Abdominal pain Flashcards

Question

What are the clinical manifestations?

Answer 1

CM 1. Usually preceded by hx of infection 2. Triad: pain, palpable sausage-shaped abdominal mass (RUQ), bloody/currant jelly stool 3. Severe paroxysmal colicky pain with straining effort, recurs at freq intervals 4. Comfortable and playing child in between paroxysms of pain, becoming progressively lethargic 5. Child usually has straining efforts with legs and knees flexed and loud crying 6. Vomiting (early phase), later becomes bilous vomiting 7. Lethargy 4. Sausage-shaped mass RUQ or epigastrium 5. If not reduced, a shock-like state, with fever and peritonitis 6. Currant jelly stool (60%) 7. DRE: bloody mucus

Answer 2

1. Abdominal UTZ – screening 98-100% sn, 98% sp. - Doughnut or target lesion (transverse view) - Tubular mass (longitudinal view) 2. Pneumatic or contrast enema – dx and tx. - Coiled spring sign: thin rim of barium trapped around the invaginating part within the intussuscipiens 3. Plain abd XR: vague and nonspecific. A density in the area of intussusception

Answer 3

Mgt: 1. Reduction of acute intussusceptions ASAP 2. Hydrostatic reduction after under fluoroscopy/UTZ (if no signs of shock, peritoneal irritation, or intestinal perforation) 3. Pneumatic/air reduction 4. Surgical reduction – if with refractory shock, bowel necrosis or perforation, peritonitis, multiple recurrences 5. 4-10% can have spontaneous reduction 6. Recurrence rate 10%, post reduction 2-5%, postresection 0%.

Answer 4

MALROTATION - Incomplete rotation of the intestine during fetal development which is completed by 3 mos AOG - MC: failure of the cecum to move into the RLQ - Majority present within the 1st YOL Embryology: - Early fetal life: midgut attach to yolk sac and loops outward - 10th week: bowel reenters abdomen, rotates counterclockwise until cecum reaches RLQ - Incomplete rotation: o Cecum near RUQ o Duodenum in front of mesenteric artery o Extremely narrow mesenteric root o Susceptible to volvulus o Abnormal mesenteric attachments (Ladd bands) --> partial obstruction

Answer 5

CM 1. Sx of acute or chronic obstruction 2. Bilious vomiting – 60% neonates, 40% infants/children. MC sx. 3. Gut ischemia – pain, tenderness, bloody emesis and stools due to volvulus. Surgical emergency. 4. Suspect in patients with vomiting and fussiness or abdominal pain

Answer 6

Dx 1. Abdominal xray with barium contrast: obstruction; Double-bubble sign 2. UTZ – malrotation 3. UGIS – gold standard. - Bird’s beak appearance of duodenum as it encounters the volvulated loop - Absent c-loop of duodenum - Right-sided jejunum - Follow-through/contrast enema: high-sided cecum - Corkscrew sign: distal duodenum and proximal jejunum do not cross the midline and instead take an inferior direction (loop twists on a small bowel mesentery)

Answer 7

Ladd’s procedure – surgery. For any px with a significant rotational abN regardless of age

Answer 8

- Life-threatening. - Twisting of a loop of intestine around its mesenteric attachment site which may occur at various parts of the GIT - MC: sigmoid and cecum - Small bowels twist around the superior mesenteric artery leading to vascular compromise of the bowel - Longitudinal: gastrohepatic, gastrosplenic, gastrocolic - Transverse: gastrophrenic, retroperitoneal attachment of duodenum - Organo-axial volvulus – along the longitudinal axis - Mesentero-axial volvulus – along the transverse axis - Combined volvulus (both)

Answer 9

Triad “SIR” a. Sudden onset of severe epigastric pain b. Inability to pass a tube into the stomach c. Retching with emesis

Answer 10

Dx 1. Abdominal XR – findings: a. Dilated stomach b. Inverted U sign (distended sigmoid colon) c. Coffee bean sign – midline crease corresponding to the mesenteric root in a greatly distended sigmoid 2. UGIS – gold standard. Partial duodenal obstruction. Dilation of the stomach and proximal duodenum with a small amount of distal bowel gas.

Answer 11

Mgt 1. Derotation and decompression by barium enema or with rectal tube, sigmoidoscope, colonoscope if with no signs of bowel ischemia or perforation 2. Laparoscopic derotation or laparotomy + bowel resection

Answer 12

- Nonspecific, self-limiting inflammation of mesenteric LNs - Usually mis-dx as acute appendicitis - “stomach flu” - Viral infection à LN inflammation in the mesentery (thin tissue that attaches to SI to the back of the abdominal wall)

Answer 13

CM “PaNT” 1. RLQ pain 2. Nausea, vomiting 3. T (Fever, LG) 4. Malaise, weight loss 5. Usually preceded by stomach flu/infection

Answer 14

Dx 1. UTZ of RLQ with graded compression – most appropriate for <14 yo with fever, leukocytosis, with presentation of atypical appendicitis. LN clustering the RLQ. Nodal hyperemia on sonogram. 2. CT scan – cluster of >3 LN (each measuring >5mm) is detected in the RLQ mesentery 3. Cbc – leukocytosis 4. Ua – r/o UTI

Answer 15

Mgt 1. Ibuprofen, paracetamol – for pain Self-limiting

Answer 16

CH 346: INCARCERATED INGUINAL HERNIA Sx usually 1st 6mos-1 yo - Greatest risk of strangulation and incarceration (30-40%) @ 1yo - 60% R, 10% B

Answer 17

Patho - 99% congenital indirect inguinal hernia – patent processus vaginalis - Direct inguinal hernia – muscular defect or weakness in the floor of the inguinal canal medial to the epigastric vessels

Answer 18

CM 1. Inguinal bulge/mass – hallmark; smooth, firm, emerges through the external inguinal ring aggravated by irritability, inc intra-abdominal P (crying, straining, coughing) 2. Incarcerated = colicky abd pain, vomiting - Non-reducible mass in inguinal canal/scrotum/labia - May contain SI, appendix, omentum, colon, ovary, FT 3. Strangulated IH – tightly constricted passage through inguinal canal --> contents ischemic/gangrenous

Answer 19

Dx 1. UTZ – As the probe is moved inferiorly, the deep inferior epigastric vessels pass from medial to lateral and superficial to deep toward their origin at the external iliac vessels. Keeping the image centered on the inferior epigastric vessels, a surrounding soft tissue bulge gradually becomes apparent deep and lateral to the posterior aspect of the rectus abdominis. This is the superior aspect of the inguinal canal. 2. Diagnostic laparoscopy 3. CT/MRI – demonstrate extracoelomic location of the bowel, bladder or female reprod organs

Answer 20

1. Herniorrhaphy – ideally w/in 6-12 mos old.

Answer 21

CH 366: GALL BLADDER DISEASES (CHOLECYSTITIS, CHOLELITHIASIS) CHOLECYSTITIS - Uncommon in children - Usually caused by infection Etiology: - Streptococci (groups A and B), Salmonella, Leptospira, Ascaris, Giardia lamblia - E.coli, Bacteroides fragilis, Klebsiella, Enterococcus, Pseudomonas

Answer 22

Patho - Obstruction of biliary outflow tract by a stone/ stricture/ kinking of the cystic duct/ intussusception of a polyp, GB torsion, LNE, or inspissate bile --> malfunction of mechanics of GB emptying --> inflammation of GB

Answer 23

CM 1. RUQ or epigastric pain 2. Nausea, vomiting 3. Fever 4. Jaundice 5. RUQ guarding and tenderness

Answer 24

Dx 1. UTZ – enlarged, thick walled GB (>5mm), without calculi, perocholecystic fluid, GB distention (>5cm), sonographic Murphy sign 2. Elev alkaline phosphatase 3. Elev DB 4. CBC – PMN leukocytosis 5. Scintigraphy – nonvisualizing GB on HIDA scan

Answer 25

Mgt 1. Bowel rest, IV hydration, correction of e’ abN, analgesia, IV abx 2. Abx: Piperacillin-Tazobactam 300-400 mkd IV q6/8 Ampicillin/sulbactam 100-200 mkd IV q6 Meropenem 60 mkd q8 IV Imipenem/cilastatin 60-100 mkd q6 IV – for severe lifethreatening cases 3. Cholecystectomy – primary mode of tx

Answer 26

CHOLELITHIASIS/ CHOLEDOCHOLITHIASIS - Rare in children - Predisposing factors: obesity, DM, PT, prolonged fasting or rapid weight reduction, CF, hemolytic ds, pregnancy, sepsis, cirrhosis - >70% pigment-type, 15-20% cholesterol stones

Answer 27

Patho - Bile is concentrated in the GB, it becomes supersaturate then precipitate to form microscopic crystals --> bile sludge --> crystals grow, aggregate, fuse to form microscopic stones (cholesterol/ calcium bilirubinate) - Gallstone in the CBD = choledocholithiasis

Answer 28

CM 1. Recurrent abd pain, colicky, localized to RUQ – most impt clinical fx - pain may radiate to area below the R scapula 2. Intolerance for fatty foods 3. Fever

Answer 29

Dx 1. UTZ – method of choice. Stones appear as echogenic foci in the GB that move freely with positional changes and cast an acoustic shadow. 2. Plain XR – may reveal opaque calculi, exclude other causes of abd pain (obstruction) 3. Hepatobiliary scintigraphy – highly accurate for cystic duct obstruction. Failure of HIDA to fill the GB, while flowing freely into the duodenum. 4. CBC – PMN leukocytosis if with cholecystitis 5. Elev LFT 6. Amylase, lipase – r/o pancreatitis 7. CT scan – more expensive, less sn than UTZ

Answer 30

Mgt 1. Expectant management – if asx’c 2. Cholecystectomy – >2 cm gallstone, nonfunctional/ calcified GB 3. Operative cholangiography – to detect CBD calculi 4. Oral bile salt tx – ursodeoxycholic acid: for xray negative cholesterol stones with N GB function 5. Extracorporeal shockwave lithotripsy – for noncalcified cholesterol stones with N GB function

Answer 31

Acute pancreatitis

Answer 32

Patho - Following an insult, trypsinogen is prematurely activated to trypsin within the acinar cell, activating either pancreatic proenzymes, leading to autodigestion - Release of active proteases, hydrolases - Inc release of cytokines and proinflamm mediators - Common causes: o Blunt abdominal injury o Multisystemic disease (HUS, IBD) o Biliary stones, microlithiasis o Drugs (valproic acid, L-asparaginase, 6- mercaptopurine, azathioprine)

Answer 33

CM 1. Severe abdominal pain – epigastric/RUQ, steady 2. Child assuming antalgic position – hips, knees flexed, sitting upright, lying on side 3. Distended abdomen 4. Persistent vomiting 5. Fever 6. Severe AP – life-threatening --> shock

Answer 34

Dx 1. Serum TB, DB, IB – plot TB in Bhutani chart 2. Transcutaneous bilirubin – linearly correlated with serum levels, used for screening 3. Blood type, Rh status of mother and infant – mom O, non-O infant. Cord blood can be sent for routine BT of NB 4. (+)Direct Coombs test – detects Ab bound to RBC surface 5. CBC and PBS – r/o anemia. 6. (+)Reticulocytosis – NV 0.5-2.5% Mgt: as above

Answer 35

Patho - Caused by transplacental passage of maternal Ab vs paternal RBC Ag of the infant à causing inc RBC destruction - Rh(-) woman + Rh(+) man conceive 1st Rh(+) child > cells from Rh(+)fetus enter woman’s bloodstream making her sensitized --> Rh Ab form vs Rh(+) blood cells - In the next pregnancy: maternal Ab attack fetal Rh(+) RBC -The severity of RHI increases with successive pregnancies

Answer 36

CM 1. Mild anemia (15%) to severe 2. Hepatosplenomegaly 3. Hydrops fetalis – excessive abN fluid in >2 fetal compartments (skin, lungs, heart, placenta, peritoneum, AF) 4. CHF – edema, ascites 5. DIC – petechiae, purpura, dec plt 6. Jaundice at 1st DOL

Answer 37

Dx 1. Antenatal Dx: a. Maternal IgG titer @12-16wks, 28-32 wks, 36 wks – titer >1:16 is (+) b. UTZ with doppler 2. Postnatal Dx: same as ABO incompatibility

Answer 38

Mgt 1. DVET of group O Rh(-) leukoreduced and irradiated FWB cross-matched vs. maternal serum - Severe hemolysis: Cord blood Hgb <10mg/dL, DB >5mg/dL 2. IVIG

Answer 39

Prevention 1. RhoGAM 300ug within 72h of delivery of Rh(+) infant then per subsequent pregnancy at 28-32 wks and at birth

Answer 40

- X-linked deficiency, spontaneous missense mutation - M>F, usually Greeks, southern Italian, Jews, Filipinos, S. Chinese, African American, Thais - MC inherited enzymatic disorder (1 in 61 children in PH)

Answer 41

Pathophysio - Genetic defect in RBC Glucose-6-phosphate dehydrogenase deficiency o Lack of this enzyme causes hemolytic anemia when exposed to oxidative stress - G6PD enzyme important in pentose phosphate pathway which provides reduced NADPH to keep glutathione in reduced form as an antioxidant. - Therefore, G6PD deficiency leads to oxidant stress to RBCs --> hemolysis

Answer 42

- Pct, ASA, VitC, chloramphenicol, ciprofloxacin, diphenhydramine, isoniazid, phenytoin, quinidine, vit.K

Answer 43

CM 1. Asymptomatic unless triggered by precipitants 2. Acute hemolytic anemia (AHA) – MC, classic Sx - Triad of hemolytic anemia: o Pallor/anemia o Jaundice o splenomegaly 3. Jaundice --> kernicterus 4. Episodic hemolytic anemia (chronic nonspherocytic) - Hemolysis 24-48h after ingestion of oxidative substance 5. Hemoglobinuria

Answer 44

Dx: 1. CBC – anemia, dec Hct, mod elev WBC, granulocyte predominance, N/inc/dec plt 2. NBS – for screening 3. G6PD assay – confirmatory test 4. PBS – Heinz bodies, anisopoikilocytosis, bite cells, normocytic, normochromic 5. Reticulocyte count elev

Answer 45

Mgt 1. Avoidance of precipitants 2. Acute hemolytic episode a. ID and remove the culprit agent b. Hydration and Blood transfusion for severe anemia o Indications for BT: § <7g/dL – ASAP § <9g/dL with hemoglobinuria § >9g/dl but persistent hemoglobinuria