acute abdo pain Flashcards
causes of acute abdo pain
INTRA ABDOMINAL - SURGICAL/MEDICAL
EXTRA- ABDOMINAL
INTRA ABDOMINAL [surgical] causes of acute abdo pain
acute appendicitis
intestinal obstruction eg intussuseption
inguinal hernia
peritonitis
inflamed meckel’s diverticulum
pancreatitis
trauma
INTRA ABDOMINAL medical causes of abdo pain
non specific abdo pain
gastroenteritis
urinary tract – uti, acute pyelonephritis, hydronephrosis, renal calculus
dka
sickle cell disease
hepatitis
ibd
constipation
lead poisonin
HSP
gynae in pubertal female
EXTRA ABDOMINAL causes of acute abdo pain
URTI
lower lobe pneumonia
testes torsion
hip+spine
acute appendicitis
> > Uncommon under 3 years
When occurs may present atypically
Acute appendicitis is the most common acute abdominal condition requiring surgery. It can occur at any age but is most common in young people aged 10-20 years.
Abdominal pain is seen in the vast majority of patients:
💓peri-umbilical abdominal pain (visceral stretching of appendix lumen and appendix is midgut structure) radiating to the right iliac fossa (RIF) due to localised parietal peritoneal inflammation.
💓patients often report the pain being worse on coughing or going over speed bumps. Children typically can’t hop on the right leg due to the pain.
Other features:
💓vomit once or twice but marked and persistent vomiting is unusual
💓diarrhoea is rare. However, pelvic appendicitis may cause localised rectal irritation of some loose stools. A pelvic abscess may also cause diarrhoea
💓mild pyrexia is common - temperature is usually 37.5-38oC. Higher temperatures are more typical of conditions like mesenteric adenitis
💓anorexia is very common. It is very unusual for patients with appendicitis to be hungry
💓around 50% of patients have the typical symptoms of anorexia, peri-umbilical pain and nausea followed by more localised right lower quadrant pain
Examination
💓generalised peritonitis if perforation has occurred or localised peritonism
💓retrocaecal appendicitis may have relatively few signs
💓digital rectal examination may reveal boggy sensation if pelvic abscess is present, or even tenderness with a pelvic appendix
💓Rovsing’s sign (palpation in the LIF causes pain in the RIF) is now thought to be of limited value
Diagnosis
💚typically raised inflammatory markers coupled with compatible history and examination findings should be enough to justify appendicectomy.
💚urine analysis: useful to exclude pregnancy in women, renal colic and urinary tract infection. In patients with appendicitis, urinalysis may show mild leucocytosis but no nitrites
💚ultrasound is useful in females where pelvic organ pathology is suspected. Although it is not always possible to visualise the appendix on ultrasound, the presence of free fluid (always pathological in males) should raise suspicion
💚CT scans are widely used in patients with suspected appendicitis in the US but this practice has not currently reached the UK, due to the concerns regarding excessive ionising radiation and resource limitations
Management
🧡appendicectomy which can be performed via either an open or laparoscopic approach. Laparoscopic appendicectomy is now the treatment of choice
administration of metronidazole reduces wound infection rates.
🧡patients with perforated appendicitis (typical around 15-20%) require copious abdominal lavage.
🧡patients without peritonitis who have an appendix mass should receive broad-spectrum antibiotics and consideration given to performing an interval appendicectomy.
> > be wary in the older patients who may have either an underlying caecal malignancy or perforated sigmoid diverticular disease.
mesenteric adenitis + non specific abdo pain
Mesenteric adenitis is inflamed lymph nodes within the mesentery.
It can cause similar symptoms to appendicitis and can be difficult to distinguish between the two.
It often follows a recent viral infection and needs no treatment (usually URTI w/ cervical lymphadenopathy)
NSAP -resolves in 24-48hrs, pain is less severe than in appendicitis
intussuception
= the invagination of one portion of bowel into the lumen of the adjacent bowel, most commonly around the ileo-caecal region.
EPIDEMIOLOGY:
Intussusception usually affects infants between 6-18 months old. Boys are affected twice as often as girls
Features:
CLASSIC TRIAD: VOMITING, COLICKY SEVERE ABDO PAIN, PR BLEEDING
-💚paroxysmal abdominal colic pain
-💚during paroxysm the infant will characteristically draw their knees up and turn pale + INCONSOLABLE CRYING
-💚vomiting —> initially non billious, becomes billious once intussusception is more established
-💚blood stained stool - ‘red-currant jelly’
-💚sausage-shaped mass in the right lower quadrant
-💚SIGNS OF DEHYDRATION
Investigation
💓💓💓ultrasound is now the investigation of choice and may show a target-like mass
💓 BLOODS : fbc (high wbc, low hb), u+e (dehydration, crp (high), group and save!
💓AXR: dilated bowel may be present, distended small bowel, absence of gas in distal colon/rectum. sometimes intussception itself can be visualised
Management
💞the majority of children can be treated with reduction by air insufflation under radiological control, which is now widely used first-line compared to the traditional barium enema
💞if this fails, or the child has signs of peritonitis, surgery is performed [surgical reduction]
complications from prolonged intussusception
- shock
- peritonitis
- intestinal perf
prog:
- highest risk of recurrence in 1st 24 hours
ddx: pyloric stenosis, uti, gastroenteritis, appendicitis
meckel’s diverticulum
=a congenital diverticulum of the small intestine. It is a remnant of the omphalomesenteric duct (also called the vitellointestinal duct)
=contains ectopic ileal, gastric or pancreatic mucosa
= is a true diverticulum containing all 3 layers of intestinal wall
Rule of 2's >>occurs in 2% of the population >> is 2 feet from the ileocaecal valve >> is 2 inches long >> commonly presents @ 2yo [males more commonly affected]
Presentation
💝(usually asymptomatic)
💝abdominal pain mimicking appendicitis due to peritoneal inflammation [RIF pain]
💝intermittent rectal bleeding, bright red [secondary to ulceration of ileal mucosa by ectopic acid production]
💝 s/s of anemia (lethargy, pallor)
💝intestinal obstruction: secondary to an omphalomesenteric band (most commonly), volvulus and intussusception
ix:
- fbc- poss anemia (low hb, low MCV)
- stool sample- for obvious occult blood w/ mcs
- meckel’s scan ie. technetium 99 scan- shows increased uptake by ectopic gastric mucosa in most cases
Management
- removal if narrow neck or symptomatic.
- Options are between wedge excision or formal small bowel resection and anastomosis. [laparoscopically]
complications
- anastamotic complications [stricture/leak]
prognosis- excellent w/ surgical outcome
ddx: appendicitis, biliary colic, infectious colitis, gastroenteritis, CD, UC, IBD, PUD
malrotation
= failure of embreyonic rotation of small intestine around SMA, predisposes to VOLVULUS, INTESTINAL OBSTRUCTION (as ladd bands cross duodenum), ISCHEMIA
2 presentations
» obstruction
» obstruction w/ compromised blood supply
different degrees of rotation may occur
epidemiology: M:F (2:1), if more than 1yo (1:1)
s/s:
- acute midgut volvulus : sudden onset billous vomiting, abdo distention, severe pain
- chronic midgut volvulus: recurrent abdo pain + malabsorption syndrome, between episodes may appear normal
- acute duodenal obstrution 2ry to kinking by ladd bands- usually presents in infancy: forceful vomiting, abdo distention
- chronic duodenal obstruction: billious vomiting, FTT, intermittent abdo pain
ACUTE OBSTRUCTION:
tachycardia
abdo distention
tinkling bowel sounds
INFARCTION/NECROSIS:
shock
pyrexia
signs of acute peritonitis
IX:
- bloods: high wcc, low hb (if gi bleed), u+e (abnormal from vomiting), acidosis
- axr: variable appearance of dilated bowel loops
- uss may show abnormal orientation of SMA + SMV
- upper gi contrast study
complication:
- bowel stangulation – necrosis, perforation => septic shock
- short bowel syndrome w/ malabsorption due to degree of viable short bowel
mx:
- pre op mx: correct fluid + electrolyte deficit, broad spectrum abx, ngt insertion to decompress proximal bowel
- surgery: ladd procedure [surgical division of ladd bands, appendicectomy, correct placement of cecum + colon
recurrent abdo pain
= common childhood problem
- pain sufficient to interrupt normal activities
- lasts for at least 3 mo
- in 10% of school kids
CAUSES:
- > 90% - no structural cause
- gastrointestinal - ibd, constipation, non ulcer dyspepsia, abdo migraine, gastritis, peptic ulcer, malroatation
- gynae- dysmenorrhoea, ovarian cysts, PID
- hepato-biliary/pancreatic- hepatits, gallstones, pancreatitis
- urinary tract- uti, PUJ obstruction
s/s suggesting organic disease:
duodenal ulcer- epigastric pain @ night, hematemesis
ibd- diarrhoea, wt loss, FTT, blood in stools
pancreatitis- vomiting
liver disease - jaundice
uti- dysuria, 2ry enuresis [involunary urination @ night]
malrotation - billious vomiting
MX:
- urine mcs - uti
- abdo us- excludes gallstones
- further ix if clinically indicated
prog:
- 50% of affected kids = rapidly free of s/s
- 25% - take few mo to resolve
- 25% - s/s continue/return in adulthood as MIGRAINE/IBS/FUNCTIONAL DYSPEPSIA
Abdo migraine
= associated abdo pain, headahces, vomiting, facial pallor
- usually fhx link
ibs
= altered gi motility + abnormal forceful contractions
s/s recur after gi infection/stress/anxiety
- abdo pain, worse before or relieved by defecation
- explosive, loose, mucousy stools
- bloating
- feeling of incomplete defecation
- constipation [oft alternating w/ normal or loose stools]
peptic ulceration, gastritis, functional dyspepsia
Helicobacter pylori is a Gram negative bacteria associated with a variety of gastrointestinal problems, principally peptic ulcer disease
Associations
-peptic ulcer disease (95% of duodenal ulcers, 75% of gastric ulcers)
-gastric cancer
-B cell lymphoma of MALT tissue (eradication of H pylori -results causes regression in 80% of patients)
atrophic gastritis
s/s: rare in kids, but suspect if epigastric pain @ night + 1st degree fhx of peptic ulceration
+ non specific abdo pain: n,v,bloating
The role of H pylori in Gastro-oesophageal reflux disease (GORD) is unclear - there is currently no role in GORD for the eradication of H pylori
Management - eradication may be achieved with a 7 day course of
- a proton pump inhibitor + amoxicillin + clarithromycin, or
- a proton pump inhibitor + metronidazole + clarithromycin
