Acute Abdominal Pain Flashcards
What are the differentials for abdominal pain?
- GI bleed secondary to ulcer
- Angiodysplasia (more commonly painless bleeding)
- HSP
- Infection/inflammation: gastroenteritis, UTI, hepatitis, pyelonephritis
- Constipation
- IBD/IBS
- Mesenteric adenitis
- Consider NAI
- Coeliac disease
- DKA, all need a BM check
- Iatrogenic/idiopathic: deliberate poisoning, excess medication use e.g. NSAIDs
- Intussusception can occur as idiopathic or secondary to conditions like HSP, lymphoma
- Neoplasm: neuroblastoma, likely to be systemic symptoms too + palpable mass
- Meckel’s diverticulum - usually causes painless PR bleeding but could present with pain if there’s perforation/intussusception
- Lactose intolerance (loose stools/abdo pain)
What do you want to know about vomiting?
- Blood or bile?
- Haematemesis is uncommon in children and when it does occur often due to Mallory-Weiss tear but other causes need to be considered; bilous vomiting»_space; always abnormal and indicates surgical pathology
What do you want to know about stools in the history?
- Frequency, how many stools, during night and day?
- Consistency: are they variable? Are they mixed?
- Blood in the stool - is it on the surface of hard stool (possible constipation) or is it just on wiping (possible constipation, or more local cause). Is it mixed through soft stool (possible infection - more likely bacterial if blood in stool, possible colitis)
- Presence of mucus: may indicate inflammation
What would be the difference in stools in bacterial and viral gastroenteritis?
- Bloody stools more likely in bacterial gastroenteritis
- Viral gastroenteritis - many, watery stools; differentials are appendicitis, UTI
What other questions would you want to ask in acute abdominal pain?
- Fever
- Are they still eating and drinking (dehydration)?
- Still passing urine?
- Risk factors for specific infections/bacterial illnesses - any contact with viral gastroenteritis; infectious contacts; foreign travel; contact with farm animals; eaten foods out of the ordinary; any contacts with similar symptoms?
What are functional GI disorder red flags?
- Poor growth
- Blood in stools
- Weight loss
- Symptoms regularly waking child from sleep
- Age <5yrs
What is functional abdominal pain?
Pain not caused by physical abnormalities - non-specific abdominal pain of childhood. There is no underlying pathology - history and examination must be aimed both at eliciting features which may be consistent with this diagnosis and also at excluding organic underlying pathology. A positive diagnosis must based on symptom based criteria and minimising investigation where possible.
What are red flag features in a history that prompt consideration of further investigation?
- Age <5
- Systemic: weight loss, recurrent oral ulcers, fever, dysphagia, vomiting (esp haematemesis, bilious)
- Nocturnal symptoms: awakening child from sleep (be sure to differentiate waking from sleep vs stopping child from getting to sleep)
- Persistent RU or RL abdo pain
- Dysuria/haematuria/flank pain
- Chronic NSAID use
- FH: IBD/coeliac/peptic ulcer disease
What are red flag features in an examination that prompt consideration of further investigation?
- Growth deceleration
- Delayed puberty
- Jaundice
- Pallor
- Rebound/guarding/organomegaly
- Perinanal disease
- Blood in stool
What are the common causes of malaena in children?
- Infective - bacterial diarrhoea e.g. campylobacter, salmonella
- IBD
- Tearing from anal vein
- Polyp
- Intussusception - acutely unwell
What are the features of ulcerative colitis?
- Large bowel only
- Continuous disease
- Ulcers in inflamed tissue
- Symmetrical
- Bloody stools
What are the features of Crohn’s disease?
- Any part of the GI tract
- Skip lesions
- Ulcers in normal looking mucosa
- Asymmetric involvement
- Cobblestone (longitudinal ulcers with intervening oedematous mucosa)
- Confluent linear ulcers
- Fistulae
- Granulomas
What are the investigations for IBD?
- FBC
- Haematinics
- U+Es, LFTs, CRP, ESR
- Stool culture
- Faecal calprotectin (indicates inflammation)
- Abdo XR - for acute setting
- Endoscopy - flexible sigmoidoscopy, colonoscopy) - under GA
- CT abdomen
- Anti-TTG
- Coagulation screen (coagulation factors get activated in IBD)
- Vit B12 and D levels (decrease due to poor absorption)
What is the treatment for IBD?
- Distal disease - suppositories or enemas
- Left sided disease - enemas or systemic therapy
- Proximal - systemic therapy
- Steroids for flare-ups > immunosuppression, eventually surgery
- Stop smoking in Crohn’s
- Stop NSAIDs
What medications are used for IBD?
- 5-aminosalicylate drugs: (e.g. mesalazine) as effective as steroids in mild to moderately active disease, less effective in Crohn’s, try before steroids
- Steroids: given when 5-ASA fails (prednisolone), in severe disease may need IV, give course and aim to stop, always attempt to reduce dose
- Immunosuppression: if relapsing after stopping steroids, azathioprine 1st line (regular monitoring needed, good in children, 60% remission), methotrexate if intolerant or non-responder (teratogenic)
- Anti-TNF Antagonist (ATA): anti-inflammatories stop cytokine action; infliximab (2hr IV infusion at hospital, 0,2 and 6 week induction then 8 weekly); adalimumab (weekly injection for first 2 weeks then fortnightly - patient can administer); risks are sepsis, TB, malignancy; SEs are rash, intolerance, demyelination
What is the acute management for bloody diarrhoea?
Urgent AXR and stool culture
- If colon dilated - some day surgical opinion and IV steroids +/- infliximab/cyclosporin
- If non-dilated colon - urgent sigmoidoscopy and IV steroids
What is the non-acute management of bloody diarrhoea?
FBC, CRP, ESR, flexisigmoidoscopy
- Topical or systemic treatment
- Steroids if systemic symptoms or abnormal blood tests
- 2nd line therapy if relapse or resistant
- If no response: anti-TNF or surgical option
What are the complications of Crohn’s?
- Frequent flares, long-standing disease
- PSC > colon malignancy
- Strictures
- Fistulae
- Abscess formation
- Haemorrhage
What are the complications of UC?
- Toxic megacolon
- Haemorrhage
- Fibrous strictures
- Malignancy
What are the symptoms of coeliac disease?
- Failure to thrive in children
- Chronic diarrhoea
- Unexplained symptoms (n+v)
- Chronic fatigue
- Abdominal cramping/distension
- Unexplained weight loss
- Large and pale and smelly stools (often don’t go away on flushing)
What are the complications of coeliac disease?
- Iron, folate and B12 deficiency
- Hyposplenism (excessive loss of lymphocytes)
- Osteoporosis
What are the investigations for coeliac disease?
- Anti-TTG
- Jejunal biopsy (not always needed)
- At risk HLA haplotype (HLA DQ2 DQ8)
What is the management of coeliac disease?
- Gluten free diet
- Hyposplenism results in immunodeficiency so all coeliac patients offered the pneumococcal vaccine (+ booster every 5yrs)
What is Haemolytic Uraemic Syndrome?
Triad of AKI (renal insufficiency), thrombocytopenia, microangiopathic haemolytic anaemia (anaemia due to breaking of RBCs from physical damage). Typically caused by E. Coli 0157
What are the symptoms of Haemolytic Uraemic Syndrome?
- Abdominal pain
- Bloody diarrhoea
- Fever
- Seizures
- Lethargy
What are the investigations for Haemolytic Uraemic Syndrome?
- FBC (anaemia, thrombocytopenia, fragmented blood film due to RBC destruction)
- U+E (AKI)
- Stool culture
What is the management for Haemolytic Uraemic Syndrome?
Mainly supportive (fluids, blood transfusion and dialysis if needed), don’t give antibiotics - can give plasmapheresis/IVIG
What is the management for Crohn’s?
- Induce remission with steroids e.g. oral prednisolone or IV hydrocortisone
- If steroids alone do not work, consider adding: azathioprine, mercaptopurine, methotrexate, infliximab, adalimumab
- Maintain remission with: azathioprine, mercaptopurine
- OR with methotrexate, infliximab, adalimumab
What is the management for UC?
- Induce remission (mild to moderate): 1st is aminosalicylate (e.g. mesalazine), 2nd is corticosteroids (e.g. prednisolone)
- Induce remission (severe): 1st is IV corticosteroids (e.g. hydrocortisone), 2nd line IV ciclosporin
- Maintain remission: aminosalicylate (e.g. mesalazine oral or rectal), azathioprine, mercaptopurine
- Surgery: panproctocolectomy (remove colon and rectum), left with permanent ileostomy or ileo-anal anastomosis (J pouch)
