Acute Abdomin And Constipaton Flashcards
Causes
• Lower lobe pneumonia may cause pain referred to
the abdomen.
• Primary peritonitis is seen in patients with ascites
from nephrotic syndrome or liver disease.
• Diabetic ketoacidosis may cause severe abdominal
pain.
• Urinary tract infection, including acute
pyelonephritis, is a relatively uncommon cause of
acute abdominal pain, but must not be missed. A
urine sample should be tested, in order to identify
not only diabetes mellitus but also conditions
affecting the urinary tract.
• Pancreatitis may present with acute abdominal pain
and serum amylase should be checked.
• The testes in boys, hernial orifices and hip joints must
always be checked.
• Consider gynaecological problems in older females,
and if testing for pregnancy is required.
urine sample
urine sample should be tested to identify not only diabetes mellitus but also conditions affecting the urinary tract.
Acute appendicitis
Acute appendicitis
Acute appendicitis is the most common cause of abdomi- nal pain in childhood requiring surgical intervention (Fig. 14.2). Although it may occur at any age, it is very uncom- mon in children under 3 years of age. The clinical features of acute uncomplicated appendicitis are:
• symptoms:
• anorexia
• vomiting
• abdominal pain, initially central and colicky
(appendicular midgut colic), but then localizing to the right iliac fossa (from localized peritoneal inflammation)
Apendicitis
preschool children:
• It is uncommon but potentially serious.
• The diagnosis is more difficult, particularly early in the
disease.
• Perforation may be rapid, as the omentum is less well
developed and fails to surround the appendix, and
the signs are easy to undere
Appendicitis is a progressive condition and so repeated observation and clinical review every few hours are key to making the correct diagnosis, avoiding delay on the one hand and unnecessary laparotomy on the other.
No laboratory investigation or imaging is consist- ently helpful in making the diagnosis. A raised neutrophil count is not always present on a full blood count. White blood cells or organisms in the urine are not uncommon in appendicitis as the inflamed appendix may be adja- cent to the ureter or bladder.
Appendicitis tt
Appendicectomy is straightforward in uncomplicated appendicitis. Complicated appendicitis includes the pres- ence of an appendix mass, an abscess, or perforation. If there is generalized guarding consistent with perforation, fluid resuscitation and intravenous antibiotics are given prior to laparotomy. If there is a palpable mass in the right iliac fossa and there are no signs of generalized peritonitis, it may be reasonable to elect for conservative management with intra- venous antibiotics, with appendicectomy being performed after several weeks. If symptoms progress, laparotomy is indi- cated. Management should be guided by the surgical team.
Non-specific acute abdominal pain and
mesenteric adenitis
Non-specific acute abdominal pain is abdominal pain which resolves in 24–48 hours. The pain is less severe than in appendicitis, and tenderness in the right iliac fossa is varia- ble. It often accompanies an upper respiratory tract infection with cervical lymphadenopathy. In some of these children, the abdominal signs do not resolve and laparoscopy and an appendicectomy is performed. Mesenteric adenitis is often diagnosed in those children in whom large mesen- teric nodes are observed and whose appendix is normal, but there are doubts whether this condition truly exists as a diagnostic entity.
Constipation is a common cause of non-specific abdominal pain, which may have an acute onset and be severe and accompanied by vomiting in extreme cases.
Acute abdominal pain in older
children and adolescents
Acute abdominal pain in older
children and adolescents
• Exclude medical causes, in particular lower lobe
pneumonia, diabetic ketoacidosis, hepatitis, and
pyelonephritis.
• Check for strangulated inguinal hernia or torsion
of the testis in boys.
• On palpating the abdomen in children with acute
appendicitis, guarding and rebound tenderness
may be absent or unimpressive, but pain from
peritoneal inflammation may be demonstrated on
coughing, walking or jumping.
• To distinguish between acute appendicitis and
non-specific acute abdominal pain may require
close monitoring, joint management between
paediatricians and paediatric surgeons, and
repeated evaluation in hospital.
Intussusception
Intussusception describes the invagination of proximal bowel into a distal segment. It most commonly involves ileum passing into the caecum through the ileocaecal valve (Fig. 14.3a). Intussusception is the most common cause of intestinal obstruction in infants
Age Intussusception
Although it may occur at any age, the peak age of presentation is 3 months to 2 years of age.
Intussusception tt
Prompt diagnosis, immediate fluid resuscitation and urgent reduction of the intussus- ception are essential to avoid complications.
venous obstruc- tion, causing engorgement and bleeding from the bowel mucosa, fluid loss, and subsequently bowel perforation, peritonitis and gut necrosis
Intussusception S&S
Paroxysmal, severe colicky pain with pallor – during
episodes of pain, the child becomes pale, especially
around the mouth, and draws up the legs. There
is recovery between the painful episodes but
subsequently the child may become increasingly
• May refuse feeds, may vomit, which may become
• A sausage-shaped mass – is often palpable in the • Passage of a characteristic redcurrant jelly stool
• Abdominal distension and shock.
Hypovolemic skock pooling in the gut
Usually, no underlying intestinal cause for the intussus- ception is found, although there is some evidence that viral infection leading to enlargement of Peyer’s patches may form the lead point of the intussusception. An iden- tifiable lead point such as a Meckel diverticulum or polyp is more likely to be present in children over 2 years of age. Intravenous fluid resuscitation is likely to be required lethargic.
bile-stained depending on the site of the intussusception.
abdomen (Fig. 14.3b).
comprising blood-stained mucus – this is a characteristic sign but tends to occur later in the illness and may be first seen after a rectal examination.
Intussusception
Viral infection > enlargement of peyer patches > intussusception
Intussusception summary
Intussusception
• Usually occurs between 3 months and 2 years of
age.
• Clinical features are paroxysmal, colicky pain with
pallor, abdominal mass and redcurrant jelly stool. • Shock is an important complication and requires
urgent treatment.
• Reduction is attempted by rectal air insufflation
unless peritonitis is present.
• Surgery is required if reduction with air insufflation
is unsuccessful or for peritonitis.
Meckel diverticulum MD
Around 2% of individuals have an ileal remnant of the vitello-intestinal duct, a Meckel diverticulum, which con- tains ectopic gastric mucosa or pancreatic tissue. Most are asymptomatic but they may present with severe rectal bleeding, which is classically neither bright red nor true
melaena. There is usually an acute reduction in haemoglo- bin. Other forms of presentation include intussusception, volvulus (twisting of the bowel), or diverticulitis, when inflammation of the diverticulum mimics appendicitis. A technetium scan will demonstrate increased uptake by ectopic gastric mucosa in 70% of cases (Fig. 14.4). A nega- tive technetium scan does not exclude the possibility and a laparoscopic examination can be used to make the diag- nosis. Treatment is by surgical resection.
Malrotation and volvulus
Malrotation is a congenital abnormality of the midgut, in which the small intestine most commonly lies predominantly on the right-hand side of the abdomen, with the caecum in the right upper quadrant. This results from a failure of the intestine to ‘rotate’ into the correct position during fetal life and secure or ‘fix’ the mesentery in the correct position. The reason for this developmental failure is unknown.
Fibrous bands called ‘Ladd bands’ tether the caecum to the right upper quadrant and these cause intestinal obstruction by compressing the duodenum (Fig. 14.5a,b). The poorly-tethered gut is able to swing and twist more readily, resulting in volvulus.
There are two presentations:
• obstruction • obstruction with a compromised blood supply.
Malrotation and volvulus
Obstruction with bilious vomiting is the usual presenta- tion in the first few days of life but can be seen at a later age. Any child with dark green vomiting needs an urgent upper gastrointestinal contrast study to assess intestinal rotation, unless signs of vascular compromise are present, when an urgent laparotomy is needed. This is a surgi- cal emergency as, when a volvulus occurs, the superior
mesenteric arterial blood supply to the small intestine and proximal large intestine is compromised, and unless it is corrected it will lead to infarction of these areas.
At operation, the volvulus is untwisted, the duodenum mobilized, and the bowel placed in the non-rotated posi-
tion with the duodenojejunal flexure on the right and the caecum and appendix on the left. The malrotation is not ‘corrected’, but the mesentery broadened. The appen-
dix is generally removed to avoid diagnostic confusion should the child subsequently have symptoms suggestive of appendicitis.
Malrotation
Uncommon but important to diagnose. • Usually presents in the first 1–3 days of life
with intestinal obstruction from Ladd bands
obstructing the duodenum or volvulus. • May present at any age with volvulus causing
obstruction and ischaemic bowel.
• Clinical features are bilious vomiting, abdominal
pain and tenderness from peritonitis or ischaemic
bowel.
• An urgent upper gastrointestinal contrast study is
indicated if there is bilious vomiting.
• Treatment is urgent surgical correction.
Recurrent abdominal pain
Recurrent abdominal pain is a common childhood problem. It is often defined as episodes of abdominal pain at least 4 times per month sufficient to interrupt normal activities and lasts for at least 2 months. It occurs in about 10% of school-age children. The pain is charac-
teristically periumbilical and the children are otherwise entirely well.
An organic cause needs to be identified but is present in less than 10% of cases (Fig. 14.6). This requires a full history and thorough examination. Particular attention needs to be paid to identify functional constipation, which is common and may cause abdominal pain, and coeliac disease, and inflammatory bowel disease. The perineum should be inspected for anal fissures and other perianal disease and child maltreatment needs to be considered. The child’s growth should be checked. The aim is to avoid subjecting the child to unnecessary investigations. ‘Red flag’ features to help identify organic causes are listed in Box 14.1. Investigations are guided by clinical features but baseline screening tests to be considered are listed in Box 14.2.
Recurrent abdominal pain
Recurrent abdominal pain is a common childhood problem. It is often defined as episodes of abdominal pain at least 4 times per month sufficient to interrupt normal activities and lasts for at least 2 months. It occurs in about 10% of school-age children. The pain is charac-
teristically periumbilical and the children are otherwise entirely well.
An organic cause needs to be identified but is present in less than 10% of cases (Fig. 14.6). This requires a full history and thorough examination. Particular attention needs to be paid to identify functional constipation, which is common and may cause abdominal pain, and coeliac disease, and inflammatory bowel disease. The perineum should be inspected for anal fissures and other perianal disease and child maltreatment needs to be considered. The child’s growth should be checked. The aim is to avoid subjecting the child to unnecessary investigations. ‘Red flag’ features to help identify organic causes are listed in Box 14.1. Investigations are guided by clinical features but baseline screening tests to be considered are listed in Box 14.2.
Red flags suggesting organic disease
In recurrent abd pain
• Persistent pain away from the umbilicus – such
as right upper or lower quadrant pain • Persistent vomiting • Family history of inflammatory bowel disease,
coeliac disease, or peptic ulcer disease • Epigastric pain at night • Haematemesis – duodenal ulcer • Diarrhoea, weight loss, growth faltering, blood in
stool – inflammatory bowel disease • Dysphagia – eosinophilic oesophagitis • Dysuria, secondary enuresis – urinary tract
infection • Night time waking • Gastrointestinal blood loss • Peri-anal disease • Delayed puberty
Screening tests to consider to identify organic
disorders
In recurrent abd pain
Full blood count with differential • Erythrocyte sedimentation rate, C-reactive protein
for inflammation • Coeliac serology (including immunoglobulin
levels) – as coeliac disease may present with
diarrhoea or constipation or as irritable bowel
syndrome • Amylase – for pancreatitis • Urea and electrolytes • Liver function tests • Ultrasound of abdomen • Thyroid function tests • Urinalysis / urine culture – to identify urinary tract
infection or haematuria from renal calculi • Faecal calprotectin – as a non-invasive screen for
inflammatory bowel disease
functional abdominal pain disorders (FAPDs)’.
A number of symptom complexes are recognized as causing ‘functional abdominal pain disorders (FAPDs)’. They are sub-classified (Fig. 14.7) as:
• irritable bowel syndrome (most common) • abdominal migraine • functional dyspepsia • functional abdominal pain (not otherwise specified,
i.e. do not meet above classification). Although described separately, there is considerable overlap between them. Diagnostic criteria have been agreed internationally.
Irritable bowel syndrome (IBS)
Irritable bowel syndrome (IBS) A family history is often present. There is a characteristic
set of symptoms, with non-specific abdominal pain, often peri-umbilical, related to one or more of:
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Urinary tract Gynaecological • Urinary tract infection • Dysmenorrhoea • Pelvi-ureteric junction • Ovarian cysts (PUJ) obstruction • Pelvic inflammatory • Renal calculi
disease
Box 14.2 Screening tests to consider to identify organic
disorders
• Full blood count with differential • Erythrocyte sedimentation rate, C-reactive protein
for inflammation • Coeliac serology (including immunoglobulin
levels) – as coeliac disease may present with
diarrhoea or constipation or as irritable bowel
syndrome • Amylase – for pancreatitis • Urea and electrolytes • Liver function tests • Ultrasound of abdomen • Thyroid function tests • Urinalysis / urine culture – to identify urinary tract
infection or haematuria from renal calculi • Faecal calprotectin – as a non-invasive screen for
inflammatory bowel disease
• defecation
• alteration in stool frequency
• change in appearance of stool (diarrhea or
constipation).
Children with functional constipation also often report pain and distinguishing it from IBS can be problematic. If the abdominal pain resolves with constipation treat-
ment, the child has functional constipation. If pain does not resolve after treatment, the child is likely to have IBS with constipation.
Abdominal migraine
In abdominal migraine there are paroxysms of intense, acute periumbilical, midline or diffuse abdominal pain, lasting at least an hour, interfering with normal activities. Additional symptoms may be vomiting, nausea, anorexia, headaches, photophobia and pallor. In between episodes, there are long periods (often weeks) of no symptoms inter- spersed with episodes following a characteristic pattern for the child, with abdominal pain the main symptom. There is often a personal or family history of migraine, and similar triggers to classic migraine (stress, fatigue, travel), similar associated symptoms (e.g. anorexia, nausea and vomiting), similar relieving factors (e.g. rest and sleep), and can evolve into migraine headaches in adult life.
Tt of functional abdominal pain disorders (FAPDs)’
This is based on a bio-psychosocial model of care
Avoiding triggers and psychosocial factors that exacerbate painful episodes need to be addressed.
Medications may sometimes be indicated. For irrita-
ble bowel syndrome, reassurance, dietary manipulations (such as low FODMAP –Fermentable Oligo-saccharides, Di-saccharides, Mono-saccharides And Polyols – diets), anti-spasmodics and alternative therapies may be helpful. For abdominal migraine, treatment with anti-migraine medication may be of benefit if the problem causes school absence. For functional dyspepsia, acid blockade with his-
tamine receptor antagonists and proton pump inhibitors can be offered.
Behaviour modification has been shown to improve coping mechanisms and avoid reinforcement of pain. These include relaxation, distraction and hypnotherapy. Of these techniques, hypnotherapy, with imagined pic-
tures, sound or sensations to distract attention from pain, has been demonstrated to be most effective.
Peptic ulcer disease
Peptic ulcer disease Duodenal ulcers are uncommon in children but should be considered in those with epigastric pain, particularly if it wakes them at night, if the pain radiates through to the back, or when there is a history of peptic ulcer- ation in a first-degree relative. These can be caused by H. pylori infection. Initial diagnosis of H. pylori infection is generally made with gastric biopsy on endoscopy. Non- invasive tests such as 13C breath test, which detects urease produced by the organism following the administration of 13C-labelled urea by mouth, or stool antigen tests for
H. pylori are used to confirm successful eradication of H. pylori infection. In children, non-invasive tests are not recommended for initial diagnosis and treatment.
Children in whom peptic ulceration is suspected or diagnosed on endoscopy should be treated with proton- pump inhibitors, e.g. omeprazole, and if H. pylori is identi- fied, eradication therapy with antibiotics should be given.
stool frequency
Breastfed infants usually have a stool frequency of 4 or more times a day
It is usually twice a day by 1 year of age
Constipation
There may be straining or pain and bleeding associated with hard stools or abdominal pain and reduced appe- tite, which waxes and wanes with passage of stool. Faecal impaction is when there are severe symptoms, overflow soiling and a faecal mass on abdominal examination. The constipation may have been precipitated by dehydra- tion or reduced fluid intake or change in diet or an anal fissure causing pain. It may relate to the child withholding stool (may be accompanied by ‘retentive posturing’ with straight legs, tip-toes with arched back) to avoid distrac- tion from play, or problems with toilet training. In older children there may be anxieties about opening bowels at school or in unpleasant or unfamiliar toilets. It may also be a side effect of medications.
Examination usually reveals a well child whose growth is normal, the abdomen is soft and any abdominal disten- sion is normal for age. The back and perianal area are normal in appearance and position and lower limb neu- rological examination is normal. A soft faecal mass may sometimes be palpable in the lower abdomen, but is not necessary for the diagnosis. Digital rectal examination should not be performed, though it may sometimes be considered by a paediatric specialist to help identify ana- tomical abnormalities or Hirschsprung disease.
A primary underlying cause for constipation is rare, but a number of underlying conditions should be consid- ered: ‘red and amber flag’ symptoms and signs indicative of more significant pathology are detailed in Box 14.6. Investigations are not required to diagnose idiopathic constipation, but are carried out as indicated by history or clinical findings. If there is growth faltering or intractable constipation, investigations for hypothyroidism, coeliac disease and hypercalcaemia may be indicated.
Constipation Management
Management
This is summarized in Fig. 14.20. Reassurance can be offered that underlying causes have been excluded. Constipation arising acutely in young children, e.g. after an acute febrile illness, usually resolves spontaneously or with the use of maintenance laxative therapy.
In more long-standing constipation, the rectum becomes overdistended, with a subsequent loss of feeling the need to defecate. Involuntary soiling may occur as contractions of the full rectum inhibit the internal sphinc- ter, leading to overflow.
Initial management is to evacuate the overloaded rectum; recovery of normal rectal size and sensation can
be achieved but may take a long time. Faecal impaction
requires a regimen of stool softeners, initially with a mac-
rogol laxative, e.g. polyethylene glycol (Movicol Paediatric
Plain). An escalating dose regimen is administered over
1–2 weeks or until impaction resolves. If this proves unsuc-
cessful, a stimulant laxative, e.g. senna, or sodium picosul-
phate, may also be required. If the polyethylene glycol is
not tolerated, an osmotic laxative (e.g. lactulose) can be
substituted.
Maintenance treatment is given following disimpac-
tion or if impaction is not present to ensure ongoing regular, pain-free defecation. Polyethylene glycol (with or
without a stimulant laxative) is generally the treatment
of choice. The dose should be gradually reduced over a
period of months in response to improvement in stool consistency and frequency.
Dietary interventions alone have not been shown to be of
benefit in managing constipation in this situation, although
Red and amber flag’ symptoms or signs in the child with constipation
Red flag’ symptom/signs – urgent referral Failure to pass meconium within 24 hours of life, constipation from or soon after birth, family history of Hirschsprung disease Abdominal distension with vomiting Ribbon stool pattern Abnormal lower limb neurology or deformity Abnormality of lumbosacral or gluteal regions, e.g. sacral dimple above natal cleft, or naevus, hairy patch, central pit, or discoloured skin over the spine Abnormal appearance / position / patency of anus Perianal bruising or multiple fissures Perianal fistulae, abscesses, or fissures Amber signs – specialist referral; start treating constipation Faltering growth / growth failure Constipation triggered by introduction of cow’s milk
Diagnostic concern Hirschsprung disease
Hirschsprung disease or intestinal obstruction Anal stenosis Neurological or spinal cord abnormality Spina bifida occulta
Abnormal anorectal anatomy Sexual abuse Perianal Crohn disease Diagnostic concern
Hypothyroidism, coeliac disease, other causes Cow’s milk protein aller
Constipaton summary
Idiopathic constipation (2 or more): • <3 stools/week • hard, large stool • ’rabbit droppings’ stool • overflow soiling and no ‘red flags’
Balanced diet and adequate oral fluids
Good toileting habits
Laxatives: (Polyethylene glycol +/– stimulant laxative, e.g. sodium picosulphate or senna +/– osmotic laxative e.g. lactulose)
• If impaction (severe symptoms, overflow soiling, faecal mass): increase doses until effective • Impaction absent or resolved − maintenance therapy: reduce laxative doses when stools soft, titrating dose with effect
Hirschsprung disease
Hirschsprung disease • Absence of myenteric plexuses of rectum and
variable distance of colon. • Presentation – usually intestinal obstruction in
the newborn period following delay in passing
meconium; in later childhood – profound chronic
constipation, abdominal distension, and growth faltering.
• Diagnosis – suction rectal biopsy.
Diagnosis is made by demonstrating the absence of ganglion cells, together with the presence of large, acetylcholinesterase-positive nerve trunks on a suction rectal biopsy. Anorectal manometry or barium studies may be useful in giving the surgeon an idea of the length of the aganglionic segment but are unreliable for diagnos-
tic purposes. Management is surgical and usually involves an initial colostomy followed by anastomosis of normally innervated bowel to the anus.
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