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Paeds: Gastro and Growth > Acute abdominal pain > Flashcards

Acute abdominal pain Flashcards

1
Q

In what proportion of children admitted to hospital with abdominal pain does the pain resolve undiagnosed?

A

nearly half

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2
Q

What is a key diagnosis not to miss/delay in the case of abdominal ain in cihldren? Why?

A

Acute appendicitis; progression to perforation can be rapid

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3
Q

What is the most common surgical cause of acute abdominal pain in children?

A

appencitis

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4
Q

What are 3 things that must always be checked in an examination of a child with abdominal pain?

A
  1. Testes
  2. Hernial orifices
  3. Hip joints
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5
Q

What are 5 causes, in addition to acute appendicitis, that are important to remember for acute abdominal pain?

A
  1. Lower lobe pneumonia - referred pain
  2. Primary peritonitis - ascites from nephrotic syndrome or liver disease
  3. DKA - may cause severe abdo pain
  4. UTI, including acute pyelonephritis - uncommon but musn’t miss (so test urine)
  5. Pancreatitis - check serum amylase
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6
Q

What are 3 groups that causes of acute abdominal pain can be split into?

A
  1. Surgical
  2. Medical
  3. Extra-abdominal
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7
Q

What are 7 surgical causes of acute abdominal pain?

A
  1. Acute appendicitis
  2. Intestinal obstruction including intussusception
  3. Inguinal hernia
  4. Peritonitis
  5. Inflamed Meckel diverticulum
  6. Pancreatitis
  7. Trauma
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8
Q

What are 14 medical causes of acute abdominal pain?

A
  1. Non-specific abdominal pain
  2. Gastroenteritis
  3. Urinary tract: UTI, acute pyelonephritis, hydronephrosis, renal calculus
  4. Henoch-Schonlein purpura
  5. Diabetic ketoacidosis
  6. Sickle cell disease
  7. Hepatitis
  8. IBD
  9. Constipation
  10. Recurrent abdominal pain of childhood
  11. Gynaecological in pubertal females
  12. Psychological
  13. Lead poisoning
  14. Acute porphyria (rare)
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9
Q

What are 4 extra-abdominal causes of acute abdominal pain?

A
  1. Upper respiratory tract infection
  2. Lower lobe pneumonia
  3. Torsion of testis
  4. Hip and spine
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10
Q

What age does acute appendicitis occur in children?

A

may occur at any age but very uncommon <3 yeras

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11
Q

What are 6 clinical features of appendicitis?

A
  1. Anorexia
  2. Vomiting
  3. Abdominal pain - initially central and colicky (appendicular midgut colic) but then localising to right iliac fossa (from localised peritoneal inflammation)
  4. Fever
  5. Pain aggravated by movement e.g. walking, coughing, jumping, bumps on road in car journey
  6. Persistent tenderness with guarding in right iliac fossa (McBurney’s point) (may be absent if retrocaecal appendix/pelvic)
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12
Q

What are 3 features of acute appendicitis in preschool children?

A
  1. Diagnosis more difficult, particularly early in the disease
  2. Faecoliths more common, can be seen on plain abdominal x-ray
  3. Perforation may be rapid - omentum less well-developed and fails to surround appendix, signs easy to underestimate at this age
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13
Q

What is most helpful in making a diagnosis of appendicitis?

A

repeated observationa and clinical review every few hours - key to making correct diagnosis

no lab investigation or imaging consistently helpful

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14
Q

Why might white blood cells or organisms be present in the urine in appendicitis?

A

Inflamed appendix may be adjacent to ureter or bladder

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15
Q

How useful are blood tests in appendicitis?

A

neutrophilia may not always be present on FBC; not consistently helpful

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16
Q

Which investigation may be useful to support the clinical diagnosis of appendicitis? What might it show?

A

Ultrasound scan: thickened, non-compressible appendix with increased blood flow, may demonstrate associated complciations: abscess, perforation, appendix mass.

May exclude other pathology causing symptoms

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17
Q

What are 3 complications of appendicitis that may be revealed by ultrasound scan?

A
  1. Abscess
  2. Perforation
  3. Appendix mass: inflamed appendix with adherent covering of omentum and small bowel
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18
Q

What investigation may be used in some centres to investigate an appendix before performed the definitive treatment?

A

Laparoscopy to see whether or not appendix is inflamed

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19
Q

What is the management of uncomplicated appendicitis?

A

Appendicectomy

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20
Q

What clinical sign is suggestive of perforation in appendicitis?

A

Generalised guarding

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21
Q

What is the management of complicated appedicitis i.e. perforation, abscess or appendix mass present?

A

Fluid resuscitation and IV antibiotics given prior to laparotomy

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22
Q

What might make you consider conservative management of appendicitis and what would this involve?

A

If palpable mass in right iliac fossa and no signs of generalised peritonitis: conservative management with IV antibiotics, with appendicectomy performed after several weeks

if symptoms progress, laparotomy indicated

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23
Q
A
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24
Q

What is meant by non-specific abdominal pain?

A

abdominal pain which resolves in 24-48 hours; pain less severe than in apendicitis, tenderness in right iliac fossa is variable

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25
Q

What features often accompany non-specific abdominal pain?

A

Upper respiratory tract infection with cervical lymphadenopathy

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26
Q

What is sometimes the outcome of non-specific abdominal pain which does not resolve?

A

appendicectomy

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27
Q

What is the diagnosis commonly made in non-specific abdominal pain in children whose large mesenteric nodes are seen at laparoscopy but whose appendices are normal?

A

Mesenteric adenitis

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28
Q

What thoughts are there about the idea of mesenteric adenitis as a diagnosis?

A

Doubts whether this condition truly exists as a diagnostic entity

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29
Q

What are 3 things that may be required to distinguish between acute appendicitis and non-specific abdominal pain?

A
  1. Close monitoring
  2. Joint management between paediatricians and paediatric surgeons
  3. Repeated evaluation in hospital
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30
Q

What is meant by intussusception?

A

Invagination of proximal bowel into a distal segment; most commonly involves ileum passing into the caecum through the ileocaecal valve

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31
Q

What is the most common cause of intestinal obstruction of infants after the neonatal period?

A

Intussusception

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32
Q

What is the peak age of presentation of intussusception?

A

3 months - 2 years (but can occur at any age)

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33
Q

What is the most serious complication of intussusception?

A

Stretching and constriction of the mesentery resulting in venous obstruction, causing engorgement and bleeding from the bowel mucosa, fluid loss, and subsequently bowel perforation, peritonitis and gut necrosis

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34
Q

What are needed to avoid complications in intussusception?

A

Prompt diagnosis, immediate fluid resuscitation and urgent reduction of intussusception

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35
Q

What are 8 features of the presentation of intussusception?

A
  1. Paroxysmal, severe colicky pain associated with pallor during pain episodes, especially around mouth, and draws up legs
  2. Recovery between painful episodes but subsequently child may become increasingly lethargic
  3. Refuse feeds
  4. Vomiting - may become bile stained depending on site of intussusception (won’t be bilious unless distal to ampulla of vater)
  5. Sausage-shaped mass - often palpable
  6. Passage of redcurrant jelly stool - blood stained mucus (later in illness)
  7. Abdominal distension and shock
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36
Q

What can cause intussception? 3 key points

A
  1. Usually no underlying intestinal cause found
  2. Some evidence viral infection leading to enlargement of Peyer’s patches may form lead point of intussusception
  3. Meckel diverticulum or polyp more likely to be present in children over 2years
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37
Q

In children of what age is there likely to be an identified lead point for intussusception, and what 2 things could this be?

A

children >2 years old; Meckel diverticulum or polyp

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38
Q

What is needed as the immediate management of intussusception and why?

A

IV fluid resuscitation - often pooling of fluid in gut, which may lead to hypovolaemic shock

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39
Q

What are 2 investigations to help confirm the diagnosis of intussusception?

A
  1. Abdominal X-ray
  2. Abdominal ultrasound
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40
Q

What may abdominal x-ray show in intussusception?

A

Distended small bowel and absence of gas in distal colon or rectum

Sometimes outline of intussusception itself can be visualised

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41
Q

What can abdominal ultrasound show in intussusception?

A

helpful to confirm diagnosis (target/doughnut sign) and check response to treatment

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42
Q

What are the 2 potential stages of management of intussusception?

A
  1. Reduction by rectal air insufflation by radiologist (if no signs of peritonitis)
    • only once resuscitated, and under supervision of paediatric surgeon in case unsuccessful/bowel perforation occurs
  2. Operative reduction
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43
Q

Under what 3 conditions can rectal air insufflation by a radiologist be performed to treat intussusception?

A
  1. No signs of peritonitis
  2. Resuscitation has been performed
  3. Under supervision of paediatric surgeon in case unsuccessful or bowel perforation occurs
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44
Q

What is the success rate of rectal air insufflation in intussusception?

A

75%

45
Q

In what proportion of children treated for intussusception does it recur?

A

5%; more frequent after hydrostatic reduction

46
Q

What is the most important complication of intussusception to remember?

A

shock

47
Q

What is a Meckel diverticulum?

A

Ileal remnant of the vitello-intestinal duct, which contains ectopic gastric mucosa or pancreatic tissue

48
Q

What proportion of individuals have a Meckel diverticulum?

A

2%

49
Q

What is the possible presentation of a Mecekl diverticulum?

A

most asymptomatic but may present with severe rectal bleeding, neither bright red nor true melaena

50
Q

What might blood tests reveal in Meckel diverticula?

A

acute reduction in haemoglobin

51
Q

In addition to rectal bleeding, what are 3 other forms of presentation of Meckel diverticula?

A
  1. Intussusceptoin
  2. Volvulus (twisting of the bowel)
  3. Diverticulitis - inflammation of diverticulum mimics appendicitis
52
Q

What is the key investigation to perform to diagnose Meckel diverticulum?

A

technetium scan: will demonstrated increased uptake by ectopic gastric mucosa in 70% of cases

53
Q

What is the treatment of a Meckel diverticulum?

A

surgical resection

54
Q

What is malrotation?

A

Failure of normal intestinal rotation and fixation during the development of the foetus; in most common form, caecum is found in upper right quadrant instead of lower right quadrant. Adhesive peritoneal bands (Ladd’s bands) may be present

55
Q

What are Ladd bands?

A

Sometimes a feature of malrotation; peritoneal bands that may extend from displaced caecum anteriorly over second portion of duodenum to lateral abdominal wall

56
Q

What is the most common form of malrotation?

A

Caecum remains high in upper right adbominal quadrant and fixed to the posterior abdominal wall, Ladd bands present obstructing duodenum

57
Q

What are 2 forms of presentation of malrotation?

A
  1. Obstruction
  2. Obstruction with a compromised blood supply
58
Q

When and what is the most common presentation of malrotation?

A

Obstruction with bilious vomiting in the first few days of life

59
Q

What features of malrotation should prompt urgent investigation, and what investigation is this?

A

Any child with dark green vomiting - urgent upper gastrointestinal contrast study to assess intestinal rotation UNLESS signs of vascular compromise present, when urgent laparotomy needed

60
Q

When should you not perform an upper GI contrast study in suspected malrotation and what should be done instead?

A

If signs of vascular compromise; urgent laparotomy needed

61
Q

If signs of malrotation with vascular compromise are present what is the management and why?

A

Emergency laparotomy: surgical emergency as in volvulus, superior mesenteric arterial blood supply to small intestine and proximal large intestine is compromise - will lead to infarction of these areas if compromised

62
Q

What is done during the emergency laparotomy for malrotation with vascular compromise?

A

Volvulus untwisted, duodenum mobilised, and bowel placed in non-rotated position with duodenojejunal flexure on right and caecum and apendix on left - malrotation not corrected, but mesentery is broaded.

appendix removed to avoid diagnostic confusion should child subsequently have symptoms suggestive of appendicitis

63
Q

Why is the appendix generally removed during emergency surgery for malrotation with vascular compromise (i.e. volvulus)?

A

to avoid diagnostic confusion should child subsequently have symptoms suggestive of appendicitis

64
Q

What is the peak age of presentation of malrotation?

A

Usually within first 1-3 days of life

65
Q

What is it that usually causes presentation of malrotation in children?

A

intestinal obstruction from Ladd bands obstructing duodenum or volvulus

66
Q

What is the treatment of all forms of malrotation?

A

Surgical correction

67
Q

What is the usual definition of recurrent abdominal pain in children?

A

Pain sufficient to interrupt normal activities and lasts for at least 3 months

68
Q

In what proportion of recurrent abdominal pain is an organic cause identified?

A

less than 10% of cases

69
Q

What is the usual presentation of recurrent abdominal pain?

A

periumbilical pain, children otherwise entirely well

70
Q

What cause of recurrent abdominal pain is common and must be excluded?

A

Constipation

71
Q

How might recurrent abdominal by associated with psychiatric issues in children?

A

no evidence it is psychogenic

may be manifestation of stress, anxiety, may lead to family distress

anxiety may cause altered bowel motility, which may be perceived as pain

72
Q

What is the aim of management of recurrent abdominal pain?

A

Identify any serious cause without subjecting child to unnecessary investigation while providing reassurance to child and parents

73
Q

What are 6 things you should do in the management of recurrent abdominal pain?

A
  1. History
  2. Examination - thorough
  3. Inspection of perineum for anal fissures
  4. Check child’s growth
  5. Urine microscopy and culture
  6. tTG and TFTs
74
Q

What are 2 situations when abdominal ultrasound can be useful for recurrent abdominal pain?

A
  1. Gallstones
  2. Pelvi-uretic junction obstruction
75
Q

What is the long term prognosis of recurrent abdominal pain?

A
  1. 50% rapidly become free of symptoms
  2. 25% symptoms take months to resolve
  3. 25% symptoms continue or return in adulthood as migraine, IBS or functional dyspepsia
76
Q

What is abdominal migraine?

A

when children get migraine sometimes abdominal pain occurs in addition to headaches, and sometimes the abdo pain predominates

Episodic abdo pain, may be without headache

77
Q

What are 4 typical features of abdominal migraine?

A
  1. Midline attacks of abdominal pain
  2. Vomiting
  3. Facial pallow
  4. Personal or family history of migraine
78
Q

What is the typical time frame of abdominal migraine?

A

Long periods (often weeks) of no symptoms then shorter period (12-48 hours) of non-specific abdominal pain and pallor, with or without vomiting

79
Q

What treatment may be considered for abdominal migraine and when?

A

treatment with anti-migraine medication may be of benefit if problem causes school absence

80
Q

What is irritable bowel syndrome?

A

altered GI motility and abnormal sesnation of intra-abdominal events

81
Q

What may precipitate irritable bowel syndrome?

A

Gastro-intestinal infection

82
Q

What has been shown by studies of pressure changes within the small intestine of children with irritable bowel syndrome? What else has been shown in adults?

A

abnormally forceful contractions occur

in adults: inflation of balloons in intestine cause pain in affected individuals at lower volumes than controls

83
Q

What modulates the factors that cause IBS in children, e.g. forceful contractions, pain at lower inflation volumes?

A

Stress and anxiety

84
Q

What are 6 classical features of IBS in children?

A
  1. Non-specific abdominal pain, often peri-umbilical, may be worse before or relieved by defecation
  2. Explosive, loose, or mucousy stools
  3. Bloating
  4. Feeling of incomplete defecation
  5. Constipation (often alternating with normal or loose stools)
  6. Family history
85
Q

Which blood test must you make sure to check in suspected IBS in children?

A

coeliac antibody serology (anti-tTG)

86
Q

What is likely a potential predisposing factor for duodenal ulcers?

A

H. pylori infection

87
Q

When should you consider duodenal ulcers in children? 4 key factors

A
  1. epigastric pain
  2. if wakes at night
  3. radiates through to the back
  4. history of peptic ulceration in first degree relative
88
Q

What does H. pylori infection cause in the stomach and what can this lead to?

A

Nodular antral gastritis, may be associated with abdominal pain and nausea

89
Q

How can H. pylori infection in the stomach causing nodular antral gastritis be identified?

A

Gastric antral biopsies

90
Q

What is a non-invasive test to diagnose H. pylori infection and how does it work?

A

13C breath test - H. pylori produces urease enzyme, so will hydrolyse orally administered 13C-labelled urea

91
Q

What are 2 additional tests to diagnose H. pylori infection in children as well as the urea breath test and how reliable are they?

A
  1. Stool antigen - may be positive in infected children
  2. Serological tests - less reliable in young children but may be helpful in older children
92
Q

How should you treat suspected peptic ulceration in children?

A

PPIs e.g. omeprazole; if investigations suggest H. pylori infection, eradication therapy (amoxicillin and metronidazole or clarithromycin)

93
Q

What should be the next stop if patients with suspected peptic ulceratin fail to respond to treatment, or whose symptoms recur on stopping treatment?

A

Upper GI endoscopy

94
Q

If upper GI endoscopy is normal following failure of treatment of suspected peptic ulceration or recurrence following end of treatment, what is the next step?

A

Functional dyspepsia diagnsed (probably a variant of irritable bowel syndrome)

95
Q

What 5 symptoms will children with functional dyspepsia have?

A

Non-specific symptoms

  1. the symptoms of peptic ulceration - epigastric pain radiating through to back
  2. early satiety
  3. bloating
  4. postprandial vomiting
  5. delayed gastric emptying due to gastric dysmotility
96
Q

What is a possible treatment for functional dyspepsia?

A

some children respond to hypoallergenic diet (but treatment is difficult)

97
Q

What is eosinophilic oesophagitis?

A

Inflammatory condition affecting the oesophagus caused by activation of eosinophils within the mucosa and submucosa

98
Q

What are 3 key symptoms of eosinophilic oesophagitis?

A
  1. vomiting
  2. discomfort on swallowing
  3. bolus dysphagia - when food ‘sticks in the upper chest’
99
Q

What type of phenomenon is eosinophilic oesophagitis likely to be?

A

Allergic phenomenon - although precise pathophysiology unclear

100
Q

In what group of children is eosinophilic oesophagitis more common?

A

those with other features of atopy e.g. asthma, eczema, hay fever

101
Q

How is a diagnosis of eosinophilic oesophagitis made?

A

by endoscopy: macroscopically, linear furrows and trachealisation of oesophagus may be seen and microscopically eosinophilic infiltration is identified

102
Q

What is the treatment of eosinophilic oesophagitis?

A

swallowed corticosteroids in the form of fluticasone or viscous budesonide

exclusion diets may be of benefit in young children

103
Q

To summarise what are 6 groups of causes of recurrent abdominal pain in children?

A
  1. >90% no structural cause found
  2. GI
  3. Gynaecological
  4. Psychosocial
  5. Hepatobiliary/pancreatic
  6. Urinary tract
104
Q

What are 8 GI causes of recurrent abdominal pain in children?

A
  1. Irritable bowel syndrome
  2. Constipation
  3. Non-ulcer dyspepsia
  4. Abdominal migraine
  5. Gastritis and peptic ulceration
  6. Eosinophilic oesophagitis
  7. Inflammatory bowel disease
  8. Malrotation
105
Q

What are 3 gynaecological causes of recurrent abdominal pain?

A
  1. Dysmenorrhoea
  2. Ovarian cysts
  3. Pelvic inflammatory disease
106
Q

What are 3 hepatobiliary/ pancreatic causes of recurrent abdominal pain?

A
  1. Hepatitis
  2. Gall stones
  3. Pancreatitis
107
Q

What are 2 urinary tract causes of recurrent abdominal pain?

A
  1. UTI
  2. Pelvi-ureteric junction obstruction
108
Q

What are 6 symptoms and signs that suggest organic cause of recurrent abdominal pain?

A
  1. Epigastric pain at night, haematemesis (duodenal ulcer)
  2. Diarrhoea, weight loss, growth failure, blood in stools (IBD)
  3. Vomiting (pancreatitis)
  4. Jaundice (liver disease)
  5. Dysura, secondary enuresis (UTI)
  6. Bilious vomiting and abdominal distension (malrotation)

Paeds: Gastro and Growth (14 decks)

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