Acute abdomen

Question 1

Know the common causes in different age groups

Answer 1

• appendicitis
  
  • ​very uncommon in < 3 years although can occur at any age
  • pre-school children
    
    • hard to diagnose
    • faecoliths more common
    • perfortion may be rapid
• intesussception
  
  • ​3m- 2 years
• malrotation
  
  • ​first few days of life (usually)
  • can be seen at later age

Causes of acute abdomen

Surgical

• acute appendicitis
• intussesception
• inguinal hernia
• peritonitis
• inflammed Meckel diverticulum
• pancreatitis
• trauma

Medical

• NS abdo pain
• gastroenteritis
• UTI
  
  • UTI
  • acute pylonephritis
  • hydropehrosis
  • renal calculus
• HPS
• diabetic ketoacidsosis
• sickle cell disease
• hepatitis
• IBS
• constipation
• recurrent abdo pain
• gynaelogical causes in pubertal females
• psychological
• lead poisoning
• acute porphyria (rare)

Extra-abdominal

• URTI
• Lower lobe pneumonia
• Torsion of tests
• Hip and spine

Question 2

Describe clinical features of acute appendicitis

Answer 2

• Symptoms
  
  • ​anorexia
  • vomiting (only a few times)
  • abdo pain (central and colicky then localising to RIF)
• Signs
  
  • ​flushed face with oral fetor
  • low grade fever (37.2- 38 “C)
  • abdominal pain aggrevated by movement walking, coughing, jumping, bumps on car journey
  • child may lay still with legs flexed
  • persistent tenderness and guarding at McBurney’s point

Question 3

Initial investigations in acute abdomen

Answer 3

• appendicitis
  
  • ​progressive therefore observations are key
  • neutrophilia not always present on FBC
  • WCC usually high
  • USS- thickened, non-compressible appendix but increased blood flow; abscess; perforation or appendix mass
  • laparscopy
• others
  
  • ​see specific cards

Question 4

Differential diagnosis of acute appendicitis

Answer 4

• Mesenteric adenitis
• Gastroenteritis
• Urinary tract infection
• Lower lobe pneumonia
• Diabetic ketoacidosis
• Nephrotic syndrome/ liver disease –> primary peritonitis

Question 5

Late presentation of appendicitis and its management

Answer 5

• Abscess
• Perforation
  
  • generalised guarding
  • fluid resusciation and IV ABx before laparotomy
• Appendicular mass
  
  • no signs of generalised peritonitis
  • conservative management with IV ABx
  • appendectomy in several weeks

Question 6

Presentation and clinical features of intussusception

Answer 6

• What? invagination of the proximal bowel into the distal segment . Commonly ileum into caecum through the ileocaecal valve. Commonest cause of intestinal obstruction in infants after the neonatal period.
• Age 3m- 2y
• Aetiology?viral infection –> enlargement of Peyer’s patches —>point of intussusception. Lead points such as polyp or Meckel’s diverticulum
• Complications stretching and constriction of mesentery –> venous obstruction –> engorgement/ bleeding from bowel mucosa –> fluid loss, bowel perforation, peritonitis, gut necrosis
• Presentation
  
  • ​paroxysmal, severe, colicky pain and pallor (during episodes of pain child becomes pale especially around mouth and draws up legs)
  • food refusal
  • vomiting (may be bile-stained depending on location of intussusception)
  • sausage-shaped mass (palpable in abdomen)
  • redcurrant jelly stool- blood stained mucous
    
    • occurs late stage
    • rectal examination
  • abdominal distension and shock

Question 7

Investigations, diagnosis and treatment of intussusception

Answer 7

• Investigations
  
  • ​AXR: distended small bowel and absence of gas in the distal colon/ rectum
• Diagnosis
  
  • ​USS- also monitors improvement
• Treatment
  
  • ​IV fluid resusciation
    
    • fluid pooling in gut –>hypovolemic shock
  • Rectal air insufflation (radiologist, not done if signs of peritonitis)
  • Surgery if signs of peritonitis

Question 8

Presentation and clinical features of malrotation/ volvulus

Answer 8

What is malrotation? mesentery not fixed at the duojejunal flexure or ileocaecal region. The base of the mesentery is shorter than normal. Commonest form of malrotation is where the caecum sits high and fixed to the posterior abdominal wall. Ladd bands obstruct the duodenum

Obstruction/ volvulus

• bilious vomiting (dark green vomit)
• abdominal pain
• tenderness- peritonitis/ ischaemic bowel

Question 9

Investigations, diagnosis and treatment of malrotation

Answer 9

• Investigations/ diagnosis
  
  • ​GI contrast study ?intestinal rotation
• Treatment
  
  • ​urgent laparotomy (where vascular compromise present)
  • Volvulus untwisted
  • Duodenum mobilised
  • bowel placed in non-rotated position (DJ flexure right, cascum/ appendix on left). Mesentery is broadened
  • Appendix usually removed to avoid diagonsis confusion when older

Question 10

Epidemiology, clinical and readiological features of necrotising enterocolitis

Answer 10

• serious illness that affects premature infants in first few weeks of life. Bacterial invasion of ischaemic bowel wall. Cow’s milk intake vs. breastmilk more likely to suffer from illness
• Epidemiology
  
  • ​M:F
  • 0.3/ 2.4 per 1,000 births
• Clincial features
  
  • ​infant does not tolerate feeds
  • milk aspirated from stomach
  • vomiting (bilious)
  • distended abdomen
  • fresh blood in stool
  • rapid shock
• Radiological features (XR)
  
  • ​distended loops of bowel
  • thickening of bowel wall
  • intramural gas
  • gas in portal tract
  • perforation

Question 11

Medical and surgical management in necrotising enterocolitis

Answer 11

Medical

• stop feeds
• broad spectrum ABx - aerobic and anaerobic organism cover
• PEN
• ventilation
• circulatory support

Surgery

Surgery is performed for bowel perforation. Complications that may occur include: strictures, malabsorption (extensive bowel resection)

Question 12

Be aware of bowel atresias in the newborn

Answer 12

• Oesophageal atresias
  
  • ​often associated with tracheo-oesophageal fistula
  • common (86%) = atresia with fistual between distal oesophagus and trachea
  • 8% = atresia without fistula
  • 4% = H-type fistula without atresia
  • associated with polyhydramnios and VACTERL (Vertebral, Anorectal, Cardiac, Tracheo-oEsophageal, Renal, Radial Limb) anomalies
  • wide-calibre feeding tube passed down to see if reaches stomach (XR confirmation)
  • persistent salivation, drooling, coughing/ choking on food, cyanotic episodes, aspirations of milk/ stomach acid
• Duodenal atresia
  
  • persistent vomiting, bile-stained (unless obstruction is above ampulla of Vater), meconium initially passed but subsequently delayed or absent, abdominal distention
  • 1/3 = DS
  • other congenital anomalies
• Jejunal/ ilieal atresias
  
  • persistent vomiting, bile-stained (unless obstruction is above ampulla of Vater), meconium initially passed but subsequently delayed or absent, abdominal distention
  • multiple atreic segments of bowel
• Rectal atresia
  
  • absence of anus at normal site

Question 13

Meckel’s divericulum

• epidemiology
• histology
• clinical features/ diverticulum

Answer 13

• Ileal remnant of vitello-intestinal duct
• Ectopic gastric mucosa or pancreatic tissue
• Clinical features/ complications
  
  • ​most asymptomatic
  • rectal bleeding (bright red nor true melaena)
  • intussusception
  • volvulus around band
  • diverticulitis
• Treatment is surgical resection