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
