
No bowel sounds indicates (2)
- Peritonitis
2. Infarcted bowels
Palpable m ass indicates (3)
- Tumor
- Cyst
- Intussusception
Nutritional Status is indicated by…
Weight, height
Edema – lack of protein
Anemia
Extraintestinal features that are red flags
- Arthritis
- Ciliary injection
- Skin (edema)
* Think about Crohn’s and inflammatory bowel disease with extraintestinal features
Abdominal distention indicates (2)
- perotinitis
2. obstruction
visible bowel loops indicates (2)
- Intussusception
2. Obstruction
High pitched bowel sounds indicates
Obstruction
Chronic Abdominal Pain (6)
- Onset may be associated with an event that the child does not want- test, gym, recess
- Cannot be localized
- Does not waken the child
- Resolves spontaneously when the child has something to do that he likes
- Pain is out of proportion to physical exam findings
- May have hyperactive gut (high level of autonomic reactivity, associated with type A child) - Lab findings are normal
Causes of Epigastric Pain (6)
a. Peptic Ulcer disease
b. GERD
c. Gallbladder disease
d. Pancreatitis
e. Trauma
f. Idiopathic
Causes of Periumbilical Pain (7)
Usually a functional cause….
a. Functional abdominal pain
b. Abdominal migraine
c. Streptococcal pharyngitis
d. Gastroenteritis
e. Appendicitis
f. Carbohydrate intolerance
g. Lactase deficiency
Pain in RLQ (8)
a. Ovarian torsion
b. Appendicitis
c. PID
d. Ectopic pregnancy
e. Mittelschmerz
f. Right lower lobe pneumonia
g. Inguinal hernia
h. Iliopsoas abscess
Pain in LLQ (2)
- Constipation
2. Right ovarian or testicular pain
Pain in Suprapubic area (4)
- UTI
- Constipation
- Urinary retention
- Hydrometrocolpos; blood stuck in ovaries
Characteristics that are NOT worrisome with abd pain (4)
- Undigested food in stool
- Green stool
- Child sleeps through the night
- Pain occurs in morning and disappears with passing of school bus and tends not to occur on the weekend
5 Types of Malformations of the Cecum
- Non rotation and therefore cecum is found in the left part of the abdominal cavity
- Malrotation and the cecum remains below the pylorus
- Subhepatic cecum and therefore the cecum is below the liver
- Mobile cecum: not fixed to the retroperitoneum
- Hyperrotation in which the cecum lies directly at the left colic flexure
Appendicitis Presentation (6)
- Pain that precedes vomiting
- Pain starts as periumbilical pain then localizes to lower quadrant
- Pain is sharp and constant - N/V
- Tenderness at McBurney’s point
- Fever
- Leukocytosis
- Tachycardia*
Signs of appendicitis in toddler (3)
- Fever and vomiting
- Pain may be intermittent and referred to right hip with limp
- Abdominal pain may be localized or generalized
Signs of appendicitis in school aged (5)
- Abdominal pain and vomiting common
- Pain with walking or movement
- Fever
- Abdominal wall tenderness that tends to be focal to RLQ (unless appendix is displaced)
- Involuntary guarding
Appendicitis MANTREL
Migration of pain Anorexia N/V Tenderness on RLQ Rebound tenderness Elevated temperature Leukocytosis
Psoas Sign
1st: Have child in supine position
2nd: Place hand above right knee
3rd: Direct child to raise leg against pressure
* Positive sign: pain in RLQ when pushing down on leg
or:
Have child drop right leg over exam table
*Positive finding: this will be painful
Positive- indicates appendicitis
extending the thigh of a patient lying on his side with knees extended, or asking the patient to actively flex his thigh at the hip. If abdominal pain results, it is a “positive psoas sign”.
Obturator Sign
Flex child’s right thigh at the hip with the knee bent, Rotate leg internally at the hip then externally
Pain occurs when there is internal and external rotation of the flexed thigh = positive sign and indicator of appendicitis
Rovsing’s Sign
Pain in RLQ with left-sided pressure (press on left side and get pain on right side)
Markle Jar Heel Test
Up on toes, down hard on heels
Have patient jump op and down
*pain in the right lower quadrant of the abdomen is elicited by dropping from standing on the toes to the heels with a jarring landing.
Rebound Tenderness (3)
- Only do this once and with older children; do not do with young child!
- Firmly and slowly push in, hold, then quickly withdraw
- There will be pain as you withdraw - Take hand, put it on McBurney’s point, distract child, keep hand there for 30 seconds, let go and the removal causes pain
*Occurs with appendicitis
Pneumonic for Pancreatitis Causes
Idiopathic Gallstones Ethanol Trauma Spider/scorpion Mumps/malignancy Autoimmune Steroids Hyperlipedemia/hypercalcemia/hyperparathryodism ERCP Drugs (HIV, furosemide, methanol, salicylates, valproac acid, organophosphates)
Signs of Pancreatitis (4)
- Lipase and amylase elevations
- Pain in upper abdomen towards right side or periumbilical pain radiating to back
- Hypercalcemia
- Ileus, distension, ascites
Murphy’ Sign
Temporary inspiratory arrest with palpation of right subcostal margin
Patient takes deep breath and you cup under the right side and ask them to exhale; they will feel pain in gallbladder
*Indicates cholecystitis
Nonalcoholic Steatophepatitis (NASH) and Nonalcoholic Fatty Liver Disease (NAFLD) (4)
- Strong association with obesity
- Elevation of liver enzymes (AST, ALT)
- NASH
- Fat in the liver, along with inflammation and damage
- Leads to cirrhosis - NAFLD
- Fat in liver without inflammation
Mallory Weiss Tear
tear in the mucosal layer at the junction of the esophagus and stomach
*Can get it from vomiting
Signs/Symptoms of Eosinophilic Esophagitis in Children and Adolescents (11)
i. Recurrent vomiting
ii. Abdominal pain
iii. Dysphagia
iv. Pain with swallowing (odynophagia)
v. Vomiting often but not always occur in association with eating
vi. Some accompanying nausea.
vii. Intense feeling of discomfort as a swallowed food bolus slowly moves down the esophagus.
viii. Often patients will try to drink liquids to help bring the foods down
ix. Episodes may last for only a few seconds or can be more prolonged and severe, and occasionally result in food becoming stuck in the esophagus ‐ that is food impaction.
x. Severe and chronic symptoms, significant weight loss can also occur.
xi. Heartburn, cough, chest pain, or epigastric (upper abdominal) pain, which does not respond to anti‐reflux therapy.
Causes of Watery diarrhea (2)
i. Infection: viral, bacterial, parasitic
ii. Appendicitis with perirectal abscess
Cause of hard or large stools
constipation
cause of decrease in stool frequency (2)
- constipation
2. obstruction
Cause of mucous containing stool
colitis (but also can be normal)
cause of bright red blood in stool (small volume) (2)
- fissure
2. hemorrhoids, suggesting constipation
Current jelly stool indicates
Intussusception
Melena stool indicates (2)
- Gastric ulcer
2. Duodenal ulcer
Alcoholic/white stool indicates (2)
- biliary disease
2. hepatic disease
Diagnosing Childhood Functional Abd Pain
Must include all of the following criteria at least once a week for at least two months prior to diagnosis:
- Continuous or episodic abd pain
- Insufficient criteria for other functional GI disorders
- No evidence of an inflammatory anatomic, metabolic, or neoplastic process that explains the symptoms
Diagnostic Criteria for IBS
Must Include both of the following criteria, fulfilled at least once pet week for two months prior to diagnosis. Abdominal pain or discomfort associated with two of the following:
- Improvement with defecation
* Gets better when child poops - Onset associated with a change in frequency of stool
- Onset associated with change in form of stool
* Will have alternating diarrhea and constipation (there are changes in the form of the stool)
Functional Dysplesia (3)
- Persistent or recurrent pain or discomfort centered in the upper abdomen
- Not relieved by defecation or associated with the onset of a change in stool frequency or stool form
- No evidence of an inflammatory, anatomic, metabolic, or neoplastic process to explain symptoms
Bilious Emesis (4)
- Bilious emesis is a mechanical obstruction unless proven otherwise!
- Bilious emesis = green vomit
- In infancy the obstruction can result from:
- Feeding problems with transient episodes of bilious vomiting
- Failure to thrive with feeding intolerance (Malrotation with volvulus) - In school-aged child, obstruction can result from adhesions from previous surgeries!!
Pyloric Stenosis (6)
- Familial with 5:1 male predominance
- Non bilious, projectile vomiting and hungry 30-60 minutes later
- Hypochloremic metabolic alkalosis
- Not a mechanical obstruction; Narrowing of pylorus valve causing difficulty getting milk from mouth to stomach
- Generally presents at 3rd-6th week of life
- Comes into ER with non-bilious vomit; child will be puking and dehydrated
Malrotation of Volvulus (6)
- Abnormal fixation of bowel mesentery with twisting around mesenteric artery
- May be due to perineum not attached well, so the gut twists - Painful distended abdomen
- Bilious vomiting present
- Blood in stool
- Abdominal Pain
- May be lethargic on presentation
Classic Triad Sign of Intussusception (and dance’s sign)
- Jelly like stool
- Vomiting
- Intermittent abdominal pain with palpable sausage-shaped mass
- Dance’s sign: concavity in RLQ and RUQ where intestine telescoped in -Empty right lower quadrant
Other Clinical Features of Intussusception (6)
- Colicky abdominal pain
- Infant pulls knees up to chest while crying
- Normal between episodes of pain
- Altered mental status
- Palpable sausage shaped mass during crying
- Dance’s sign: concavity in the right lower quadrant due to absence of underlying bowel
Newborn Hirschsprung’s Disease physical exam (9)
- Newborn: well constipated with distended soft abdomen with normal or hyperactive bowel sounds
- Rectal exam: slight pressure on examining finger with no stenosis or obstruction
- Ampulla is empty: on removal explosive evacuation of stool or gas
Ill newborn will present with….
- More distention without peritoneal signs unless perforation
- React minimally to examiner
- Can be lethargic
- Fever
- Tachycardia
- Ominous hypotension
Older infant and child with Hirschsprung’s presentation (4)
- Chronically distended, non-tender abdomen with large fecal masses ON LEFT SIDE
- Rectal exam: ampulla is empty
- Anal tone is normal
- Explosive stool will also occur after examining finger is withdrawn
Hematochezia
maroon stools which indicated distal GI source or
short transit time from briskly bleeding proximal
source
Melena
dark or black tarry stools when the bleeding is from
upper tract
Hematemesis (3)
- vomiting of blood or blood per rectum
- Appearance of coffee grounds or bright red - Can occur if newborn swallows maternal blood during delivery
- Esophagitis will occur secondary to reflux (bleeding can occur due to reflux)
APT Test
Dx whether newborn hematemesis is from swallowing maternal blood during delivery
Mix emesis with 1% sodium hydroxide
- Fetal blood remains pink or bright red
- Maternal hemoglobin turns brown
Upper GI Bleed Causes (8)
- Stress
- Vascular malformaiton
- Gastric/esophageal duplication
- Hemorrhagic gastritis
- Esophagitis
- Varices from portal HTN
- Vascular malformations
- Bleeding diathesis from such hemorrhagic disease of the newborn
Lower GI Bleed Causes (3)
- Juvenile polyps (may be from Gardner’s syndrome)
- Anal fissure
- Meckel Diverticuli
Meckel Diverticuli (4)
- Most common source of significant lower GI bleeding in children
- Preschooler bleeding is the result of
- HCL secreted from ectopic gastric mucosa within diverticulum
- Ulceration forms on ileal mucosa - Painless but can be massive
- Part of stomach mucosa in the small intestines because mucosa secrets HCL and they get massive GI bleed
Manifestations of Ulcerative Colitis (12)
- Most diagnosed between 15-30 years old
- Acute bloody diarrhea
- Cramping
- Tensemus
- Pallor
- Growth retardation
Extraitestinal manifestations:
- Arthralgia
- Uveitis
- Oral ulceration: aphthous ulcers
- Liver disease by fatty infiltration or sclerosing cholangitis (15%)
Skin manifestations:
- Erythema nodosum
- Pyoderma granulosum (non-healing ulcer)
Where do ulcerative colitis ulcers occur? (2)
- Diffuse, continuous superficial inflammation
- Edema and shallow ulceration and small pseudopolps in rectum, descending colon as far as ileocecal juncture (limited to colon)
Where do Crohn’s Disease ulcers occur? (2)
- Focal asymmetrical inflammation anywhere on GI tract (from anus to mouth)
- Most common in terminal ileum proximal colon and ileocecal junction
Crohn’s Disease Manifestations (8)
- WEIGHT LOSS (90% of the time)
- Abdominal pain, typically in RLQ since inflamed edematous terminal ileum (70%)
- Diarrhea (67%)
- Fever (25%)
- Bloody diarrhea***
- Anal skin tag
- Perianal ulceration***
- Same extraintestinal manifestations as ulcerative colitis
Neuroblastoma History (7)
- Hx of vasoactive intestinal peptide
- Watery diarrhea with abdominal distention and electrolyte imbalance
- Opsoclonus-myoclonus (dancing eyes with myoclonic jerks w/ or w/o cerebellar ataxia)
Catecholamine excess (More common if renal in origin)
- Flushing
- Tachycardia
- Headache
- HTN
Neuroblastoma head and neck exam and thoracic exam signs (7)
Head and Neck:
- Visual changes
- Exopthalmos
- Horner’s syndrome: ptosis, meiosis, anhydrosis
- Cerebellar ataxia
- Periorbital ecchymosis – raccoon eyes
- Heterochromia iridis – different color iris’
Thoracic exam
1. If dumb bell extension into spine- neurological abnormalities, cough, SOB
Signs and Symptoms of Wilm’s Tumor
- Abdominal mass that is firm, flank, non-tender, minimally mobile and doesn’t usually cross midline
- Well appearing
- Asymptomatic mass
- Pain rarely reported
- HTN and micro-hematuria
