GI Flashcards
What are the 9 quadrants of the abdomen?
Right hypochondriac, epigastric, Left hypochondriac, right flank, umbilical, left flank, right iliac fossa, hypogastric, left iliac fossa
What can the causes of abdominal pain in children be split up into?
Non-organic, medical and surgical causes
What is the most common cause of abdominal pain in children over 5?
Non-organic/ functional
What are the differential diagnoses of organic abdominal pain?
Constipation UTI Coeliac IBD IBS Mesenteric adenitis Abdominal migraine Pyelonephritis HSP Tonsilitis DKA Infantile colic
What additional causes of abdominal pain are there in girls?
Dysmenorrhea Mittelschmerz (ovulation pain) Ectopic pregnancy PID Ovarian torsion Pregnancy
What are the surgical causes of abdominal pain?
Appendicitis
Intussusception
Bowel obstruction
Testicular torsion
What are the red flags for abdominal pain?
Persistent/ bilious vomiting Severe chronic diarrhoea Fever Rectal bleeding Weight loss/ faltered growth Dysphagia Night pain Abdominal tenderness
What investigations should be done to rule out what pathologies?
FBC for anaemia (IBD or coealiac) Inflammatory markers (IBD) Anti-TTG/ Anti-EMA (coeliac) Faecal calprotectin (IBD) Urine dipstick (UTI)
When is a diagnosis of recurrent abdominal pain made?
When a child presents with repeated episodes of abdominal pain without an identifiable cause. (Non-organic/ functional pain)
What does recurrent abdominal pain usually correspond to?
Stressful life events
What is the leading theory for the cause of recurrent abdominal pain?
Increased sensitivity and inappropriate pain signals from visceral nerves in response to normal stimuli
What measures can be used to manage recurrent abdominal pain?
Distraction
Encourage parents not to ask about it
Sleep/ eating/ hydration/ reducing stress advice
Probiotic supplements
Avoid NSAIDS
Address pshycosocial triggers/ exacerbating factors
What is an abdominal migraine?
Episode of central abdominal pain lasting more than 1 hour
What symptoms may also occur with an abdominal migraine?
N&V Anorexia Pallor Headache Photophobia Aura
How can you treat an acute attack of abdominal migraine?
Low stimulus environment
Paracetamol
Ibuprofen
Sumatriptan
What medications can be used to prevent abdominal migraines?
Pizotifen
Propanolol
Cyproheptadine
Flunarazine
What is the main medication used to prevent abdominal migraine and what information should patients be given about it?
Pizotifen
Needs to be withdrawn slowly when stopping as it is associated with withdrawal symptoms (depression, anxiety, poor sleep, tremor)
What is the most common cause of constipation in children?
Idiopathic/ functional
What are some secondary causes of constipation in children?
Hirschsprung's disease Cystic fibrosis Hypothyroidism Spinal cord lesion Sexual abuse Intestinal obstruction Anal stenosis Cows milk intolerance
What are the typical features of a constipation history/ examination?
< 3 stools per week Hard/ difficult to pass stools Rabbit dropping stools Straining/ painful passage Abdominal pain Retentive posturing Rectal bleeding Overflow soiling caused by faecal impaction Palpable abdomen Loss of sensation of neeed to open bowels
What is encopresis?
Term for faecal incontinence
At what age does encopresis become pathological?
Older than 4
What is the most common cause of encopresis?
Chronic constipation causing the rectum to become stretched and lose sensation. Large hard stools remain, and only loose stools are able to bypass the blockage and leak out
What are other causes of encopresis?
Spina bifida Hirshchprung's disease Cerebral palsy Learning disability Psychosocial stress Abuse
What lifestyle factors can contribute to the development/ continuation of constipation?
Bad toilet habits Low fibre diet Poor fluid intake Sedentary lifestyle Psychosocial problems
What is faecal impaction?
Where a large, hard stool blocks the rectum
What is desensitisation of the rectum and when does it occur?
When patients develop the habit of not opening their bowels and ignore the sensation of a full rectum, leading to retained faeces and faecal impaction. THis causes the rectum to stretch and dill with more faeces, leading to further desensitisation.
What red flags should you look our for with a constipation presentation?
No meconium within 48 hours of birth Neurological signs Vomiting Ribbon stool Abnormal anus Abnormal lower back/ buttocks Failure to thrive Acute severe abdominal pain/ bloating
What are the complications of constipation?
Pain Reduced sensation Anal fissures Haemorrhoids Overflow/ soiling Psychosocial morbidity
How is idiopathic constipation managed?
High fibre diet
Good hydration
Start laxatives ( may need disimpactation regimen)
Encourage good toilet habits
What laxative is usually used in children with constpation?
Movicol
What is GORD?
Where contents of the stomach reflux through the lower oesophageal sphincter into the oesophagus, throat and mouth
Why is GORD common in babies?
Due to immaturity of the lower oesophageal sphincter
By what age do 90% of infants stop having reflux?
1
What are signs of problematic reflux?
Chronic cough Hoarse cry Distress/ crying Reluctance to feed Pnaeumonia Poor weight gain
What symptoms of GORD may children over 1 have?
Similar to adults: Heartburn Acid regurgitation Retrosternal/ epigastric pain Bloating Nocturnal cough
What are the causes of vomiting in infants?
Overfeeding GORD Pyloric stenosis Gastritis/ gastroenteritis Appendicitis Infections Intestinal obstruction Bulimia
What are the red flags of vomiting?
Not keeping food down Projectile/ forceful vomiting Bile stained vomiting Haematemesis/ melaena Abdominal distention Reduced consciousness/ bulging fontanelle/ neurological signs Resp symptoms Blood in stools Signs of infection Rash, angiodema/ other signs of allergy Apnoeas
What are the key differential diagnoses with projectile or forceful vomitin?
Pyloric stenosis or intestinal obstrution
What are the key differential diagnoses with not being able to keep any feed down?
Pyloric stenosis or intestinal obstruction
What is the key differential diagnosis with bile stained vomit?
Intestinal obstruction
What are the key differential diagnoses with haematemesis/ melaena?
Peptic ulcer
Oesophagitis
Varices
What is the management advice for mild cases of GORD?
Small frequent meals
Burping regularly
Don’t overfeed
Keep baby upright after feeding
What is the management advice for more problematic cases of GORD?
Gaviscon
Thickened milk or formula
Ranitidine
Omeprazole
What may need to be done in severe cases of GORD?
Further investigation with barium meal and endoscopy
Surgical fundoplication in very severe cases
What is Sandifer’s syndrome?
Rare condition causing brief episodes of abnormal movements associated with GORD in infants
What are the key features of Sandifer’s syndrome?
Torticollis (forceful contraction of neck muscles)
Dystonia (abnormal muscle contractions causing twisting movements, arching of the back or unusual postures
How does Sandifer’s syndrome resolve?
As the reflux is treated/ improves
What is the pyloric sphincter?
The ring of smooth muscle that forms the canal between the stomach and duodenum
What is pyloric stenosis?
Hypertrophy and therefore narrowing of the pylorus
What is the key feature that indicates pyloric stenosis?
Projectile vomiting
Why does pyloric stenosis cause projectile vomiting?
Pyloric stenosis causes increasingly powerful peristalsis in the stomach to try to push food into the duodenum. Eventually it becomes so powerful that it ejects food into the oesophagus, out of the mouth and accross the room
What age range is affected by pyloric stenosis?
Neonate (birth- 6 months)
When does pyloric stenosis usually present?
In the first few weeks of life
How does a baby with pyloric stenosis usually present?
Projectile vomiting
Thin
Failing to thrive
Hungry
What might examination of pyloric stenosis show?
Visible peristalsis
What may you feel on examination of pyloric stenosis?
Firm round mass in upper abdomen- feels like large olive
Why can you feel a large mass in the upper abdomen in pyloric stenosis?
Hypertrophy of the pylorus muscle
What will blood gas analysis show in pyloric stenosis?
Hypochloric metabolic alkalosis
low chloride
Why do you get hypochloric metabolic alkalosis in pyloric stenosis?
The baby is vomiting hydrochloric acid from the stomach
How is pyloric stenosis diagnosed?
History/ examination
Blood gas analysis
Abdominal USS
What does USS show in pyloric stenosis?
Thickened pylorus
How is pyloric stenosis managed?
Laparoscopic pyloromyotomy (Ramstedt’s operation)
What is a Laparoscopic pyloromyotomy?
Incision made into smooth muscle of pylorus to widen canal
What causes pyloric stenosis?
Unknown?
Sex, race, prematurity, family history ect risk factors
What is acute gastritis?
Inflammation of the stomach
How does acute gastritis present?
Nausea and vomiting
What is enteritis?
Inflammation of the intestines
How does enteritis present?
Diarrhoea
What is gastroenteritis?
Inflammation in the stomach and intestines
How does gastroenteritis present?
Nausea
Vomiting
Diarrhoea
What is the most common cause of gastroenteritis?
Viral
What is the main complication of gastroenteritis?
Dehydration
What are the key differential diagnoses of diarrhoea?
Gastroenteritis IBD Lactose intolerance Coeliac disease Cystic fibrosis Toddler's diarrhoea IBS Medications (Abx)
What are the most common causes of viral gastroenteritis?
Rotavirus
Norovirus
What are the most common causes of bacterial gastroenteritis?
E.coli Campylobacter jejuni Shigella Salmonella Bacillus Cereus Yersinia Enterocolitica Staph aureus
Where is E.coli found under normal circumstances?
Normal intestinal bacteria
What strains of E.coli cause gastroenteritis?
E.coli 0157
How is E.coli infection spread?
Contact with infected faeces, unwashed salads or contaminated water
How does E.coli cause symptoms of gastroenteritis?
Produces the shiga toxin which causes abdominal cramps, bloody diarrhoea and vomiting.
What is the additional complication of infection by the Shiga toxin produced by E.coli?
Destroys blood cells and leads to haemolytic uraemic syndrome (HUS)
Why should antibiotics be avoided in E.coli infection?
Increases risk of haemolytic uraemic syndrome
What is the most common cause of travellers diarrhoea?
Campylobacter jejuni
How is campylobacter spread?
Raw/ uncooked poultry
Untreated water
Unpasteurised milk
What are the symptoms of infection with campylobacter?
Abdo cramps
Diarrhoea (without blood)
Vomiting
Fever
How long does campylobacter take to resolve?
Incubation 2-5 days
Symptoms resolve after 3-6 days
When would antibiotics be considered with campylobacter infection?
After isolating the organism
If there are severe symptoms
If there are other risk factors (HIV, heart failure)
What antibiotics would be considered with campylobacter jejuni?
Azithromycin
Ciprofloxacin
How is Shigella spread?
By food, water or pools containing contaminated faeces
What is the incubation period for Shigella and how long does it take to resolve?
1-2 days
Resolves within 1 week
How is salmonella spread?
By eating raw eggs, poulty or food infected with animal faeces
What is the incubation period for salmonella and how long does it take to resolve?
incubation= 12 hours- 3 days
Resolves within 1 week
What are the symptoms of salmonella?
Watery diarrhoea associated with mucus or blood, abominal pain and vomiting
What type of bacteria is bacillus cereus?
Gram positive rod
How is bacillus cereus spread?
Through inadequately cooked food (e.g fried rice left out)
How does bacillus cereus cause symptoms?
It produces the cereulide toxin which causes abdominal cramping and vomiting within 5 hours of ingestion, then produces different toxins in the intestines that cause watery diarrhoea/
What is the usual time course for bacillus cereus infection?
Vomiting within 5 hours, diarrhoea after 8 hours, resolution within 24 hours
What kind of bacteria is Yersinia Enterocolitica?
Gram negative bacillus
How is Yersinia spread?
Pigs= carriers so eating raw/ undercooked pork.
Contimation with urine or faeces of other mammals
Who is most affected by Yersinia infection?
Children
What are the symptoms of Yersinia?
Watery/ bloody diarrhoea
Abdominal pain
Fever
Lymphadenopathy
What is the time course or Yersinia infection?
4-7 day incubation period
Symptoms can last >3 weeks
How may older children with Yersinia infection present and what may this be confused with?
Mesenteric lymphadenitis, causing right sided abdominal pain and giving the impression of appendicitis
What does staph aureus produce and how does this cause gastroenteritis?
Enterotoxins, which can cause small intestine inflammation
What is Giardia lamblia?
Microscopic parasite
Where does giardia live?
In small intestines of mammals
How is giardiasis transmitted?
Faecal- oral transmission (mammals release cysts in stools which then contaminate food and water)
How is giardiasis diagnosed and treated?
Diagnosed by stool microscopy
Treated with metronidazole
What are the principles of gastroenteritis management?
Infection control (Isolation and barrier nursing)
Stay of school for 48 hours
Manage dehydration
How is gastroenteritis investigated?
Can do stool sample for microscopy, culture and sensitivities
How is dehydration managed in gastroenteritis?
Establish if they can keep fluids down or need admission for IV fluids (fluid challenge)
What is a fluid challenge?
Recording a small volume of fluid given orally every 5-10 minutes to see if it is tolerated. If so, can be managed at home
How is gastroenteritis managed?
Fluid challenge
Dioralyte
IV fluids if required
Slowly introduce food once tolerated
Should you use antidiarrhoeal medication with gastroenteritis?
No- especially with e.coli or shigella infection
What are the possible post-gastroenteritis complications?
Lactose intolerance
IBS
Reactive arthritis
Guillain-Barre syndrome
What is Toddler’s diarrhoea?
Chronic nonspecific diarrhoea
What kind of condition is coeliac?
Autoimmune
What is the pathophysiology of coeliac?
Autoantibodies are created in response to gluten exposure, which target the epithelial cells of the intestine and lead to inflammation. Inflammation causes atrophy of the intestinal villi, which leads to decreased nutrient absorption
What are the two antibodies created in coeliac disease?
Anti-tissue transglutaminase (anti-TTG)
Anti-Endomysial (enti-EMA)
Which part of the GI tract is most affected by the inflammation caused by coeliac?
Jejunum
How does coeliac disease present in children?
Often asymptomatic Failure to thrive Diarrhoea Fatigue Weight loss Mouth ulcers Anaemia Dermatitis herpetiformis Neurological symptoms
What is dermatitis herpetiformis?
Itchy blistering skin rash on the abdomen
What genes are associated with coeliac disease?
HLA-DQ2 (90%)
HLA-DQ8
How is coeliac disease investigated?
Blood tests for IgA levels and antibodies
Endoscopy and intestinal biopsy
Why must immunoglobulin A levels be checked when testing for coeliac disease?
Anti-TTG and anti-EMA are both IgA, so in IgA deficiency, these may be low despite the presence of coeliac disease
How can you test for coeliac if the patient has IgA deficiency?
Test for the IgG version of the anti-TTG or anti-EMA antibody
Endoscopy
What will endoscopy and biopsy show in coeliac?
Crypt hypertophy
Villous atrophy
What key conditions if coeliac disease associated with?
T1 diabetes Thyroid disease Autoimmune hepatitis Primary biliary cirrhosis Primary sclerosing cholangitis Down's syndrome
What are the complications of untreated coeliac disease?
Vitamin deficiency Anaemia Osteoporosis Ulcerative jejunitis EATL of the intestine Non-Hodgkin lymphoma Small bowel adenocarcinoma
What is the treatment of coeliac disease?
Lifelong gluten free diet
What are the two forms of inflammatory bowel disease?
Crohn’s disease
Ulcerative colitis
What are the key features of Crohns that differentiate it from UC?
(NESTS) No blood or mucus Entire GI tract affected Skip lesions on endoscopy Terminal ileum most affected Transmural inflammation Smoking is risk factir
What are the key features of UC that differentiate it from Crohn’s?
(CLOSEUP) Continuous inflammation Limited to colon and rectum Only superficial mucosa affected Smoking= protective Excrete blood and mucus Use aminosalicylates Primary sclerosing cholangitis associated
How does IBD present?
Perfuse diarrhoea Abdominal pain Bleeding Weight loss Anaemia Systemically unwell during flares (fevers, malaise, dehydration)
What are some extra-intestinal manifestations of IBD?
Finger clubbing Erythema nodosum Pyoderma gangrenosum Episcleritis & Iritis Inflammatory arthritis Primary sclerosing cholangitis
How is IBD diagnosed?
Blood tests
Faecal calprotectin
Endoscopy
Imaging
What blood tests are done to investigate IBD?
Anaemia Infection TFT's LFT's U&E's Inflammatory markers
What is faecal calprotectin and when its raised what does it indicate?
Marker for inflammation in the GI tract
What is the gold standard test for diagnosis of IBD?
Endoscopy
When might imaging be done in IBD?
To look for complications such as fistulas, abscesses and strictures
Who should managed the care of a child with an IBD?
MDT: Paediatrician Specialist nurses Pharmacists Dieticians Surgeons if necessary
What should be monitored in children with IBD?
Growth and pubertal development
What are the IBD treatment aims?
Inducing remission during flares and maintaining remission
How is Crohn’s treated to induce remission during a flare?
Steroids (oral prednisolone or IV hydrocortisone)
May need further immunosuppressant medication
What are the first line medications used to maintain remission in Crohns?
Azathioprine
Mercaptopurine
What are alternative options for maintaining remission in Crohns?
Methotrexate
Infliximab
Adalimumab
How else may Crohn’s be managed?
If it only affects distal ileum, can surgical resect this area
What medications are used to induce remission in mild/ moderate UC?
Aminosalicyclate
Corticosteroids
What medications are used to induce remission in severe UC?
IV corticosteroids
IV ciclosporin
What medications can be used to maintain remission in UC?
Aminosalicyclate
Azathioprine
Mercaptopurine
How can UC be cured?
Removing the colon and rectum (panproctocolectomy)
What is the pateint left with after surgery for UC?
Ileostomy (stoma bag) or J-pouch (ileo-anal anastomosis)
What is a J-pouch?
Where the ileum is folded back on itself and fashioned into a larger pouch that functions like a rectum. Is then attached to the anus
What is biliary atresia?
Congenital condition where a section of the bile duct is narrowed or absent
What does biliary atresia cause?
Cholestasis (bile cannot be transported from liver to bowel)
How and when does biliary atresia present?
With significant jaundice shortly after birth
Why do you get jaundice in biliary atresia?
Conjugated bilirubin is excreted in the bile, so biliary atresia prevent the excretion of conjugated bilirubin
When should biliary atresia be suspected?
In babies with persistent jaundice
What time frame is classified as persistent jaundice?
> 14 days in term babies
>21 days in premature babies
What is the initial investigation for biliary atresia?
Conjugated and unconjugated bilirubin levels
What will investigations into biliary atresia show?
High proportion of conjugated bilirubin
How is biliary atresia managed?
Surgery- attaching section of small intestine to opening of liver where bile duct attached
Often will need full liver transplant to resolve condition
What is intestinal obstruction?
Where physical obstruction prevents the flow of faeces through the intestines
What does the blockage cause?
Back pressure that causes vomiting
Absolute constipation
What are the causes of intestinal obstruction?
Meconium ileus Hirschsprung's disease Oesophageal/ duodenal atresia Intussusception Imperforate anus Malrotation of intestines with volvulus Strangulated hernia
What is meconium ileus?
Where the meconium is thick and sticky, causing it to get stuck and obstruct the bowel (Common in CF)
How does a bowel obstruction present?
Persistent vomiting Abdominal pain Distention Failure to pass stools or wing Abnormal bowel sounds
What are the classic bowel sounds in bowel obstruction?
High pitched ‘tinkling’, followed by absence of bowel sounds
What is the investigation of choice for bowel obstruction?
Abdominal xray
What will xray show with bowel obstruction?
Dilated loops of bowel proximal to the obstruction
Collapsed loops of bowel distal to the obstruction
Absence of air in the rectum
How are bowel obstructions managed?
Emergency paediatric surgery referral
Initial= nil by mouth, insert NG tube to help drain stomach and stop vomiting
IV fluids to correct dehydration/ electrolyte imbalances
Treat underlying cause
What is the myenteric plexus?
The brain of the gut- forms the enteric nervous system
What is the myenteric plexus also known as?
Auerbach’s plexus
Where does the myenteric plexus run?
All the way along the bowel in the bowel wall
What is the myenteric plexus made up of?
Complex web of neurones, ganglion cells, receptors, synapses and neurotransmitters
What is the myenteric plexus responsible for?
Stimulating peristalsis in the large bowel
What is Hirschsprung’s disease?
Congenital condition where nerve cells of the myenteric plexus are absent in the distal bowel and rectum
What is absent in Hirschsprung’s disease?
Parasympathetic ganglion cells in the distal colon and rectum
How do the parasympathetic ganglion of the cells usually form and develop?
Cells start higher in the GI tract and gradually migrate down to the distal colon and rectum
How does Hirschsprung’s occur?
When the parasympathetic ganglion cells do not travel all the way down the colon, so a section is left without them
What is it called when the whole colon is affected by Hirschsprung’s disease?
Total colonic aganglionosis
What happens to the aganglionic section in Hirschsprung’s disease?
It does not relax, causing it to become constricted
What does the constriction of the aganglionic colon lead to?
Loss of movement of faeces and obstruction in the bowel
What happens to the bowel proximal to the obstruction?
It becomes distended and full
What increases the risk of Hirschsprung’s disease?
Genetics Family history Downs syndrome Neurofibromatosis Waardenburg syndrome Multiple endocrine neoplasia type II
How does Hirschsprung’s vary in its presentation?
Depends on age at diagnosis and extent of bowel affected:
May be acute intestinal obstruction shortly after birth or more gradual
What are symptoms of Hirschsprung’s disease?
Delay in passing meconium (>24 hours) Chronic constipation since birth Abdominal pain and distension Vomiting Poor weight gain Failure to thrive
What is Hirschsprung-Associated Enterocolitis (HAEC)?
Inflammation and infection of the intestine occurring in around 20% of neonates with Hirschsprung’s disease
When does Hirschsprung-Associated Enterocolitis usually present?
Within 2-4 weeks of birth
How does Hirschsprung-Associated Enterocolitis present?
Fever
Abdominal distention
Diarrhoea (often bloody)
Features of sepsis
What can Hirschsprung-Associated Enterocolitis lead to?
Death
Toxic megacolon and perforation of bowel
How is Hirschsprung-Associated Enterocolitis managed?
Urgent antibiotics
Fluid resuscitation
Decompression of obstructed bowel
How is Hirschsprung’s disease managed?
Abdominal Xray
Rectal biopsy
How does rectal biopsy confirm a diagnosis of Hirschsprung’s disease?
Demonstrates absence of ganglionic cells
How is Hirschsprung’s disease managed acutely?
Fluid resuscitation
Management of intestinal obstruction
What is the definitive management of Hirschsprung’s disease?
Surgical removal of aganglioinic section of bowel
What is intussusception?
Where the bowel folds inwards (invaginates/ telescopes) into itself
What does intussusception do to the overall size of the bowel and the lumen?
Thickens overall size of bowel and narrows lumen at folded area
What age range and population us most affected by intussusception?
6 months- 2 years
More common in boyrs
What conditions are associated with intussusception?
Concurrent viral illness HSP Cystic fibrosis Intestinal polyps Meckel diverticulum
How does intussusception present?
Signs of bowel obstruction Severe colicky abdominal pain Pale, lethargic unwell child Bloody stool Right upper quadrant mass Vomiting Intestinal obstruction
What is the typical description of the stool in intussusception?
Redcurrant jelly stool
What is the typical description of the mass felt on palpation of intussusception?
Sausage shaped
Why do you get ‘redcurrant jelly stool’ in intussusception?
Trapped section of bowel goes ischaemic, and the mucosa responds by causing sloughing off into the gut
What is the investigation of choice for intussusception?
USS (or contrast enema)
What is the initial treatment of intussusception?
Therapeutic enemas- pumping contrast, water or air into the colon to force the folded bowel out into its normal position
What can be done to treat intussusception if enema doesnt work?
Surgical reduction
What must be done is the bowel becomes gangrenous or perforated?
Surgical resection
What are the complications of intussusception?
Obstruction
Gangrenous bowel (due to disruption of blood supply)
Perforation
Death
What is the appendix attached to?
The caecum
When does the appendix become inflamed?
Due to infection trapped in the appendix by obstruction at the point where it meets the bowel
What can inflammation of the appendix be quickly be proceeded by?
Gangrene and rupture
What does rupture of the appendix lead to?
Release of faecal content and infective material into the abdomen, leading to peritonitis
When is the peak incidence of appendicitis?
Patients afed 10-20 years
What is the key presenting feature of appendicitis?
Abdominal pain
What is the characteristic progression of the pain in appendicitis?
Central abdominal pain that moves down to right iliac fossa, and then becomes loalised at McBurney’s point
What is McBurney’s point?
Localised area one third the distance from the anterior superior iliac spine (ASIS) to the umbilicus.
What are the classic features of appendicitis?
Tenderness/ pain at McBurney's point Anorexia N&V Rovsing's sign Guarding Rebound tenderness Percussion tenderness
What is Rovsing’s sign?
Palpation of the lLIF causing pain in the RIF
What signs indicate peritonitis?
Rebound tenderness
Percussion tenderness
How is appendicitis diagnosed?
Based on clinical presentation and raised inflammatory markers
What scans may be done to investigate appendicitis?
CT to confirm
USS to exclude ovarian/ gynae pathology
What is the next step when a patient has a clinical presentation suggestive of appendicitis but investigations are negative?
Perform a diagnostic laparoscopy to visualise the appendix directly
What are the key differential diagnoses of appendicitis?
Ectopic pregnancy Ovarian cysts/ torsion Meckel's diverticulum Mesenteric adenitis Appendix mass
What is Meckel’s diverticulum?
Congenital malformation of the distal ileum that causes bulge in lower part of small intestine
What are the complications of Meckel’s diverticulum?
Can bleed, become inflamed, rupture or cause a volvulus or intussusception
What is mesenteric adenitis?
Inflamation of the abdominal lymph nodes, presenting with abdominal pain
What is an appendix mass and when does it occur?
When the omentum surrounds and sticks to the inflamed appendix, forming a mass in the right iliac fossa/
How is appendicitis managed?
Appendicectomy
What are the complications of appendicectomy?
Bleeding, infection, scars, pain Damage to bowel and bladder Removal of normal appendix Anaesthetic risks VTE risks
What are the causes of vomiting in infants?
GORD Feeding problems Infection Dietary protein intolerances Intestinal obstruction Inborn errors of metabolism Congenital adrenal hyperplasia Renal failure
What are the causes of vomiting in preschool children?
Gastroenteritis Infection Appendicitis Intestinal obstruction Raised intracranial pressure Coeliac disease Renal failure Inborn errors of metabolism Torsion of the testis
What are the causes of comiting in shool age/ adolescent children?
Gastroenteritis Infection Peptic ulceration H.pylori Appendicitis Migraine Raised ICP Coeliac Renal failure DKA Alchol/ drug ingestion Cyclical vomiting syndrome Bulimia Pregnancy Testicular torsion
What causes bile stained vomit?
Bowel obstruction
What is infant colic?
When in the first few months of life, there is paroxysmal inconsolable crying or screaming often accompanied by drawing up the knees and passing excessive flatus, for unknown reasons
What is volvulus?
Condition where the bowel twists around itself and the mesentery
Where does the blood supply to the bowel come from?
The mesentery (through mesenteric arteries)
What does twisting in the bowel lead to?
Closed-loop bowel obstruction (where section of bowel is isolated by obstruction on either side), leading to ischaemia and necrosis
What is malrotation?
When the bowel does not rotate into the normal position during fetal development
What are the two presentations of malrotation?
Obstruction
Obstruction with compromised blood supply
How does malrotation usually present?
With volvulus in the first week of life
What are the symptoms of malrotation?
Bilious vomiting
How is malrotation managed?
Surgery to untwist volulus and return bowel to correct position.
