Chronic Abdo Pain + Masses Flashcards
GI Causes of Chronic Abdo Pain
most common
- constipation
- IBS
- lactose intolerance
Other
- esophagitis/gastritis
- celiac
- PUD
- IBD
- parasite
- recurrent pancreatitis
- hiatus hernia
- choledochal cyst
- malrotation
gynecologic/uro causes of chronic abdo pain
dysmenorrhea mittelschmerz ovarian cyst endometriosis renal colic, uretopelvic junction obstruction
neurologic causes of chronic abdo pain
abdominal migraine
migraine
endocrine causes of chronic abdo pain
addisons disease
hyperparathyroidism
cardiovasc causes of chronic abdo pain
SMA syndrome
arrythmias
hematologic causes of chronic abdo pain
sickle cell disease
leukemia/lymphoma
prophyria
abdominal neoplasm (Wilm’s, neuroblastoma)
Other causes of Chronic abdo pain
Recurrent abdo pain of childhood
aerophagia
discitis
Encopresis definition
overflow incontinence of stool
Constipation Complications
encopresis, appetite suppression, recurrent UTI / incomplete voiding, self-esteem, missed school
Constipation etiology / ddx
functional (99%)
- behaviour, diet, poor fluids
- trigger: start cows milk, toilet training, school
organic
- hypothyroidism, DM, hypercalcemia
- hirschprung’s disease, spinal cord trauma
- diabetes insipidus
- CF
- celiac disease
- bowel obstruction
- anal atresia, stenosis, displacement
- chemotherapy, opioids
Hirschprung’s Disease Signs
Delayed mec >48h FTT small stool bilious vomiting tight sphincter
Spinal cord abnormality signs
decreased lower reflexes
hypotonia
no anal wink
hypothyroidism signs
fatigue
FTT
cold intolerance
bradycardia
cystic fibrosis signs
diarrhea
FTT
fever
recurrent pneumonia
celiac signs
diarrhea or constipation after wheat
rash
Rome Criteria for Functional Constipation
4 years old, not meeting IBS criteria, with 2+:
- <2 BM in toilet per week
- 1+ fecal incontinence per week
- retentive volition/ posturing
- painful or hard BM
- large fecal mass in abdomen
- large diameter stool
Constipation Treatment
- education/behaviour: sit on toilet 10min 2x/d, praise, diary (may delay training until soft)
- diet changes to increase fibre (no supplement), can try cow milk free if unresponsive
- meds: PEG - larger dose to disimpact, them maintenance for months - years
Functional Abdominal Pain Definition
3+ attacks of severe pain, 3+ years old, for at least 3 mo, without cause
lower abdo pain may be associated with altered bowel habits
Functional abdo pain presentation
- paroxysmal, varies in intensity, gradual onset
- periumbilical
- peptic sx (bloating, etc)
- +/- headaches, dizziness, fatigue
- interferes with activities
- difficulty falling asleep but doesn’t wake from sleep
- other somatic sx (limb pain)
- psychologic stress at first episode
- famHx: IBS, migraine, dyspepsia
Red Flags for Abdo Pain (non-functional)
- weight loss or growth decel
- fever
- joint pain / swelling
- oral lesions, rash
- rectal bleeding
- pain away from umbilicus
- rebound tenderness
- radiation to back, shoulders, legs
- wakes from sleep regularly
- severe N/V/D or encopresis
Work-up for functional abdominal pain
usually none needed
could consider from hx:
- UA / culture, CBC, stool culture or occult blood
- no routine AXRs
- if <4 years or hx/px point to organic causes, do more tests
treatment of functional abdominal pain
affirm pain address psychosocial family therapy or CBT? good f/u no elimination diets, but could avoid food triggers probiotics ?
Abdominal Masses DDx
flank: MCD kidney, PCKD, hydronephrosis, renal vein thrombosis, neuroblastoma, wilm’s tumor, adrenal hemorrahage
RUQ: liver mass, choledochal cyst, intussusception
periumbilical: GI duplication, mesenteric cyst, omental cyst, urachal cust, meconium pseudocyst, pancreatic pseudocyst
low mid: hydrometrocolpos, ovarian cyst/tumor, sacroccygeal teratoma
RLQ mass: appendix abscess, lymphoma, ectopic kidney, ovarian or testicular mass
LLQ: ovary/test mass, fecal impaction
Initial W/U for abdominal mass
- CBC
- catecholamine metabolites (VMA, HVA), urine or serum (neuroblastoma /w adrenal involvement)
- skeletal survey - bone mets
- abdo US
- AXR if think bowel obstruction
- abdo CT after US, can show calcifications + detail (don’t do if cyst)
Neuroblastoma description
Neural crest cell tumor: adrenal medulla, abdominal paraspinal, thoracic, cervical, pelvic ganglia
Neuroblastoma presentation
+ workup
median age 19mo, sometimes fam hx
abdo: mass, fever, weight loss
thoracic: resp distress
cervical/upper chest: horners
nerve root/spinal compression
paraneoplastic: HTN, secretory diarrhea, opsoclonus-myoclonus
tests:
Catecholamines + urinary mets if adrenal
US or MRI, then staging
Neuroblastoma Treatment + Prognosis
Surgery +/- radiation, chemo, biologics, immunotherapy
prognosis extremely variable: depends on stage, ploidy, MYCN gene, age, etc
Wilm’s Tumor Description
Nephroblastoma - primary renal neoplasm
Wilm’s Tumor Presentation
Ages 2-5
80% = asymptomatic unilateral abdo mass
HTN gross hematuria abdo pain vomiting dyspnea - pulmonary mets
risk factors for Wilm’s Tumor
African American Fam Hx WAGR (wilms, aniridia, geniturinary tract anomaly, mental retardation) denys-drash syndrome beckwidth-wiedemann
workup for ? wilm’s tumor
US, +/- CT
look for mets:
- CXR
- bone scan
- chest CT
Wilm’s Tumor Treatment
- surgery
- +/- chemo, rads, neoadjuvent chemo
precursor = nephrogenic rests, monitor contralat kidney
90% long term survival
