Child with Acute Tummy Pain

Question 1

What are the differential considerations for abdominal pain in children (10-14yo?

Answer 1

• Part of a generalised illness
  
  • Mesenteric adenitis,
  • HSP,
  • HUS,
  • DKA,
  • TLA
• Emanating from and localised to the abdomen
  
  • Appendicitis,
  • Ovarian,
  • Small bowel,
  • Meckel’s, Intuss
• Referred from elsewhere
  
  • Testicular,
  • pyelonephritis,
  • pneumonia,
  • arthritis,
  • discitis

Question 2

What is the pathophysiology of appendicitis?

Answer 2

• Luminal obstruction
  
  • lymphoid hyperplasia (viral illness, bacterial enterocolitis)
  • foreign body ( faecolith, worms, tumour)
• most common age is 14yo (where lymphoid hyperplasia is most common too
• presentation can be related to where the inflamed appendix is touching (surrounding structures)

Question 3

Key aspects to consider for appendicitis evaluation?

Answer 3

• Course of disease
  
  • Cyclical pain
  • ?Rectal bleeding - uncommon in appendicitis but common in other
• Careful history
  
  • Travel
  • Other family
  • Past Hx (eg operations, gastro-type symptoms, rectal bleeding)
• Observation
• Physical examination

Question 4

Important aspects of history?

Answer 4

• Age, sex
• Location
• Timing
• Intensity
• History
• Course
  
  • When were you last perfectly well
  • Have you ever had a pain like this before
  • Waxing and waning
• Associated symptoms - feeding, sleeping, nausea, vomiting, urine, stools

Question 5

Important aspects on examination?

Answer 5

• Observation
  
  • Walking / posture / guarding
  • Jumps on spot / climbs onto bed - if cannot ?peritonism
  • Respiratory rate / effort
  • Tongue / breath
• Tachycardia/fever
• Testis
• Abdominal tenderness
  
  • Deep, muscle tensed
  • Guarding (involuntary)
  • Rovsing’s sign
  • Hip movements
• Distractability – Stethoscope !!

Question 6

Important investigations to consider?

Answer 6

• WCC
• Urine MSU

Consider the below:

• Abdominal X-ray (rare; only if suspecting bowel obstruction)
• Ultrasound
• CT scan
• Laparoscopy (treatment)

Question 7

What makes evaluation of appendicitis in <5yo more difficult?

Answer 7

• Difficult history
• Short history (>50% perf, i.e. fast to perforate)
• PUO (pyrexia of unknown origin)
• Difficult examination
• Advanced signs -> IVF and abx (aim to stabilise prior to operation)
• Vigorous resuscitation
• High morbidity / mortality

Question 8

What makes evaluation of appendicitis in post menarche girls more difficult?

Answer 8

• Careful history
• Menstrual cycle
• Sexual history when older
• Past History
• History and location of pain
  
  • If starts in RIF, rather than umbilicus, may be ovarian origin
• Consider USS to exclude ovarian cause (USS not great for appendicitis)
• LAPAROSCOPY

Question 9

What to do while observing a patient without concerning signs?

Answer 9

• Safe
• Observation at home
• Hx and repeated examination by an experienced clinician 93% accurate

Question 10

Parental counselling: what factors warrant an earlier return for re-evaluation?

Answer 10

• fever
• vomiting
• increasing abdominal pain

Question 11

What antibiotics would you consider empirically?

Answer 11

• Tazocin
• Cefotaxime + metronidazole