Abdominal pain Flashcards
Key components of GIT history overview
Nutrition Vomiting Bowel habits Pain Family history GU symptoms
History of nutrition (11)
Infant feeding patterns- duration of breast feeding
Any breast feeding problems
Key professional support for breast feeding
If formula fed- type and volume
Review intake- typical is 150ml/kg/24 hours
Age at weaning to semi solids, any choking problems, foods taken
Detail what the child eats in a typical day
Review calorie intake and nutritional balance
Level of appetite and difficult feeding behaviours
Pattern of weight gain
Review parent hand held health record
Volume of one fluid oz to ml
one fluid oz is 28 ml
Typical infant intake of milk
100-150ml/kg/24 hours
History of vomiting
Vomiting frequency and colour
What does green, posseting, blood in vomit of small and older children
Green= bile
Posseting= vomiting milk
Blood in vomit of infant->maternal blood in milk
In older children blood may suggest esophageal bleeding due to vomiting
History of bowel habits
Feces->frequency, consistency, colour, mucus, blood, greasy
Diarrhea->frequency, urgency, consistency, blood, link with diet
Meconium passed
Age of potty training
Constipation->straining, pain, reduced frequency, hard faeces
Soiling of faeces in underwear
Encopresis
In newborns when should meconium be passed
Within the first 24 hours
What is encopresis
Behavioural problem of passing faeces in inappropriate places
Components of abdominal examination
Observation Palpation Percussion Auscultation Genitalia and anus Rectal examination
Observation
Child should be relaxed Assess nutritional status->percentiles, BMI, HC, AC Jaundice Pallor Abdominal distension Wasting of buttocks
Organs to be palpated on abdominal examination
Liver
Spleen
Kidneys
What is to be examined for on genitals in boys
Hypospadias Epispadias Undescended testes Hydrocele Hernia
Causes of acute abdominal pain in neonates
Hirschprung's enterocolitis Incarcerated hernia Intussusception Irritable/unsettled infant Meckel's diverticulum UTI Volvulus
Causes of acute abdominal pain in infants and preschool
Appendicitis Gastroenteritis Intussusception Pneumonia UTI Volvulus Constipation
Causes of acute abdominal pain in school aged children
Appendicitis Gastroenteritis DKA Henoch-schnolein purpura Mesenteric adenitis Migraine Ovarian pathology Pneumonia Constipation Testicular torsion UTI Viral illness
Causes of acute abdominal pain in adolescents
Appendicitis DKA Ectopic Cholecystitis Gastroenteritis IBD Ovarian cyst torsion/rupture Pancreatitis Pelvic inflammatory disease Renal calculi Testicular torsion UTI Viral illness
History in acute abdomen
SOCRATES Billous vomiting->obstruction Pallor and lethargy->intussusception Rash and purpura on extensor surfaces->HSP Cough and fever->pneumonia Dysuria and frequency->UTI Polyuria polydipsia, loss of weight->DKA Menstural history in post pubertal->ectopic, torsion Loss of appetite Blood in stool
Past medical history
- Hirschsprungs, CF complicated by enterocolitis->sudden painful abdominal distension and bloody diarrhea
- Primary bacterial peritonitis->liver disease, nephrotic syndrome, splenectomy, ascites, VP shunt.
- Pancreatitis->chemotherapy, immunosuppressants
- IBD->toxic megacolon
What should you suspect when acute onset of pain
Testicular/ovarian torsion
Intussusception
Perforated viscus
What should you suspect with episodic severe pain
Intussusception
Mesenteric adenitis
Gastroenteritis
Constipation
Important associated features
Billous vomiting Pallor and lethargy Rash and purpura on extensor surfaces Cough and fever Dysuria and frequency Polyuria polydipsia, loss of weight Menstural history in post pubertal
Examination in acute abdomen
Assess hydration
Assess overt signs of peritonism: not moving, not walking comfortably, tender to percussioin
Examine the abdomen
Respiratory examination
Inguinoscrotal examination
Rectal/vaginal examination avoided in children
Investigations that may be required in acute abdomen
FBC Urine MCS Glucose UEC LFTs Lipase Urine bHCG
Imaging:
AXR if obstruction suspected, dilated=obstruction, abnormal gas in intussusception, fecal loading in constipation
CXR if pneumonia suspected
USS->discuss with senior, renal tract abnormals
Acute management of acute abdomen
ABC Early referral if surgery likelye Fluid resuscitation IV/IO access Measure UEC and glucose if appear deH NBM Analgesia- morphnine/fentanyl may be required NGT if BO suspected IV antibiotics in surgical
D/C advise following acute abdomen
Many can be d/c after good H/E/urine
Clear f/u plan, with GP
Conditions which may present with recurrent abdominal pain only
Inflammatory bowel disease
Chronic urine infections
Parasites
Management of “recurrent abdominal pain”- as functional problem
Assure parents no major illness
Cause is unknown, pain is very real
Do not communicate to the parent that the child is malingering
Identify those signs and symptoms to watch for and which would suggest need for re-evaluation
Develop a schedule for re-visits to monitor symptoms. Have family keep a diary of pain episodes and related symptoms
During return visits, allow patient and parents to express concerns and stresses
Make every effort to normalise the life of the child, encourage attendance and participation in activities
Liase with school to ensure attendance
Psychogenic abdominal pain
Psychosomatic->related to stress at home/school
Assure parents of no major illness
Link pain with the stresses
Causes of recurrent abdominal pain
Idiopathic recurrent abdominal pain
Hepatic->hepatitis
Pancreatic->pancreatitis
GIT: IBS Esophagitis Peptic ulcer IBD Constipationn Malabsorption Giardia Celiac
UTI
Psychogeni, abdominal migraine, sickle cell
Gynaecological: Dysmenorrhea PID Hematocolpos Ovarian cyst
History in recurrent abdominal pain
SOCRATES Affect daily activities Constitutional symptoms/red flags->vomiting, diarrhea, weight loss, lethargy GIT, GU, gynaecological symptoms Psychosocial history School
Must ask parents if they are specifically concerned that their child has a serious disease not being investigated/being missed
Examination in recurrent abdominal pain
Growth->++percentile
General examination: jaundice, palor, deficiencies
Abdominal examination
Anorectal->not routine
Investigations and significance in chronic abdominal pain->if suspect organic cause
Bloods: FBC->anemia, eosinophils, infection CRP->add stool test for H pylori antigen LFTs Celiac screen UEC Amylase
Urinalysis and culture
Stool for OCP
Occult blood
Imaging:
Abdominal and pelvic USS: urinary obstruction, organomegaly, abscess, pregnancy, cyst/torsion
AXR: constipation, renal calculi, lead poisening
Barium swallow->esophagitis, GORD, peptic ulcer, crohns, congenital malformations
Endoscopy: esphagitis, reflux, peptic ulcer, IBD
Red flags in abdominal pain
Pain not confined to periumbilical area (the further the
pain is from the umbilicus the less likely it is to be
functional).
Pain at night / waking from sleep
Change in bowel habit or blood in the stools
Vomiting
Intermittent fever
Weight loss
Lethargy
Poor growth
Involvement of other system e.g. rash, joint pain
Anaemia or raised acute phase reactants
Information to gain re school
School:
Academic progress, any change?
Peer relationships: does he have a good friend, any change in friends?
Is there bullying at his school?
Does he feel mostly happy or sad?
How would he rate his mood on a scale of 1 – 10 where 1 is very happy and 10 is very sad
Abdominal masses in children
Common abdominal masses in children include faecal masses, neuroblastoma, nephroblastoma (Wilm’s tumour) and lymphoma.
