Aquifer - GI/GU Flashcards
In general, a pattern of insidious onset of abdominal pain suggests what?
Inflammation of the visceral peritoneum alone or a well-contained process like an abscess
In general, crampy or colicky abdominal pain suggests what?
Obstruction in a peristaltic organ (like a bowel or ureter)
Progression of abdominal pain from a dull, diffuse pain to a sharp, well-defined pain suggests what?
Disease progression and possible need for surgery
DDx - Abdominal Pain and Vomiting (adolescent female)
- Appendicitis
- Cholecystitis
- Pregnancy
- Hepatitis
- Pancreatitis
- PID
- UTI
- Acute gastroenteritis
- Mesenteric adenitis
- Ovarian torsion
Presentation of appendicitis?
Classic pattern (60%): periumbilical pain followed by migration of pain to the RLQ; diffuse abdominal pain is possible (as in the case of peritonitis due to rupture)
Note - tenderness over McBurney’s point is commonly seen in adults, but less frequently found in children
Common: anorexia, N/V, fever (non-specific finding)
Uncommon: diarrhea
Presentation of cholecystitis?
Steady, usually constant pain, most often in the RUQ, that may radiate to the shoulder
Murphy’s sign (specific for cholecystitis) - increased pain upon palpation of the area when the patient takes a deep breath
Pain worsens after eating, especially fatty foods
Episodes may be intermittent (colicky) and accompanied by decreased appetite, N/V
Less common in children than adults, but does occur
Presentation of pregnancy?
Delayed or missed periods
Non-specific complaints - lower abdominal pain, urinary frequency, fatigue, N/V
Must be considered even when sexual activity is denied
Chadwick’s sign (bluish color of vaginal wall and cervix), changes to the uterus
Ectopic pregnancy must be considered, especially with history of STI alone or with PID
Presentation of unruptured ectopic pregnancy?
Lower abdominal pain, vaginal bleeding, abnormal menstrual history
Physical exam may be completely normal, though classic signs include diffuse abdominal tenderness and unilateral adnexal or cervical motion tenderness
Fever and uterine changes are rare
Presentation of ruptured ectopic pregnancy?
Surgical emergency
Abominal guarding suggesting intraperitoneal bleeding, hypotension correlates with degree of blood loss
Presentation of hepatitis?
Fever, malaise, diffuse or RUQ abdominal pain, N/V, NO diarrhea
Jaundice, change in color of urine
Onset of symptoms depends on etiology
Alcohol use may directly cause hepatitis or predipose to increased risk-taking behaviors and acquisition of infectious hepatitis
Hepatitis A is transmitted fecal-oral, recent travel would make this a possibility
Hepatomegaly on exam
Presentation of pancreatitis?
Diffuse abdominal pain, but other patterns (epigastric or RUQ) are more common; band-like pain radiating to the back
Pain is constant and usually severe
N/V almost always present
Low-grade fevers are common
Causes include gallbladder disease, infection, alcohol use, injury, certain medications, and inherited conditions
Presentation of PID?
Abdominal pain, more typically in the lower abdomen; RUQ pain occur with Fitz-Hugh-Curtis syndrome, an occasional (5%) complication of PID caused by N. gonorrhea or C. trachomatis - this pain is sudden and may refer to the R shoulder
Fever, if severe
Vomiting (sometimes)
Cervical motion tenderness, uterine tenderness, and adnexel tenderness
Purulent cervical discharge
Presentation of UTI?
Dysuria, frequency, and urgency
Poorly localized abdominal pain
Fever or CVA tenderness suggests pyelonephritis
Previous history of UTIs may suggest underlying structural abnormalities
More common in sexually active women
Presentation of acute gastroenteritis?
Vomiting
Diarrhea typically becomes the most pronounced symptom after a few days
History of sick contacts
Presentation of mesenteric adenitis?
Acute or chronic abdominal pain
May mimic appendicitis
Dx - U/S
Viral (most common) or bacterial infection, IBD, and lymphoma
Presentation of ovarian torsion?
Most common in post-menarchal women, can happen in any age
Abdominal pain (stabbing) in the lower abdomen or pelvic region
N/V
Mot common condition requiring emergency surgery in the pediatric population?
Acute appendicitis (60,000-80,000 cases/year in the US)
What age group is appendicitis more common in?
School age children (vs. children <5 y/o)
What percent of children presenting with abdominal pain have acute appendicitis?
1-8%
True or false - up to 1/3 of pediatric patients have atypical presentations, leading to missed diagnoses and a high incidence of perforation
True
Diagnosis of appendicitis?
Difficult, requires an accurate history and thorough physical
CBC with differential or CRP
What is McBurney’s point? Sensitivity and specificity for appendicitis?
1.5-2” from the anterior superior spinous process of the ilium on a straight line drawn from that process to the umbilicus
Sensitivity - 50-94%
Specificity - 75-86%
Presentation of testicular torsion?
Usually occurs in early adolescence
Acute onset of severe hemi-scrotal pain, N/V, may cause referred adominal pain
Physical exam - enlarged tender testis, scrotal edema, absence of cremasteric muscle reflex
Management of testicular torsion?
Emergent urology consult
Dx mainly by clinical suspicion, color doppler or nuclear testicular scan may be useful but should not delay Rx if Dx is evidence
Surgical exploration and detorsion must occur promptly (irreversible changes can occur within 4 hours)
Indications for a pelvic examination in adolescents?
- Abdominal vaginal discharge
- Unexplained dysuria or urinary tract symptoms in a sexually active female
- Dysmenorrhea unresponsive to NSAIDs
- Amenorrhea
- Abnormal vaginal bleeding
- Lower abdominal pain
- Contraceptive counseling for an IUD or diaphragm
- Pap test (21+ years only)
- Suspected/reported rape or sexual abuse
- Pregnancy
- Suspected PID
Diagnostic criteria for PID?
CDC recommends empiric treatment for PID in sexually active females with pelvic/lower abdominal pain if no other cause is identified and at least one of the following minimum criteria is met: cervical motion tenderness, uterine tenderness, adnexal tenderness.
Supportive criteria (enhance specificity of minimum criteria): oral temperature >101 F, abnormal cervical mucopurulent discharge or cervical friability, presence of abundant WBCs on saline microscopy of vaginal fluid, elevated ESR or CRP, documentation of cervical infection with N. gonorrhea or C. trachoamtis
Who is at highest risk for PID and why?
Sexually active females 15-19 years:
Fewer protective antibodies in the vagina compared to older women
Cervical ectropion which represents the transitional zone between columnar and squamous epithelium is not fully matured. Cells in this zone are easily susceptible to STDs, and the cervix is therefore easier to infect
Behavioral factors including intercourse during menses, infrequent or no condom use, and multiple sexual partners
Microorganisms involved in PID?
C. trachomatis and N. gonorrheae have been implicated in 1/3-1/2 of cases. However, it is often polymicrobial and may include GP and GN anaerobes and aerobic facultative bacteria found in women with BV
Lower-tract infection with these pathogens leads to an alteration of the normal vaginal flora and allows bacteria such as E. coli, Bacteroides species, other anaerobes, Mycoplasma hominis, or Ureaplasma urealyticum access to the uterus and fallopian tubes
Complications of PID?
Short-term: sepsis, perihepatitis, periappendicitis, tubo-ovarian abscess, other intra-abdominal abscess
Long-term: ectopic pregnancy, infertility, chronic abdominal pain, increased risk of recurrent PID
Rx for PID?
Ceftriaxone (gonorrhea) + Doxycycline or Azithromycin (chlamydia) + consider metronidazole (anaerobe)
Never use a single agent
When should a patient with PID be hospitalized?
Pregnancy
Previous noncompliance
High fever
Intractable vomiting
Inability to exclude a surgical emergency
Inadequate response on oral therapy within 72 hours
Tubo-ovarian abscess
Most common cause of abdominal pain in school-age children?
Functional abdominal pain
What is functional abdominal pain?
Pain without demonstrable evidence of a pathologic condition such as an anatomic, metabolic, infectious, inflammatory, or neoplastic disorder
Diagnosis of functional abdominal pain without additional diagnostic evaluation?
Children 4-18 years with chronic abdominal pain when there are no alarming symptoms or signs, the physical exam is normal, and stool sample tests are negative for occult blood.
Treatment of functional abdominal pain?
Reassurance that no serious illness is present, follow closely, refer for psychological evaluation and treatment if appropriate
List some of the red flag symptoms/signs of abdominal pain requiring further evaluation.
- Involuntary weight loss
- Deceleration of linear growth
- GI blood loss
- Significant vomiting
- Chronic severe diarrhea
- Persistent RUQ or RLQ pain
- Unexplained fever
- Family hx of IBD
- Abnormal or unexplained physical findings
Rectal exam in pediatric patients can aid in the diagnosis of what illnesses?
GI bleeding
Intussusception
Rectal abscess
Impaction
DDx - Abdominal Pain and Bloody Stools (school-aged)
- IBD
- Celiac disease
- Bacterial gastroenteritis
- Giardiasis
- Peptic Ulcer Disease
- HSP
Presentation of IBD?
Severe and acute or mild and subacute abdominal pain
Bloody stools
Presentation of celiac disease?
6-24 months of age Chronic abdominal pain Abdominal distention Diarrhea (common) Anorexia Vomiting Poor weight gain Can present with occult blood loss leading to anemia (gross blood would be unusual)
Variable presentation
Bacterial GI infections (give examples) frequently cause bloody diarrhea and are relatively common. ___ is another bacterial cause of colonic infection following exposure to antibiotics.
Salmonella, Shigella, Yersinia, Campylobacter
C. difficile
What is the most common intestinal parasite in the US?
Giadia lamblia
Presentation of Giardiasis?
Acute or chronic abdominal pain with few other symptoms
Travel history
Most do not have weight loss, though some may
Less likely than other parasites or bacterial organisms to cause grossly bloody stool
Presentation of PUD?
Relatively uncommon in children
Recurrent abdominal pain
Occult blood - frankly bloody stools are not consistent with this diagnosis
Lab Evaluation of Abdominal Pain and Bloody Stools
- CBC with differential (anemia, elevated platelet count (acute phase reactant))
- ESR (acute phase reactant - would support IBD)
- LFTs (low protein and albumin - malnutrition, hepatic disease with poor synthetic function, or losses from a protein-losing enteropathy)
- IgA tissue transglutaminase antibodies (TTG) - sensitive and specific for celiac (small bowel biopsy showing villous atrophy is the gold standard, IgA antiendomysial antibodies are useful, antigliadin antibodies are less reliable)
- Stool ova and parasites (can also do Giardia-specific antigen tests)
- Stool culture/C. diff toxin if suspected
Red flags for possible Crohn’s disease in a child with abdominal pain?
Pain that awakens the child at night
Pain that can be localized
Involuntary weight loss or growth deceleration
Extraintestinal symptoms (fever, rash, joint pain, aphthous ulcers, dysuria)
Sleepiness after attacks of pain
Positive family history of IBD (only positive in ~30% of patients)
Abnormal labs such as guaiac-positive stool, anemia, high platelet count, high ESR, hypoalbuminemia
Abnormalities in bowel function (e.g., diarrhea, constipation, incontinence)
Vomiting
Dysuria
Pathology of ulcerative colitis?
Generalized inflammation confined to the mucosa, starting the rectum and involving a variable extent of colon proximally
Crypt abscess common
Rarely, patients may have discontinuous inflammation at diagnosis or event relative rectal sparing - becomes more confluent over the course of the illness
Pathology of Crohn’s?
Inflammation in any portion of the alimentary tract, from mouth to anus
Mucosal inflammation may become more generalized or remain patchy and may extend into the submuocsa, muscularis, and serosa
Transmural inflammation can result in fistual formation
Definitive diagnosis of CD or UC?
Upper endoscopy and colonoscopy +/- small bowel series, MRI, or video capsule endoscopy
Small bowel imaging -> CT enterograph and MR enterography (replaced fluoroscopic small bowel follow-through as modality of choice)
-UC limited to colon, but can show evidence of ileal inflammation (backwash ileitis)
True or false - the phenotype of pediatric vs. adult IBD differs.
True
What elements of the clinical history can help determine disease severity in CD?
# of diarrheal stools/day Daily abdominal pain ratings Ratings of well-being Presence of other related symptoms/findings Abdominal fullness/palpable mass Hematocrit Height growth velocity Weight
The onset of IBD typically occurs in which decades?
Second and third (25-30% develop symptoms before age 20, 5% before age 10)
Goals in treatment of pediatric IBD?
Eliminate symptoms and improve quality of life
Restore normal growth
Eliminate complications
Treatment of CD?
Induction therapy (remission of disease) - often corticosteroids +/- enteral nutrition therapy Maintenance therapy - immunomodulators (thiopurines, MTX), anti-TNF (moderate to severe CD)
