Abdominal Pain in Children Flashcards
Presentation of constipation
Infrequent passage of stool Poor appetite Lack of energy Irritable Pale Black bags under eyes Abdominal pain / distention Withholding or straining Diarrhoea - overflow and liquid stool
Causes of constipation
Poor diet - insufficient fluids - excessive milk Potty training / School toilet Intercurrent illness Medication (opiates / Gaviscon) FH Psychological (secondary) Organic (RARE) - anal stenosis - anterior anus
What happens if you need to go and do not go?
Constipation
Viscous cycle of constipation involves….
A large hard stool when young
Painful or caused an anal fissure
this leads to toddler withholding of stool to prevent pain
What is a megarectum?
The stool stretches the rectum as there is so much hard stool stored
Results of megarectum
UTIs
Wetting
Soiling
Who particularly gets UTIs / wetting due to megarectum and why?
Girls as short urethra
Why does soiling occur when have a megarectum?
Internal sphincter is held open by the stool and so can only rely on the external sphincter
Soft watery stool leaking around hard stool
Why does stool get harder if it is not let out?
Bowel sucks out more and more water
Treatment of constipation
Diet - increased fibre - increased fruit and veg - increased fluid - decreased milk Psychological - reduce adverse factors (make going to the toilet a pleasant experience) - Soften stool and remove pain - Avoid punitive behaviour of parents - Reward good behaviour (praise, star charts) Soften stool and stimulate defecation - drugs (osmotic laxatives, stimulant laxatives, isotonic laxatives)
How can going to the toilet be made into a pleasant experience for children?
Correct height
Not cold
How long is treatment for constipation given?
Under no longer required - enough to make them go
Treatment of impaction
Empty impacted rectum and colon = movicol
Maintain regular stool passage
Slow weaning off treatment
Investigations of impaction
Abdominal exam
- sometimes feel a suprapubic mass
Colonic marker study
Symptoms of Crohn’s and UC
Diarrhoea (>UC) Rectal bleeding (>UC) Abdominal pain Fever Weight loss (>C) as puts off eating Growth failure (>C) Arthritis Mass (C)
Pattern of inflammation in crohn’s
Can affect anywhere so the site of inflammation predicts the symptoms
Skip lesions
Long deep inflammation like snail tracks
Particular features of UC
Bloody mucosal diarrhoea
Fluctuating
Features of investigations for Crohn’s
Symptoms not strong esp in those who dont have diarrhoea
Abnormal bloods
Features of investigations for UC
Dont always get abnormal bloods
Symptoms
Lab tests for UC / chron’s
FBC - anaemia - thrombocytosis ESR - raised Stool caprotectin Raised CRP Low albumin No stool pathogens
Investigations for UC / C
MRI Barium meal (< 5s) Endoscopy
Features of inflammation in UC
Not patchy
Continuous
Usually gets better as go round and check on endoscopy
Aim of treatment for IBD in children
Induce and maintain remission
Correct nutritional deficiencies
Maintain normal growth and development
Treatment of IBD
Anti inflammatorys Immunosuppressants Biologics (infliximab) Steroids (possibly) Nutrition - immune modulation - nutritional supplementation Surgical
What to ask in the history of abdominal pain?
Vomiting? - colour SOCRATES Bowel symptoms Urinary symptoms - dysuria WHERE Gynae / sexual history If teenagers Systemic features Vaccinations
How do you check for peritonism?
Get the child to jump
On abdo examination in children, what is done instead of rebound tenderness?
Percussion
What are the areas of the abdomen?
Right hypochondriac region Epigastric Left hypochondriac Right lumbar Umbilical Left lumbar Right illac fossa Hypogastrium Left iliac fossa
What investigations could be done for abdominal pain?
Urinalysis - microscopy - culture -BhCG possibly Stool culture - enteric pathogens - H pylori Bloods AXR / CXR AUSS MRI Colonoscopy / sigmoidoscopy
Causes of abdominal pain in infants
Colic CMPA Food intolerance Gastroenteritis Malrotation Intussception (PS) UTI Hernia (strangulation) Meckles diverticulum
Which cause of abdo pain in infants is an emergency?
Malrotation
Causes of abdo pain in a child
Pancreatitis (uncommon) Appendicitis IBS Meckles diverticulum Gastroenteritis UTI IBD
Causes of abdomen pain in adolescence
Menstruation IBS IBD Ovarian - torsion - cyst Appendicitis
What is intussception?
Telescoping of the bowel
Presentation of intussception
Episodes of pain and drawing legs up
Sausage like mass
Redcurrent jelly stools (late sign)
Investigations of intussception
AUSS
Tx of intussception
Air enema
- 90% successful
Theatre 10%
Risks of air enema
15% recurrence
Risk of perforation
Pathology of intussception
Peristalsis when younger
Pathological if older
What age normally gets intussception?
4 - 18 months
Special signs of appendicitis
Press in LIF get pain in RIF
Internal rotation of the hip causing pain
Bring knee up causing pain
Lifetime incidence of appendicitis
6 - 8%
Pathology of appendicitis
Blocked lumen leads to - swelling - ischaemia - necrosis Results in - perforation - abscess formation
Pattern of the pain in appendicitis
Starts central
Moves to RIF
What rule goes with Meckles diverticulum?
Rule of 2s
- 2% of pop have it
- 2% will become symptomatic
- 2 ft from ileocaecal valve
- 2cm long
Definition of Meckles diverticulum
Congenital diverticulum of the small intestine
Pathology of meckles diverticulum
Remnant of the omphalomesenteric duct and contains ectopic ileal, gastric or pancreatic mucosa
Presentation of meckles diverticulum
Abdo pain mimicking appendicitis
Rectal bleeding
Intestinal obstruction
- intusseception
Tx of meckles diverticulum
Removal if
- narrow neck
- symptomatic
Definition of mesenteric adenitis
Inflammed lymph nodes within the mesentery after viral infection causing abdominal pain
Treatment of mesenteric adenitis
No treatment
What does the vomiting look like in gastroeneteritis?
Clear or foodstuffs
Features of vomiting and diarrhoea in GE
Diarrhoea lasts 5 - 7 days, resolves by 2 weeks
Vomiting lasts 1 - 2 days, resolves by 3 days
Causes of GE in children
Rotavirus Adenovirus Enterovirus Norovirus E coli Shigella Salmonella Campylobacter Giardiasis Amoebiasis
Which usually comes first in GE, the diarrhoea or the vomiting?
Vomiting
Most common cause of GE in children
Rotavirus
Fluid replacement in a child with no clinical dehydration
Continue breast feeding
Encourage fluid intake
Discourage fruit juices and carbonated drinks
Offer ORS if risk of dehydration
What % dehydration is mild?
< 5%
What % is moderate dehydration?
5 - 10%
What can be seen in the nappy in under 1s in dehydration?
Urate crystals
- Look like orange crystals in the nappy
Examples of High H20 content foods
Jellys
Yogurts
Treatment of clinical dehydration
Oral replacement therapy - ORS 50ml/kg over 4 hours then maintenance often in small amounts Continue breast feeding Consider ORS via NG tube If clinically deteriorate for IV fluids
Management of clinical shock
Fluid bolus 20ml/kg
IVT - for maintenance and fluid deficient replacements
Add 100ml/kg for children initially shocked or 50ml/kg for children who were not initially shocked to maintenance fluids
How do you work out maintenance fluids in children?
4, 2, 1 rule
4ml/kg 10kg
2ml/kg 10kg
1ml/kg / kg everything else
150ml/kg/day < 1s or sometimes pyloric stenosis
What is the resus fluid in children?
20mls/kg 0.9% NaCl
10mls/kg if bleeding
Types of fluid treatment
Replacement
Resuscitation
Maintenance
How to work out replacement fluid for children?
ml for ml
What are the maintenance fluids used in children?
0.9% NaCl
5% Dextrose
0.15% KCl
Types of dehydration
Hypernatraemic
Hyponatraemic
Isotonic
Who is especially at risk of hypoglycaemia and why?
< 5s
Dont have some reserves
What does the stool look like in coeliac disease?
Mucous in it
Treatment of hypernatraemic dehydration
Isotonic solution
Replace fluid deficit over 48 hours
Aim to reduce plasma Na less than 0.5mmol/l per hour
What fluid replacement is done after rehydration?
ORS 5ml/kg for each large watery stool
Red flags in GE
Temperature Tachypnoea Altered consciousness state Neck stiffness Blood in stool Bilous vomiting Severe or localised abdominal pain Abdominal distension
Who is at increased risk in GE?
Children < 1 y/o LBW infants > 6 stools in 24 hours > 3 vomits in 24 hours Children not tolerating supplementary fluids Children with malnutrition
Complications of GE
Electrolyte imbalances - Decreased Na - decreased K Hypoglycaemia Metabolic acidosis Seizures (febrile convulsions)
If have D + V, what is the school exclusion advice?
48 hours after symptoms have settled
Common complication after viral GE
Transient lactose intolerance
What is a red flag for hirschprungs disease?
Passage of meconium after 48 HOURS
Stools / diarrhoea containing undigested food typically point towards what diagnosis?
Toddlers diarrhoea
If movicol isn’t working, what else can be done?
Add senna
