Abdominal Pain in Children Flashcards
What common differentials should be considered in neonates with abdominal pain
Colic (self-limiting), Necrotising enterocolitis, Volvulus, Testicular torsion and CMPA (Cow’s milk protein allergy)
What common differentials should be considered in infants (1 month-2 years) with abdominal pain
Viral illness (self-limiting), Gastroenteritis (self-limiting), UTI, Constipation (self-limiting), Food allergy, intussusception and haemolytic uraemic syndrome
What common differentials should be considered in young children (2-5 years) with abdominal pain
Viral illness (self-limiting), Gastroenteritis (self-limiting), UTI, constipation (self-limiting), Appendicitis, Haemolytic uraemic syndrome, HSP and Foreign body ingestion.
What common differentials should be considered in older children (>5 years) with abdominal pain
Viral illness (self-limiting), gastroenteritis (self-limiting), UTI, Constipation (self-limiting), Appendicitis, primary bacterial peritonitis, lower lobe pneumonia, DKA, inflammatory bowel disease and abdominal migraine.
Does appendicitis occur in children <4yrs
Rare before age of 4 but perforation is high in this group so must be aware of it.
What are the risk factors for appendicitis?
<6 months of breast feeding Low dietary fibres Improved personal hygiene Smoking More common in Caucasians
What causes appendicitis?
Faecolith
Lymphoid hyperplasia
Impacted stool
Appendiceal or caecal tumour
How does appendicitis usually present?
Dull and poorly localised abdominal pain that starts in the umbilical region and then moves towards the RIF becoming well localised and sharp
Rebound tenderness + percussion pain at McBurney’s point 2/3rd between umbilicus + ASIS
Anorexia
Nausea and slight vomiting
Absence of cough
Fever and tachycardia
If child is well, can sit unsupported and hop it is unlikely to be appendicitis
Psoas sign – RIF pain with extension of the right hip (suggesting retrocaecal position)
What is Rovsing’s sign?
Rovsing’s sign – RIF pain on palpation of the LIF
What is Psoas sign?
Psoas sign – RIF pain with extension of the right hip (suggesting retrocaecal position)
How should suspected appendicitis be investigated?
FBC + CRP Urinalysis Transabdominal USS (younger patients) – dilated appendix, echogenic peri-appendiceal fat and target appearance CT scan (older patients) Pregnancy test
How is appendicitis managed?
Laparoscopic appendicectomy
Some evidence to suggest uncomplicated cases can be treated with antibiotics
How often to children normally open their bowels?
The frequency at which children open their bowels varies widely, but generally decreases with age from a mean of 3 times per day for infants under 6 months old to once a day after 3 years of age.
What causes constipation in children?
The vast majority of children have no identifiable cause which is termed idiopathic constipation. Other causes of constipation in children include: • Dehydration • Low-fibre diet • Medications: e.g. Opiates • Anal fissure • Over-enthusiastic potty training • Hypothyroidism • Hirschsprung's disease • Hypercalcaemia • Learning disabilities • Psychological issues and toilet training
How do you make a diagnosis of idiopathic constipation?
After making a diagnosis of constipation you must exclude secondary causes. If no red or amber flags are present, then a diagnosis of idiopathic constipation can be made.
What clinical features might indicate constipation?
Infrequent bowel activity
Foul smelling wind and stools and excessive flatulence
Irregular stool texture and passing occasional huge stools or frequent small pellets
Soiling and overflow
Abdominal pain, distention or discomfort
Poor appetite, lack of energy, unhappy irritable mood and general malaise
What factors would indicate idiopathic constipation?
Starts a week after life
Meconium within 48 hours
Normal stool pattern, growth and abdomen
Precipitating factors such as fissures, change of diet, potty/toilet training, infections, moving house, starting new school, fears and phobias, family change and taking medicines
What are red flag signs in relation to constipation?
From birth Meconium after 48 hours Ribbon stools Faltering growth Distended abdomen Concern with child maltreatment
Previously unknown weakness in legs or motor delay
What factors might suggest faecal impaction?
- Symptoms of severe constipation
- Overflow soiling
- Faecal mass palpable in abdomen (digital rectal examination should only be carried out by a specialist)
How should faecal impaction be treated in children?
If faecal impaction is present must break the cycle of large faeces–fissure–pain
- Polyethylene glycol 3350 + electrolytes (Movicol Paediatric Plain) using an escalating dose regimen as the first-line treatment.
- Add a stimulant laxative if Movicol Paediatric Plain does not lead to disimpaction after 2 weeks
- Substitute a stimulant laxative singly or in combination with an osmotic laxative such as lactulose if Movicol Paediatric Plain is not tolerated
- Inform families that disimpaction treatment can initially increase symptoms of soiling and abdominal pain
- Continue medication at maintenance dose for several weeks after regular bowel habit is established, then reduce dose gradually
How should constipation in infants not yet weaned (usually <6 months) be managed?
Bottle-fed infants: give extra water in between feeds. Try gentle abdominal massage and bicycling the infant’s legs.
Breast-fed infants: constipation is unusual and organic causes should be considered
Infants who have or are being weaned
Offer extra water, diluted fruit juice and fruits. If not effective consider adding lactulose
What laxative types are used in paediatrics?
Bulk forming laxatives: Methylcellulose and fybogel
Stool softener: glycerol suppository and arachis oil
Osmotic laxatives: lactulose and macrogols (movicol)
Stimulate laxatives: sodium pyrosulphate, senna and docusate
What are the clinical features of an abdominal migraine
Abdominal pain that is dull and achy Each attack lasts between 1hrs and 3days Nausea and vomiting Appetite loss Pale skin Most common between ages of 7 and 10
What are the risk factors for abdominal migraine?
Family history of migraines
Female
How is abdominal migraine diagnosed?
At least 5 attacks each lasting 1-72 hours
Dull pain around the belly button
At least 2 of appetite loss, nausea, vomiting and pale skin
No evidence of other condition.
What are common triggers for abdominal migraine?
Nitrates and processed foods
Swallowing excessive air
Exhaustion
Motion sickness
How should abdominal migraines be managed?
NSAIDs
Anti-emetics
Triptan drugs
Adequate sleep, regular meals, and hydrated
What is mesenteric adenitis?
Inflammation of the mesenteric lymph nodes in response to infection, usually viral.
What are the clinical features of mesenteric adenitis?
Abdominal pain – diffuse Fever Recent or current respiratory tract infection Diarrhoea Constipation Nausea and vomiting Cervical lymphadenopathy
How should mesenteric adenitis be investigated?
USS to rule out appendicitis
