Abdominal Pain

Question 1

2 rare but serious causes of abdominal pain and masses in children?

Answer 1

Wilm’s tumour - nephroblastoma
neuroblastoma - tumour of immature nerve cells usually in the adrenal glands

Question 2

What is it important to rule out in abdominal pain that is not an abdominal cause as such?

Answer 2

torsion of the testes
UTI - sometimes presents only as vomiting and abdominal pain in children

Question 3

What would you see on examination if a child had peritonitis?

Answer 3

any movement of the abdomen would cause pain, touching anywhere would be sore, if you asked child to suck tummy in and push it out they would not be able to do this (most kids would find this funny to do)

Question 4

Ask children where in abdo is sore what usually happens?

Answer 4

• Children generally point to umbilicus or all over
• If point away from umbilicus this is unusual and should take note

Question 5

What can be a good general indicator of abdominal pain severity?

Answer 5

can the child walk and move comfortably, can they lie down and climb on and off the examination couch

Question 6

If a child is constipated ____

Answer 6

you can often feel hard faeces in the LIF

Question 7

Urinalysis in abdominal pain in children is important to rule out _______

Answer 7

infection or DKA

Question 8

Commonest cause of peritonitis in childhood is?

Answer 8

a perforated appendix

Question 9

Some causes of abdominal masses?

Answer 9

rare but serious - wilms tumour and neuroblastoma
appendicitis can present with a late appendix abscess
constipation

Question 10

Bilious vomiting should be _________

Answer 10

considered as intestinal obstruction until proven otherwise

Question 11

What is testicular torsion?

Answer 11

• This occurs when the spermatic cord and its contents twist within the tunica vaginalis, compromising blood supply to the testicle
• It is a surgical emergency as without treatment the affected testicle will infarct within hours

Question 12

Who gets testicular torsion?

Answer 12

• It can occur at any age but peaks in adolescents between age 12-15 and neonates
• In adolescents it is more common in those with certain anatomical variations
• In neonates it is more common because the scrotum and tunica vaginalis are not fully formed meaning torsion is more likely
• More common in those with a FH
• Undescended testes is also a risk factor
• Previous episodes of testicular pain that have previously self resolved may a sign of previous torsion with self detorsion

Question 13

Clinical features of testicular torsion?

Answer 13

• Sudden onset severe unilateral testicular pain
• Often associated with nausea and vomiting secondary to the pain
• Referred abdominal pain can also occur
• On exam the testis will have a high position (compared to contralateral side) with a horizontal lie
• It can also appear swollen and will be extremely tender
• Classically the cremasteric reflex is absent and pain continues despite elevation of the testicle (negative Prehns sign)

Question 14

Explain Prehns sign and the cremasteric reflex and interpretation?

Answer 14

Cremasteric reflex: stroking the medial part of the thigh in a downward direction causes the cremaster muscle to contract and pull the ipsilateral testicle upwards, absence of this reflex is considered diagnostic for testicular torsion
Prehn’s sign: pain relief upon elevation of the scrotum, positive sign is associated with epididymitis

Question 15

Investigations and management for testicular torsion?

Answer 15

• Diagnosis is clinical and any suspected cases need taken straight to theatre for scrotal exploration
• If torsion is confirmed intra-operatively the cord and testis will be untwisted and both testicles fixed to the scrotum, termed bilateral orchidopexy (this prevents further episodes of torsion)
• In cases where the testis is non viable an orchidectomy may be warranted with prosthesis which can be inserted at time of surgery or on a later date

Question 16

Complications for testicular torsion?

Answer 16

• Chance of infarction increases with time
• Despite surgery some testis can still undergo atrophy later on
• Patients may also have chronic pain, palpable sutures, reduced future fertility and risk of torsion despite fixation
• If surgery is performed within 6hrs of onset salvage rates are 90-100%

Question 17

Explain what intestinal malrotation and volvulus is?

Answer 17

• Intestinal malrotation is a congenital condition where the intestines do not form correctly and are “malrotated”
• Often wont know a child has malrotation until they develop a complication
• Volvulus is a complete twisting of a loop of intestine around its mesenteric attachment site – in adults can get sigmoid volvulus and other types of volvulus for different reasons – however in children it is often a complication of intestinal malrotation
• Most of these will present in the first year of life

Question 18

Presentation of malrotation/ volvulus?

Answer 18

• Malrotation can be asymptomatic or may cause intermittent symptoms of intestinal obstruction
• If a volvulus develops the obstruction will be complete
• Bilious vomiting is a key presenting feature
• Once intestinal ischaemia develops pain becomes more pronounced symptom
• In volvulus there may be palpable abdo mass, abdominal distension and signed of peritonitis, blood or sloughed tissue may pass pr
• Baby may develop shock

Question 19

Investigations for malrotation/ volvulus?

Answer 19

• Plain XR may be normal in simple malrotation, in volvulus may see the double bubble sign (dilatation of the proximal duodenum and stomach)
• CT contrast can show malrotation and volvulus
• US can also be used

Question 20

Management of malrotation/ volvulus?

Answer 20

• Asymptomatic malrotation should be fixed surgically due to risk of volvulus
• Volvulus should generally be treated surgically

Question 21

Is GORD in babies common?

Answer 21

yes it affects half of babies younger than a year

Question 22

Clinical features of GORD in babies?

Answer 22

• Usually babies bring up their milk/ are sick during or shortly after feeding (it isn’t forceful like proper vomiting is)
• They may cough or hiccup when feeding
• They may be unsettled during feeding and may cry
• They may swallow or gulp after burping or feeding
• It can happen a lot, some babies bring up milk 6 or more times a day
• It normally happens less often as the baby gets older

Question 23

At what age does GORD in babies usually occur?

Answer 23

before 8 weeks old

Question 24

Management of GORD in babies?

Answer 24

generally no tests or treatment needed, it gets better on its own

Question 25

What are hernias and what are the 2 most common types in children?

Answer 25

• Hernias are a protrusion of viscus through a defect of the walls of its containing cavity
• The 2 most common types of hernias in children and babies are umbilical and inguinal hernias

Question 26

What type of inguinal hernia is more common in babies? Explain?

Answer 26

• Indirect inguinal hernias (more common than direct inguinal hernias in children) occur when the abdominal contents protrude through the deep inguinal ring into the inguinal canal and the superficial inguinal ring into the groin
• This is due to incomplete closure of an outpouching of the peritoneum called the processus vaginalis after the descent of testes in utero
• direct hernias are due to weakness in Hesselbachs triangle, more likely to occur in older men who are obese, or have increase intraabdominal pressure for other reasons

Question 27

Risk factors for inguinal hernias in babies?

Answer 27

prematurity, male sex and family history

Question 28

Presentation/ examination of inguinal hernias in babies?

Answer 28

• Babies/ children present with a groin swelling
• If there are symptoms of nausea, vomiting, constipation, pain this could indicate strangulation
• On examination there is a mass that you cannot get above, does not transilluminate, has a cough reflex

Question 29

How to tell difference between direct and indirect inguinal hernias?

Answer 29

• Indirect inguinal hernias if you reduce and occlude the deep inguinal ring and ask patient to cough, the hernia will not come back

Question 30

Indirect and direct hernias relation to inferior epigastric vessels?

Answer 30

• Indirect hernias are lateral to inferior epigastric vessels whereas direct are medial

Question 31

Diagnosis of inguinal hernias?

Answer 31

• Diagnosis is largely on a clinical basis however can do US to confirm, CT scan is mainly used if there is uncertainty of diagnosis or worried about obstruction or strangulation

Question 32

Management of inguinal hernias?

Answer 32

• Surgical repair is done for inguinal hernias in babies (note this is different in adult where repair is only done if symptomatic)

Question 33

Explain why umbilical hernias occur in babies?

Answer 33

• Umbilical hernias are very common in neonates, particularly those born prematurely
• It occurs when the muscles around the umbilical cord opening don’t seal properly after birth

Question 34

Management/ prognosis of umbilical hernias in babies?

Answer 34

• Most umbilical hernia disappear by the time a child is 4 or 5
• A child may get surgery for the hernia if it is vert large or it hasn’t disappeared by age 4 or 5
• If there was obstruction or strangulation the child would need emergency surgery

Question 35

In infants when do you repair umbilical vs inguinal hernia?

Answer 35

inguinal hernia repaired straight away
umbilical hernia wait and see

Get INto surgery for inguinal
UM I’ll wait and see for umbilical

Question 36

List 7 causes of bowel obstruction to consider in children?

Answer 36

meconium ileus
hirschsprungs
duodenal atresia
intussusception
imperforate anus
malrotation of intestines with volvulus
strangulated hernia

Question 37

Presentation of bowel obstruction in children?

Answer 37

pain
vomiting (may be bilious)
failure to pass stool or gas
abnormal bowel sounds (tinkling or absent)

Question 38

General management of bowel obstruction in children?

Answer 38

NG tube
IV fluids
surgery for underlying cause

Question 39

Failure to pass meconium - two causes to remember?

Answer 39

Hirschsprung disease
CF

Question 40

What is Hirschsprung’s disease?

Answer 40

congenital condition where nerve cells are absent in distal bowel and rectum
the aganglionic colon does not relax so faeces cannot pass through and get bowel obstruction

Question 41

Presentation of hirschsprungs?

Answer 41

depends on severity and how much of the colon has no nerves
if a lot of colon affected can present with bowel obstruction shortly after birth e.g.failure to pass meconium
can present with chronic constipation, failure to thrive, abdominal pain, vomiting

Question 42

Diagnosis of hirschsprungs?

Answer 42

rectal biopsy
absence of ganglionic cells on histology

Question 43

Definitive management of hirschsprung disease?

Answer 43

surgical removal of aganglionic portion of the bowel
most patients live normal life following surgery

Question 44

Explain what Meckels diverticulum is?

Answer 44

Meckel’s diverticulum is a congenital diverticulum of the small intestine. It is a remnant of the omphalomesenteric duct (also called the vitellointestinal duct) and contains ectopic ileal, gastric or pancreatic mucosa.
.
Rule of 2s
occurs in 2% of the population
is 2 feet from the ileocaecal valve
is 2 inches long

Question 45

Presentation of meckel diverticulum?

Answer 45

Presentation (usually asymptomatic)
abdominal pain mimicking appendicitis
rectal bleeding
Meckel’s diverticulum is the most common cause of painless massive GI bleeding requiring a transfusion in children between the ages of 1 and 2 years
intestinal obstruction
secondary to an omphalomesenteric band (most commonly), volvulus and intussusception

Question 46

Most common cause of painless GI bleeding requiring transfusion in children aged 1-2?

Answer 46

meckels diverticulum