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
Cause of intussusception
Enlarged lymphatic may form the leading edge of the intussusception. This is often following a viral infection.
Adenovirus or rotavirus
Very rarely due to pathological lesion such as polyp or lymphoma or complication of HSP.
Ix of intussusception
AXR - rounded edge of intussusception against gas filled lumen of the distal bowel with signs of proximal bowel obstruction
USS - Doughnut sign
Presentation of Inflammatory bowel disease
Blood/mucus in stools
Family Hx of diarrhoea
Wt less and poor growth
Presentation of Mesenteric adenitis
Recent viral infection
No peritonism or guarding
Pain can mimic appendicitis
Presentation of peptic ulcer
Pain at night
Relief with milk
Think Helicobacterpylori
Prevention intestinal obstruction
Bile stained vomiting
Abdominal distension
Consider a volvulus
Presentation of constipation
Hard or infrequent stools
Mass in left iliac fossa
Faecal loading on radiograph
Presentation of UTI
Dysuria, frequency Bedwetting Back pain vomiting Evidence of infection on urinalysis or microscopy.
Presentation of Henoch-Schonlein purpura
palpable purpuric rash on lower half of body (buttocks and extensor surfaces). disappears on pressure, due to signifying intradermal bleeding
- Joint pain and Arthritis - Usually main compliant and most pain resolves in 24-48 hrs.
+/-Swelling - eg scrotum, hands, feet and sacrum - can be very painful.
Abdominal pain due to GI vasculitis risk of +/- intussusception. Blood in stool and acute abdomen
If uncomplicated - resolves spontaneously 72 hr
Complications - intussusception, blood stools, haematemesis, spontaneous bowel perforation, pancreatitis
Renal
+/- Glomerulonephritis
haematuria (90%),
Less common proteinuria, hypertension, nephrotic syndrome and rarely Renal failure
Can present as abdominal pain or arthralgia before rash.
Commonly 2-8 yrs
Hx of URTI
Mx of Henoch schonlein purpura
Consult senior staff
Steroids helpful in abdominal & joint pain - prednisolone 1mg/kg
Look for complications e.g. Intussusception, Perforation, pancreatitis, stone,
Admit if Cx presentation or severe pain from joint, abdomen or subcutaneous oedema.
when DC follow up with GP for BP and urine
Education - on need for follow up and rash being the last to go. Worsen in child is active.
DDX for blood in stools
Intussusception
inflammatory bowel disease
Henoch Schonlein purpura
Some types of gastroenteritis.
Surgical causes of abdominal pain
Acute appendicitis Intussusception Ovarian cysts Volvulus Renal, ureteric and biliary stones
Non surgical causes of abdominal pain
Gastroenteritis - common, colicky, V&D PID Ectopic UTI DKA Lower lobe pneumonia Henoch Schonlein purpura Anxiety Mesenteric adenitis
Mx of mesenteric adenitis
Diagnosis of exclusion
tx if simple analgesia
Hx and Examination finding for chronic abdominal pain
Hx
where it is worse
when it is worse
Does the pain affect daily activities
Constitutional symptoms - wt loss, anorexia, fever
emotional, anxiety or daily problem
Ex
Growth - wt loss or fall off in growth indicated serious pathology
GI - look for pallor, jaundice and clubbing
Abdo - hepatomegaly, splenomegaly, enlarged kidneys or distended bladder.
PR - not routine in children.
Presentation of IBS
functional condition associated with recurrent abode pain and minor GI symptoms such as bloating and altered bowel habit e.g. ranging from pellets to unformed stools. Gas.
Hx of colic as infant.
Acute symptoms resolve with time but relapse occur.
Red flags are change in symptoms e.g. wt loss, bleeding or anaemia
Tx of IBS
Reassurance
Diet education
Low FODMAP
Smooth muscle relaxants eg mebeverine for spasms
Presentation of gastritis and peptic ulcer
epigastric pain Relieved by food May be family hx ALARM Symptoms: A – anorexia L – loss of weight A – anemia R – recent onset/ progressive symptoms M – melaena/ haematemesis S – swallowing difficulty
Work up and Mx for peptic ulcer
Ix - stool examination for helicobacter antigen, Hydrogen breath test or endoscopy H2 receptor eg ranitidine PPI eg ezomerprazole Helicobactor pylori - PPI - Ezomerprazole - ABx - Amoxicillin, clarithroycin
Causes of constipation
Idiopathic - Fluid depletion - low fibre diet - lack of mobility & exercise Gastrointestinal - Hirschsprung's disease - anal disease - infection, stenosis, ectopic, fissure, hypertonic sphincter) - Bowel obstruction - food hypersensitivity - Coeliac disease Non-gastrointestinal - Hypothyroidism - Hypercalcaemia - Neurological disease e.g. spinal disease - Chronic dehydration eg diabetes insipidus - Drugs e.g. opiate and anticholinergics - sexual abuse
Clinical features of constipation
Infrequent stool
Mx of constipation
Short term
- soften retained stool e.g. movicol
- Colonic stimulant eg Senna.
Continue until bowel pattern regular and then decrease
Long term
- Soften retained stool for at least a week
- Oral colonic stimulant eg senna
- if failure then try oral bowel evacuation preparation, enema, manual evacuation under general sedation
Maintenance tx
- Increase dietary fibre and fluid
- Regular bulk laxative
- Reg colonic stimulant
- Persist with medication for at least 6 months.
- Behaviour management - establish toilet routine
- Assessment by a clinical psychologist and therapist if there is a degree of family discord
Presentation of Hirschprung’s disease
in newborn period with delayed passage of meconium and abdominal distention.
If only small segment then may present later with constipation and FTT.
Commoner in boys then girl
Dx by barium enema and then rectal biopsy
Mx resection of abnormal section of bowel.
risk factors for constipation
Diet - not drinking enough fluid or high fibre foods
Holding of stools - e.g. not liking public toilet
Change in routine - e.g. holiday, moving house, or school or even changing of formula
Lack of exercise
Genetic
Medication eg codeine, cough medicine, some anticonvulsants, antihistamines.
how to differentiate organic causes of abdominal pain to non organic causes
Non organic - periodic pain with intervening good health, often periumbilical, may be related to school hours
Organic pain- pain occurring at night, wt loss, reduced appetite, lack of energy, recurrent fever, organ-specific symptoms e.g. change in bowel habit, polyuria, menstrual problems, vomiting, occult or frank bleeding
Ill appearance, growth failure, swollen joint.
how to calculate likelihood of appendicitis
Alvarado score uses the Acromin MANTRELS Migration of pain 1 Anorexia 1 Nausea 1 Tenderness in RLQ 2 Rebound pain 1 Elevated temperature 1 Leucocytosis 2 Shift of WBC count to the left 1 Score 1-4 D/C (30%) Score 5-6 Observation/admission (66%) Score 7-10 Surgery 93%
Presentation of Oesphagitis
heartburn,
difficult feeding with crying
Painful swallowing
haematemesis
Causes of UTI
90% Escherichia coli - important recurrence UTI - 40% - very common Rarely - 10% Staph Saprophyticus Proteus Klebs Entero Ureaplasma - rare
underlying causes for Paediatric UTI
Obstructed urinary system Pelviureteric obstruction Urinary stones Posterior urethral valves 0 in boys with poor urinary stream) Duplex kidney with obstructed pole Horse shoe kidney Organism - E.coli most of the time Gram -ve - E.coli, Klebsiella, proteus, enterobacter, pseudomonas Gram +ve - S.saprophyticus, enterococcus
Paediatrics risk factors for UTI
Non modifiable - female, caucasian, previous UTIs, FmHx
Modifiable - Urinary tract abnormalities (vesicoureteral reflux, neurogenic bladder catheterisation, uncircumcised males, labial adhesions, sexually active, constipation, toilet training
Increase chance of spread to kidney in
Clinical features for UTI in paediatric patients
Distal system - Dysuria, Low grade fever, frequency, urgency,
Pyelonephritis. Flank pain, high fever,
Paediatrics
Hx
often non-specific e.g. fever, irritability, poor feeding and vomiting, failure to thrive, septic
May have
loin or abdominal pain, frequency and dysuria but are often absent in younger patients
varies from children looking well to appearing very unwell.
NICE
3 months Preverbal - Most common - Fever
Less common - Abdominal pain, loin tenderness, vomiting, poor feeding
Least common - Lethargy, irritability, Haematuria, offensive urine, failure to thrive
> 3 months Verbal - Most common - frequency, Dysuria
Less common - Dysfunctional voiding, changes to continence, abdominal pain, loin tenderness
Least common - Fever, Malaise, Vomiting, Haematuria, Offensive urine, cloudy urine.
O/E
Often normal other then fever
May have Loin or supra-pubic tenderness
Toxic vs non toxic, FTT, Jaundice, look for external genitalia abnormalities (Phimosis, labial adhesions), Lower back signs of occult myelodysplasia (eg hair tufts), which may be associated with neurogenic bladder.
Old child - febrile, suprapubic and/or CVA tenderness, abdominal mass (enlarged bladder or kidney); may present with short stature, FTT or hypertension secondary to renal scarring from previously unrecognised or recurrent UTIs
IX UTI
Blood: Leukocytosis – neutrophilia
Midstream clean catch Urine specimen*
Dipstick: Leukocyte esterase (only in neutrophils) & nitrite +ve.
Urine: pyuria, neutrophils, bacteria, cloudy
MCS
Urinanalysis - blood, nitrates, leucocytes esterase, screening test only.
bHCG - confirm that they are not pregnant - changes treatment
Methods for getting a urine samples in kids
Clean catch - sterile around and give the parents a jar and ask them to watch and wait
SPA -
indications - Don’t have time to wait for a clean catch e.g. septic and need to give antibiotics
in a child
Tx of UTI in kids
If unwell or
presentation of DKA
Symptoms PolyUria polydipsia weight loss weakness Nausea vomiting leg cramps blurred vision abdominal pain Sign Kussmaul breathing (deep and laboured breathing), dehydration Hypotension - postural or supine Cold extremities/peripheral cyanosis tachycardia smell of acetone hypothermia confusion, drowsiness, coma
criteria for DKA
combination of hyperglycemia, metabolic acidosis, and ketonaemia
BGL >/= 11.1 mol/L
bed side Blood ketone >0.6 mol/L or urinanlysis
vBG pH
Work up for DKA
1 degree of dehydration: None/mild (7%): poor perfusion, rapid pulse, reduced blood pressure e.g. shock
2 level of consciousness
3 Investigations: VGB, FBC, Blood glucose, urea, electrolytes, blood ketones. investigations for cause.
if new diabetic: Insulin antibodies, GAD antibodies, coeliac seen (total IgA, anti gliadin Ab, tissue transglutaminase Ab) and TFT
Urine - ketones and culture
Management of DKA
DRSABCDEFG IV O2 cardiac monitor - signs of hyperkaleia (Peaked T waves, widened QRS) or hypokalemia (flattened or inverted T waves, ST depression, wide PR interval. Blood cultures if febrile Catheterise and fluid control Fluid requirements - if hypo perfusion - give 0.9% NS at 10ml/Kg initial fluid replacement - NS + potassium Insulin 0.1units/kg/hr - Glucose Nil by mouth
Ongoing monitoring and management
- Strict fluid balance
- Hourly observation - HR, BP, RR, GCS, neuro signs:pupillary responses, assess for change e.g. restlessness, irritability, headache.
Hourly glucose and ketones
recheck K+ within 1 hr of commencing insulin infusion
VBG and lab glucose 2 hourly for initial 6 hrs and then 2-4 hourly there after.
Serum U&E 2-4 hourly for initial 12-24hr
2-4 hourly temp
nursed head up
Things to look for when treating DKA
Hyper/hyponatraeia
Hypoglycaemia
Cerebral oedema
How to describe an enlarged liver
5S Site Size Shape Surface, Skin Consistency - hard, soft Young liver is 4-6cm big. Starts at 5th rib.
