Abdominal pain Flashcards
Causes of acute abdominal pain in infantsand children
GIT - Gastroenteritis, Appendicitis, Meckel’s diverticulum, Mesenteric adenitis, Ileus, Intestinal obstruction (Incarcerated hernia, intussusception, volvulus), Malabsorption, IBS, Constipation.
Hepatobillary tract - Cholecystitis, Pancreatitis
Genitourinary -UTI, Nephrolithiasis, testicular torsion, Ovarian torsion, ectopic pregnancy, PID, Endometriosis Menstruation.
Hematologic - Henoch-Schonlein Purpura, Sickle cell crisis
Other - DKA, pneumonia, somatisation.
Important questions to ask on history for acute abdomen pain
Description of pain
Relations to meals
Associated sysmtpoms
Nausea, vomiting, diarrhoea, fever.
What to look for on examination of acute abdomen pain
Abdominal exam , peritoneal signs, bowel sounds, rectal exam, rash.
Ix for acute abdominal pain
FBC, Differential, urinalysis to rule out UTI.
Most common cause of acute abdomen in children
Appendicitis
Clinical features of appendicitis
Low grade fever Abdominal pain Anorexia N/V after onset of pain Peritoneal signs - generalised peritonitis is common in infants and young children.
Who get Intussusception
CF or gastrojejunostomy
Children between 3 months to 2 yrs.
Clinical features of intussusception
Classic triad (abdo pain, palpable mass(Sausage shape), red current jelly)
Sudden onset of recurrent , paroxysmal, severe periumbilical pain with pain-free intervals (episodic screaming)
Later vomiting may be bilious
Rectal bleeding (late
Shock and dehydration
Dx of intussusception
US, air enema
Tx of Intussusception
Air enema or surgery
Clinical features of gastroenteritis
diarrhoea with or without vomiting or cramping abdominal pain
Check dehydration level
Red flags for abdominal symptoms
Severe abdominal pain or abdominal signs Persistent diarrhoea >10 d Blood in stool Very unwell appearance Billions vomit vomiting without diarrhoea
Ix for gastroenteritis
None unless the following
Stool sample if >7 days, suspect septicaemia, blood or mucus or immunocompromised
Blood test if - Severe dehydration, renal disease, ALOC, Hypernataemia, Profuse or prolonged losses, ileostomy.
Mx of gastroenteritis
Simple cases - Oral rehydration
Shocked - resus
discuss with consultant
No/Mild dehydration - Trail of fluids, advice, arrange follow up and D/C
Moderate dehydration - trail of fluids, NGT if needed
ORS = 10-20mls/kg over 1hour. NGTR Rapid 25l/kg/hr for 4 hours. Slower if
How to calculate fluids
Maintenance = 4:2:1 upper limit is 100ml/hr
Deficit = % of dehydration X wt x 10
Ongoing loss
Define chronic abdominal pain
3 episodes of severe pain
Child >3yr old
Over 3 month period
Red flags for chronic or recurrent abdominal pain
Any of the following make functional chronic or recurrent abdominal pain unlikely
- Pain not confined to periumbilical area
- Pain at night/waking from sleep
- Change in bowel habit or blood in stool
- vomiting
- Intermittent fever
- Wt loss
- lethargy
- poor growth
- Involvement of other system e.g. rash, joint pain
- Anaemia or raised acute phase reactants
DDX of chronic abdominal pain
Organic (105)
GIT - constipation, IBD, esophitis, peptic ulcer disease, lactose intolerance, anatomic anomalies, masses,Pancreatic, oesophagitis, IBS, Malabsorption, Giardiasis
hepatobiliary- hepatitis
Genitourinary - recurrent urinary tract infection, nephrolitiasis, chronic PID, Mittelschmerz, dysmenorrhoea, ovarian cysts,
Neoplastic
Abdominal migraine
Sickle cell disease
Non Organic - Function recurrent abdominal pain
Clinical features of function/recurrent abdominal pain
Clustering episodes of vague, crapy periubilical/epigastric pain, vivid pain description.
Seldom, awakens child from sleep, less common on weekends
aggravated by exercise, alleviated by rest
Psychological factors related to onset and or maintenance of pain, school avoidance
Psychiatric coorbidity - anxiety, somatoform, mood, learning disorder, sexual abuse, eating disorders, elimination disorders
Diagnosis of exclusion
Ix for function/recurrent abdominal pain
FBC, ESR, urinalysis, stools for O&P, Occult blood.
Mx for function/recurrent abdominal pain
Continue to attend to school
Manage any emotional or family problems, counselling
Trail of high fibre diet, trail of lactose free diet
Reassurance that it is real but not pathological problem
Education on red flags
Follow up - for review and expression of stresses
Prognosis - resolves in 30-50% of kids 2-6 wks after dx. 30-50% have functional pain as adults e.g. IBS.
who get appendicitis
commonest in post pubertal,
uncommon in under 5 yr
Clinical features of appendicitis
Periumbilical pain that become localised over RLQ when peritoneum becomes involved lay very still worse on movement Nausea Vomiting - bile stained anorexia Tachycardia constipation occasional diarrhoea & vomiting low grade fever
Ix for appendicitis
leucocytosis
Neutrophilic
Urine to exclude infection
USS if unsure of Dx
DDX for pain in Iliac fossa
mesenteric adenitis Gastroenteritis Constipation Urinary tract infection Hence-schonlein purpura Inflammatory bowel disease Ovarian pain Ectopic pregnancy Pyelonephritis
Mx of appendicitis
Appendicectomy Laparoscopically Excellent prognosis Perforation is commoner in children If peritonitis = severe illness and adhesions may lead to bowel obstruction. Other Resus IV Blood - G&H, cross hold, FBC, U&E, CRP, B Fluid bolus Antibiotics - cefuroxime, metronidazole Hx Reassess - ABC and vital signs Examination Reassess Ix - Abdo Xray - stones, SBO or servere constipation. Urinalysis +/- microscopy RBC/CRP/UE/BCs USS - Reassess surgery refer to paediatric surgery for Appendicectomy Laparoscopically
