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Yr 5 > Acute Abdo Paeds > Flashcards

Acute Abdo Paeds Flashcards

1
Q

Describe the MANTRELS score for Acute Appendicitis?

A 
M = Migration of pain
A = Anorexia
N = Nausea and Vomiting
T = Tenderness in RIF
R = Rebound tenderness
E = Elevated Temp
L = Leukocytosis
S = Shift of WBC count to the left

T and L = 2 points

Higher Score = Higher Likelihood

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2
Q

Describe the Tx of Uncomplicated Acute Appendicitis?

A

1st line
- Nil-by-mouth
- IV Saline
- Laparoscopic Appendicectomy (better cosmetics, shorter hospital stay and fewer SSIs)
Adjunct
- IV Cefoxitin (1-2g pre-op with 2x 1-2g post-op 8 hours apart)

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3
Q

Describe the Tx of Complicated Acute Appendicitis?

A

1st line
- Nil-by-mouth initially
- IV Saline
- Cefoxitin or Pip/Taz until afebrile and normal WBC (Meropenem if severe)
2nd line
- Laparoscopic Appendicectomy with drainage of abscess and wash-out if required

PROGRESSION OF SYMPTOMS = IMMEDIATE LAPAROSCOPIC APPENDICECTOMY

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4
Q

18 month old presents with intermittent abdominal pain lasting 1-3 minutes. The mother says the child goes pale during these episodes and is lethargic in between. The child is also refusing to feed and is producing green vomit. What is the most likely Dx?

  1. Appendicitis
  2. Intussusception
  3. Volvulus/Malrotation
  4. Pyloric Stenosis
A

Intussusception

  • Appendicitis uncommon <3yrs
  • Paroxysmal nature, pallor and lethargy characteristic of Intussusception
  • Signs of severe Intussusception = Redcurrant Jelly Stool, abdominal distension and shock
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5
Q

A child presents with vomiting that is green in Colour, what investigations and actions would you immediately perform?

A
  • IV access
  • Drip and Suck
  • USS (for intussusception)
  • Contrast and AXR (AP and Lateral views)
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6
Q

What are the USS signs of Intussusception?

A
  • Target/Doughnut sign (Hyper echoic center with hypo echoic lumen)
  • Pseudokidney sign (Stacks of Hyper/Hypo-echoic)
  • Dilation proximal to intussusception
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7
Q

What are the AXR sign’s of intussusception?

A
  • Meniscus sign

POOR SENSITIVITY AND SPECIFICITY

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8
Q

Describe the Tx of Intussusception?

A

1st line

  • NBM
  • IV Saline
  • Contrast enema with reduction
  • SURGERY 1ST LINE IF ENEMA CONTRAINDICATED OR PATIENT UNSTABLE

2nd line
- Pneumatic reduction

3rd line
- Surgical reduction (25% require surgical reduction)

Adjunct

  • Broad spectrum antibiotics covering intra-abdo pathogens
  • Some trusts do not give if stable
  • ALL PATIENTS WHO ARE UNSTABLE, PERITONITIC OR PERFORATED
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9
Q

18 month old presents with severe PR bleeding that is neither bright red nor Melaena. The child also appears pale. What is the most likley Dx?

A

Meckel’s Diverticular

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10
Q

What is the most useful test for Meckel’s?

A

Technetium/Meckel’s Scan showing ectopic focus

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11
Q

Describe the Tx of Meckel’s?

A
  • Asymptomatic = leave alone
  • Incidental finding during surgery = Resection
  • Symptomatic = Surgical resection with removal of adhesions/abscesses + Cefotaxime + Metronidazole/Clindamycin if peritonitic
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12
Q

Mother is concerned that her 2 day old baby is inconsolable and and is vomiting green. O/E the neonate is tachycardia, hypotensive and has abdominal distension. What is the most likely Dx and given that Dx what is your management?

  1. Appendicitis
  2. Intussusception
  3. Pyloric Stenosis
  4. Malrotation/Volvulus
A

Dx = Malrotation/Volvulus

Managment

  • Urgent AXR with Contrast (Right-side duodenum with Corkscrew/Bird-beak appearance)
  • Emergency Surgery as the child is unstable indicating ischaemia
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13
Q

What is the surgery of choice for Malrotation/Volvulus?

A
  • Correct Volvulus with Ladd procedure (Cut Ladd bands, Mobilise duodenum by widdening mesentery, remove appendix and place bowels in unrotated position)
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14
Q

Complications of malrotation?

A
  • 10% mortality with Volvulus
  • 10% Volvulus reoccurence rate
  • Risk of adhesions following Ladd procedure
  • Short bowel syndrome if resection required
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15
Q

A child presents with umbilical pain and a sore throat. After careful monitoring, you notice the abdo pain is less severe than you expect and hasn’t migrated. O/E you notice enlarged cervical lymph nodes. What is the most likely Dx?

  1. Lymphoma
  2. Infectious Mono
  3. Non-specific pain
  4. Appendicitis
A
  1. Non-specific pain

These patients often have appendectomies and are diagnosed with Mesenteric Adenitis if Appendix is normal and enlarged Mesentric lymph nodes observed.

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16
Q 
A mother brings her 6 y/o child into the GP as she has noticed they are suffering from painful episodes that stop them playing. When asked the pain is periumbilical and has being off and on for about 3 and 1/2 months. The child appears well other than this with normal bowel habits. Examination = normal.
What is your most likely Dx?
1. IBS
2. Recurrent Abdo pain
3. Pancreatitis
4. Constipation
5. IBD
A
  1. Recurrent Abdominal Pain
  • IBS, IBD and constipation would present with altered bowel habits
  • Pancreatitis is more severe and acute
17
Q

What tests should be conducted on a child you suspect with Recurrent Abdominal Pain?

A
  • Full Hx and Abdo exam
  • Urine MC&S
  • TFTs
  • Coeliac antibodies
18
Q

What is the prognosis for children with Recurrent Abdo Pain?

A

50% rapidly resolve, 25% resolve over 2-3 months and 25% re-present as adults with IBS, Migraines and/or Functional Dyspepsia

19
Q

Describe the characteristic presentation of abdominal migraine?

A
  • Longer asymptomatic periods with acute episodes over a 12-48hr period
  • Periumbilial pain
  • Headache and pallor +/- vomiting
  • FHx
  • O/E = normal
20
Q

A child presents with abdominal pain, bloating and diarrhoea. They say that everything gets better after going to the toilet but they don’t ever feel like they go fully relieve themselves. What is the most likley Dx?

  1. IBD
  2. IBS
  3. Constipation
  4. Coeliac’s
A
  1. IBS
    - Symptoms relieved by defaecation are more indicative of IBS but as this is a Dx of exclusion and so other causes should be discounted (CRP and Faecal Calprotectin for IBD, anti-tTG and Endomysial for Coeliac’s)
    - Obstruction leading to constipation can also cause Overflow Diarrhoea but this is less likely given the other symptoms and age
21
Q

How do you treat IBS?

A
  • Lifestyle modification to avoid triggers such a caffeine, Fructose and Lactose
  • Anti-diarrhoeals or laxatives depending on symptoms
22
Q 
A 4 y/o presents with epigastric pain 2-3 hours post-prandial. They have not been given any recent medication but the mother does say that her husband has suffered from a similar issue that occur immediately after eating.
What is the most likely Dx?
1. Pancreatitis
2. Indigestion
3. Pyloric Stenosis
4. Gastric Ulcer
5. Duodenal Ulcer
A
  1. Duodenal Ulcer
  • Pain occuring 2-3hr post-prandially is typically Duodenal
  • FHx suggests H.Pylori is the causative agent (Impaired somatostatin secretion -> increased gastrin production)
23
Q

How do you Ix for H.Pylori in children?

A
  • C13 Urease breath test
  • Stool antigen
  • Serology less useful in younger children but useful in older
  • Endoscopy with biopsy if unresponsive to frontline Tx
24
Q

What is the frontline Tx for H.Pylori?

A
  • Triple Therapy = PPI (or equivalent), Clarithromycin and either Metronidazole or Amoxacillin
25
Q

What is the Dx if the patient is unresponsive to H.Pylori Tx and the biopsy is -Ve?

A

Functional Dyspepsia

26
Q

This 2-year-old boy had a history of poor growth from 12 months of age. His parents had noticed that he tended to be irritable and grumpy and had three or four foul-smelling stools a day. He has recently had a change in diet. O/E he has buttock wasting and abdominal distension. What is the most likely Dx?

  1. IBD
  2. IBS
  3. Coeliacs
  4. Gatsroenteritis
  5. Malnutrition
A
  1. Coeliac’s
  • Developmental stunting with irritability and abnormal stools following a recent change in diet suggests Coeliac’s
  • IBS/IBD would be more likely if there was constipation/Diarrhoea
  • Gastroenteritis would present with a more acute/infective picture: Fevers, diarrhoea +/- mucus/blood and inconsolable with growth retardation unlikely
27
Q

What is the pathology of Coeliac’s and what are the diagnostic features?

A
  • Anti-tTG and/or EMA antibodies -> villous atrophy and malabsorption within the SI
  • Dx confirmed via duodenal biopsy showing villous atrophy, crypt hyperplasia and lymphocyte:epithelial cell >25:100 (confirm via CD3 staining)
28
Q

Explain the difference between UC and Crohn’s presentation?

A
  • Crohn’s = Crampy abdominal pain and diarrhoea that is rarely bloody +/- mucous. Children also tend to present with growth retardation. Erythema nodusum may be present
  • UC = Colicky abdominal pain with bloody diarrhoea and PR bleeding. Growth retardation is uncommon and Eryhtema Nodosum is not seen
29
Q

Explain Crohn’s Tx

A

1st line = Induce remission
• Enteral nutrition with whole protein modular feeds if concerned about growth defects/side-effects of drugs
• Drugs
o Oral prednisolone or IV Hydro (ONLY Tx FOR EXACERBATIONS OR SEVERE PRESENTATIONS)
 Budesonide if traditional steroids refused/contraindicated or distal ileum, ileo-caecal or right sided disease
• Explain there are fewer side-effects but is less effective
• DO NOT OFFER FOR SEVERE PRESENTATIONS OR EXACERBATIONS
o ASA if steroids refused/contraindicated
 Explain they are less effective
 DO NOT OFFER FOR SEVERE PRESENTATIONS OR EXACERBATIONS
o Add Azathioprine or 6-Mercaptopurine if:
 2 or more exacerbations in previous 12 months or steroids cannot be tapered
 ASSESS TMPT ACTIVITY BEFORE ADMINISTRATION
o Biologics (Infliximab or Adalimumab) if above fails to induce remission
• Surgery
o Consider if disease limited to distal ileum and have growth retardation or refractory disease
- 2nd line = Maintain
• Follow-up if maintenance refused
• Azathioprine or mercaptopurine monotherapy following drug therapy
o Methotrexate if TMPT deficient or intolerant to above
o Add metronidazole if surgical remission
o PACES Counselling
- Explain the diagnosis (a disease with an unknown cause that causes inflammation of the digestive system leading to malabsorption and bloody diarrhoea)
- Explain that it is a life-long condition and there is always a risk of relapse
- Reassure that there are many medications that can be used to settle down the inflammation any time it flares up (and explain that they will be seen by a gastroenterologist)
- Explain complications (malabsorption and bowel cancer)
- There is no special diet but you may find that certain foods will make it worse
- Support: Crohn’s and Colitis UK

30
Q

Explain the Tx of UC

A

o UC (Induce remission and then maintain)
- Assess severity using PUCAI (Paediatric Ulcerative Colitis Activity Index)
• Severe >65
• Mild-moderate 10-64
- Mild-moderate proctitis/proctosigmoiditis
• Induce
o 1st line = Topical Aminosalicylates (Mesalazine)
 Oral if they decline 1st line but explain this is less effective
o If no response after 4 weeks, add Oral Aminosalicylates
o If further Tx, add Oral or topical corticosteroid
o Consider adding Tacrolimus if still no response
• Maintain
o Topical +/- oral ASA
 Oral inferior to topical as stand-alone
o Oral Azathioprine or mercaptopurine if:
 2 or more exacerbations within a year requiring steroids
 ASA remission failure
- Mild-moderate left-sided
• Induce
o 1st line = Topical Aminosalicylate
 Oral if they decline 1st line but explain this is less effective
o If no response after 4 weeks + high-dose oral Aminosalicylates or switch to high-dose oral Aminosalicylates + Oral Corticosteroid
o Consider adding Tacrolimus if still no response
• Maintain
o Oral ASA
o Oral Azathioprine or mercaptopurine if:
 2 or more exacerbations within a year requiring steroids
 ASA remission failure
- Mild-Moderate Extensive
• Induce
o 1st line = Topical and Oral Aminosalycylate
o If no response after 4 weeks
 Stop Topical
 Continue oral and add oral Corticosteroid
o Consider adding Tacrolimus if still no response
• Maintain
o Oral ASA
o Oral Azathioprine or mercaptopurine if:
 2 or more exacerbations within a year requiring steroids
 ASA remission failure
- Further Treatments
• Biologics if azathioprine fails
o Infliximab, Adalimumab an Golimumab (Anti-TNF α)
- Severe - EMERGENCY
• MDT assessment including Paeds gastro
• Asses likelihood of surgery and give IV steroids
o IV Ciclosporin or Surgery if steroids declined or contraindicated
o Add IV Ciclosporin to steroids if no improvement after 72hrs or worsening
o Use infliximab if Ciclosporin contraindicated
• Factors increasing likelihood of surgery
o >8 stools per day
o Pyrexia
o Tachycardia
o Dilation on AXR
o Low albumin or Hb
o High Plt or CRP
• Maintenance
o Oral Azathioprine or Mercaptopurine
 ASA if above contraindicated or intolerable
• PACES Counselling
• Explain the diagnosis (condition with unknown cause that leads to inflammation of the bowel, which leads to symptoms)
• Explain that it isn’t common but is a well-known disease
• Explain that there is no cure and it is a condition that tends to come and go in flare-ups every so often
• Reassure that there are medications that can be used to reduce the likelihood of flare-ups and to treat flare-ups when they happen
• Explain the complications (growth issues, bowel cancer and surgery)
• Explain that they will be seen by a gastroenterologist
• Support: Crohn’s and Colitis UK

Yr 5 (11 decks)

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