Gastroenterology: Abdominal migraine Flashcards
Describe what is meant by abdominal migraine [1] and the clinical features [5]
Abdominal migraine presents with episodes of central abdominal pain lasting more than 1 hour. Examination will be normal.
Features:
* Nausea and vomiting
* Anorexia
* Pallor
* Headache
* Photophobia
* Aura
Describe how you treat abdominal migraine
- treating the attack [4]
- preventative medications [4]
Management of abdominal migraine is similar to migraine in adults. Careful explanation and education is important. It involves treating acute attacks and preventative measures. Preventative medications are initiated by a specialist.
Treating the acute attack:
* Low stimulus environment (quiet, dark room)
* Paracetamol
* Ibuprofen
* Sumatriptan
Preventative medications:
* Pizotifen, a serotonin antagonist
* Propranolol, a non-selective beta blocker
* Cyproheptadine, an antihistamine
* Flunarazine, a calcium channel blocker
TOMTIP:
Pizotifen is the main preventative medication to remember for abdominal migraine. It needs to be withdrawn slowly when stopping as it is associated with withdrawal symptoms such as depression, anxiety, poor sleep and tremor.
TOMTIP:
[] is the main preventative medication to remember for abdominal migraine.
How do you instruct how to manage this medication? [1]
Pizotifen is the main preventative medication to remember for abdominal migraine. It needs to be withdrawn slowly when stopping as it is associated with withdrawal symptoms such as depression, anxiety, poor sleep and tremor.
Describe what is meant by mesenteric adenitis [1] and how it can present [1]
Mesenteric adenitis is inflamed lymph nodes within the mesentery.
It can cause similar symptoms to appendicitis and can be difficult to distinguish between the two. It often follows a recent viral infection and needs no treatment
NB: Keep in mind could still be appendicitis
How do you differentiate between mesenteric addenitis and appendicitis? [6]
- no anorexia or vomiting like appendicitis
- Higher fever
- More normal CRP and WBC
- Self limiting in 24-48 hours
- Pain starts in RIF
- Coryzal symptoms due to viral infection before hand
A child presents with abdominal pain.
What are the medical differentials? [+]
Mesenteric adenitis
Constipation
Gastroenteritis
Pneumonia
Pyelonephritis
Henoch Shonlein Purpura
Inflammatory bowel disease
A child presents with abdominal pain.
What are the surgical differentials? [+]
Acute appendicitis
Intussusception
Obstruction secondary to congenital lesion eg Meckel’s band
Torsion testes or ovary
Ovarian cysts
Renal stones
(Pregnancy related)
A child presents with abdominal pain.
What are the rarer differentials? [4]
Diabetes
Sickle cell crisis
Pancreatitis
Primary peritonitis
In a clinical examination of appendicitis, what is important to assess? [1]
Full Assessment - including ENT. Look at throat
A newborn presents at birth with mild respiratory distress and increased oral secretions. An attempt to pass a suction catheter meets with resistance. An attempt to pass a replogle tube also meets with resistance.
What is the most likely dx? [1]
Oesophageal atresia (OA)
Describe what is meant by an oesophageal atresia (OA) [1]
Which is the most common type? [1]
Oesophageal atresia (OA) and tracheo-oesophageal fistula (TOF) are congenital malformations that result from the defective separation of the common embryologic precursos to both the oesophagus and trachea.
The most common type is a blind-ending upper oesophageal pouch with a fistulous connection between the distal oesophageal segment and the trachea.
How would OA likely to present? [4]
presence of risk factors - including trisomy 21
maternal history of polyhydramniosis
inability to swallow secretions
inability to pass a nasogastric tube
What is the treatment plan for OA? [3]
NG tube placement
Abx
Referal to surgery
Dx of OA? [3]
BMJ BP
One - US: A part of routine antenatal screening or in cases of suspected chromosomal anomaly or familial syndrome. If evidence of polyhydramnios, fetal MRI is also recommended.
- Result: polyhydramnios and a small or no stomach bubble
Two - Fetal MRI can assist in confirming the diagnosis and determining other congenital anomalies.
- oesophageal pouch and small stomach
Three - CXR & AXR
- Evidence of respiratory distress or poor handling of secretions, or an inability to pass a nasogastric tube warrants an x-ray. An x-ray of the chest and abdomen with a nasogastrc tube in place should also be obtained immediately after birth in patients who are suspected to have an oesphageal atresia/tracheo-oesophageal fistula on antenatal ultrasound
What is midgut malrotation? [1]
When does it present? [1]
Congenital problem in which the midgut remains unfixed and suspended on a narrow based mesentery due to abnormal rotation in utero
Presents in first 6 months of life
How does midgut malrotation present? [3]
Malrotation: Presentation:
* Acute strangulating obstruction: Shocked, bilious vomiting, tender, dark blood PR
* Recurrent episodes of subacute obstruction: bile-stained vomiting, forewarning of volvulus
* Intermittent vomiting, occasionally bile stained, intermittent abdominal pain and malabsorption
How is midgut dx [1] and malrotation mx ? [2]
1st line: upper gastrointestinal contrast series
- Diagnostic standard test for malrotation
- DJ flexion to the right
- right-sided duodenum (malrotation); duodenum courses inferior or medial to normal (malrotation); bird-beak cut-off of duodenum (volvulus); corkscrew of duodenum (volvulus); a web in the duodenum (duodenal atresia)
Management:
* urgent / emergency surgery (if ischaemic or not): open laparotomy and Ladd’s procedure
* Nasogastric tube, antibiotic coverage for gram-negative organisms (e.g., cefoxitin), and aggressive intravenous fluid resuscitation should be performed en route to the theatre
Why can pyloric stenosis be difficult to treat with regards to anaesthesia? [1]
Gas needs to be corrected.
Often alkalotic - if not corrected and given anaesthestic the respiratory system can fail to make you breath
Why does intussusception peak in winter / early spring? [1]
Viral illness classically precedes it
Dx? [1]
Target sign - bowel within bowel
= intussusception
