Acute Abdomin And Constipaton Flashcards

Question

Tt of functional abdominal pain disorders (FAPDs)’

Answer 1

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.

Answer 2

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.

Answer 3

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

Answer 4

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.

Answer 5

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

Answer 6

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

Answer 7

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

Answer 8

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. 2gens - RET = down EDNRB