GI and Liver 2 Flashcards
List some common causes of recurrent abdominal pain
Bowel: Acute appendicitis Intussusception Mesenteric adenitis HSP Peptic ulceration IBD Intestinal obstruction Constipation Gastroenteritis
Renal:
UTI
Hydronephrosis
Renal calculus
Abnormal migraine
Lead poisoning
What is important to include in a physical examination of a child presenting with recurrent abdo pain?
Growth - height and weight measurements
General exam - pallor, jaundice and clubbing
Abdo examination - hepatomegaly, splenomegaly, enlarged kidneys or distended bladder
Anorectal examination - not routine but necessary if ?sexual abuse or constipation
What may ESR show when investigating recurrent abdo pain?
Elevated in IBD
What may amylase levels be when investigating recurrent abdo pain?
Raised in pancreatitis
What may be analysed in a stool sample when investigating recurrent abdo pain?
Ova and parasites (x3 samples) - GI parasites eg giardiasis
Occult blood - GI blood loss eg IBD or peptic ulcer
What may a pelvic and abdo USS show when investigating recurrent abdo pain?
Urinary obstruction at all levels Oragomegaly Abscesses IBD Peptic ulcer
What may an X-ray show when investigating recurrent abdo pain?
Plain abdo:
- Constipation
- Renal calculi (if radiopaque)
- Lead poisoning
Barium swallow and follow through:
- Oesophagitis and reflux
- Peptic ulcer
- IBD
- Congenital malformations of the gut
What may an endoscopy show when investigating recurrent abdo pain?
Peptic ulceration
Colitis
What does periodic periumbilical pain in which the child is well between episodes suggest?
Idiopathic recurrent abdo pain
What does epigastric pain relived by food and acids suggest?
Peptic ulcer
NB in children <6years, pain is often exacerbated by food (opposite to adult pattern)
What does retrosternal pain, associated with vomiting and FTT suggest?
GORD
What is the type of abdo pain in Crohn’s disease?
Colicky
What does colicky recurrent abdo pain with hard, infrequent stools suggest?
Constipation
What does back or loin pain combined with dysuria, frequency and enuresis suggest?
UTI
What does lower abdo pain with vaginal discharge suggest?
PID
What does anorexia, irritability, pica, hypochromic microcytic anaemia suggest?
Lead poisoning
Abdo pain is variable / vernalised
What does recurrent, potentially severe, abdo pain with n&v suggest?
Abnormal migraine
May have FH migraine
What is haematocolpos?
Medical condition in which the vagina fills with menstrual blood
Often caused by the combination of menstruation with an imperforate hymen
How does a child typically respond to pain caused by peritonism?
Child lies very still and movement causes severe pain
Reluctance to move spontaneously, rebound tenderness, guarding and rigidity
What conditions remote from the abdomen may cause abdo pain?
Tonsillitis
Mesenteric adenitis
Basal pneumonia causing pain referred to the abdo
What may a plain abdo x-ray show when investigating acute abdo pain?
Intussusception
Obstruction
What may an USS be useful in showing when investigating acute abdo pain?
Intussusception
Exclude renal pathology
What is a contrast enema used for when investigating acute abdo pain?
For diagnosis and treatment of intussusception
What does acute abdo pain with tachycardia, anorexia and peritoneum suggest?
Acute appendicitis
What does acute abdo pain with intermittent screaming, pallor and ‘redcurrant jelly’ stool suggest?
Intussusception
What does acute abdo pain with recent viral infection and no peritonism suggest?
Mesenteric adenitis
What does acute abdo pain with joint pain / swelling, blood in stool and pupura on extensor surfaces suggest?
HSP
What does acute abdo pain worse at night that is relived by food suggest (if >6yr)?
Peptic ulceration
What are some red flags of acute abdo pain in children? (5)
Peritonitic Rigid abdo Guarding Focal signs of shock Bilous vomiting
What ages does acute appendicitis most commonly affect?
> 5yr
But can affect any age
How does acute appendicitis present?
In older children, presents classically:
- Pain initially in periumbilical area, moving after a few hours to RIF
In young children it is difficult to diagnose - mother says child is in pain, also:
- anorexia
- reluctance to move
+/- constipation
+/- vomiting
+/- low-grade fever
What must be included in an examination of a child with suspected acute appendicitis?
Abdo exam - guarding and rebound tenderness. Pain at McBurney’s point
PR exam - marked tenderness against anterior rectal wall due to peritonism
What investigations should be performed for acute appendicitis?
FBC - leucocytosis / neutrophilia
U&Es
Urinalysis to exclude infection
CT / USS if diagnosis uncertain or appendix abscess suspected
Abdo x-ray not very helpful
How is acute appendicitis managed?
Surgical appendectomy
What is the prognosis of acute appendicitis?
May take a few weeks for recovery
If intraperitoneal adhesions occur as a result of peritonitis, later bowel obstruction
What are the different possible positions of the appendix?
Retrocolic and retrocaecal = 75%
Subcaecal and pelvic = 20%
Reto-ileal and pre-ileal = 5%
What is the pathophysiology of appendicitis?
Begins with acute obstruction of the lumen of the appendix, often with a faecolith. After 6-12 hours an inflammatory process involves the full thickness of the wall of the appendix. After 24-36 hours the appendix will become gangrenous and perforate
NB blockage can also be from FB, cancer, or a swelling in response to any infection in the body
What is McBurney’s triad?
1) Pain in RIF
2) Fever
3) N&V
What is coeliac disease?
Autoimmune hypersensitivity reaction to gliadin, a protein found in gluten
Gluten is found in wheat and rye
What does coeliac disease have associations with?
T1DM
Arthritis
Downs syndrome
Turner syndrome
What can increase the risk of coeliac disease?
Early introduction of cereals into the diet (before 4 months)
When do children with coeliac disease usually present?
<2yrs
How does coeliac disease usually present in children? (4)
1) FTT
2) Irritability
3) Anorexia
4) Vomiting and diarrhoea
5) Pale and foul stools
But some have few symptoms
Can present with delayed puberty
What may examination of a child with coeliac disease reveal?
1) Abdo distension
2) Wasted buttocks
3) Irritability
4) Pallor
Occasionally:
5) Mouth sores
6) Smooth tongue
7) Excessive bruising
8) Clubbing
9) Peripheral oedema
Most constant feature = decrease in weight gain and linear growth
What may investigations show in coeliac disease?
FBC:
- Anaemia (usually iron deficient but folate may be low)
Steatorrhoea may be present and faecal smear will demonstrate fat globules
Coeliac antibody screening in blood:
- IgA anti-tissue translglutaminase or anti-endomysial antibodies
Small bowel endoscopy
Definitive diagnosis made by jejunal biopsy
What is the characteristic finding on a jejunal biopsy of coeliac disease?
Subtotal villous atrophy
Crypt hyerplasia
What is the management of coeliac disease?
Gluten-free diet
- Quick resolution of diarrhoea, good mood and good growth
Rechallenge after 2 years of diet to allow full villi regeneration and repeat biopsy
What is a coeliac crisis?
Life-threatening dehydration due to diarrhoea accompanying malabsorption
What genetics are associated with coeliac disease?
HLA-DQ2 or DQ8
What is a classic skin manifestation of coeliac disease?
Dermatitis herpeteformis
What is dermatitis herpetiformis?
Chronic, polymorphic, pruritic skin disease
What do almost all pt with dermatitis herpetiformis have?
Detectable villous atrophy or minor mucosal changes
When does the suck reflex develop?
35 weeks
Prom babies must be fed through NG tube
What is a hydrocele?
Accumulation of fluid in the tunica vaginalis
Do not fluctuate in size (unless they communicate with the peritoneal cavity)
What is the management of hydrocele?
Most resolve by age 1
Occasionally large ones persist and require surgical treatment
Rarely, in older boys can indicate malignancy
What is an inguinal hernia?
Protrusion of abdo contents through the internal inguinal ring
Hernia contains a portion of peritoneal sac and may contain viscera, usually small bowel and omentum
What are the two types of inguinal hernia?
Indirect
Direct
What is an indirect inguinal hernia?
A protrusion through the internal inguinal ring passes along the inguinal canal through the abdo wall, running laterally to the inferior epigastric vessels
80% of inguinal hernias and most common in children
What is an indirect inguinal hernia associated with?
Failure of the inguinal canal to close properly after passage of the testis in utero or during the neonatal period
What is a direct inguinal hernia?
Hernia protrudes directly through a weakness in the posterior wall of the inguinal canal, running medially to the inferior epigastric vessels
More common in elderly and rare in children
Are inguinal hernias more common in boys or girls? R or L?
Much more common in boys = persistent patency of processus vaginalis which normally closes at birth
More common on R side due to later descent of right testis
Particularly more common in preterm babies
How may an inguinal hernia present?
Swelling in the groin which may extend down into the scrotum
Most obvious when intra-abdo pressure is raised eg crying, straining or coughing, often disappears when relaxed and lying down
Hernia is not painful unless incarcerated, when signs of intestinal obstruction may also be present
No transillumination
What is diagnostic of an inguinal hernia?
Clinical observation of an inguinal or inguinoscrotal mass that reduces spontaneously or on manipulation
How is an inguinal hernia managed?
Elective surgical herniotomy surgical procedure
- Hernial sack is resected and defect repaired
- Infants should be repaired within a few weeks as high risk of incarceration, but this lessens after age 1yr
If incarcerated and irreducible = emergency
- Advise parents of what to look for
What % of inguinal hernias are bilateral?
15%
What are some complications of inguinal hernias?
Incarceration leads to intestinal obstruction
30% risk of testicular infarction due to pressure on the gonadal vessels
Ddx of inguinal hernia
Hydrocele - exclude with transillumination
Groin LN
Undescended testis
What is intussusception? What is the pathophysiology?
Invagination / telescoping of one part of the bowel into another
The mesentery of this intussuscepted bowel becomes compressed. The bowel wall distends and obstructs the lumen. Peristalsis is disrupted leading to colicky abdo pain and vomiting. Lymphatic and venous obstruction occurs causing ischaemia
Can lead to a gangrenous bowel and possible perforation
What is the most common part of the bowel to telescope into another part?
Usually ileum into the caecum (75%)
What age group does intussusception usually affect?
3-24 months
Only 10% occur in those >3yr
What may cause intussusception?
Most commonly follows a viral infection (adenovirus or rotavirus) in which enlarged lymphatic tissue in bowel walls (Peyer’s patch) form the leading edge of the intusussception (less flexible to peristalsis)
Rarely due to a pathological lesion such as polyp or lymphoma or as a complication of HSP (more common in older children)
How may a child with intussusception present?
Episodic screaming and pallor and between episodes may appear well
Bile stained vomiting
+/- shock or dehydration
Passage of blood and mucus in stool = ‘redcurrant jelly’ stool
- Present in 75%
- But late sign
What investigations are carried out for intussusception and what may they show?
Abdo radiograph:
- Rounded edge of the intussusception against the gas-filled lumen of the distal bowel
- With signs of proximal bowel obstruction
USS can confirm the presence of bowel within bowel = “doughnut sign”
How can an intussusception be reduced?
By air or barium enema
Diagnostic and curative - pressure when the contrast is inserted can be gradually increased to force back the intussuscepting bowel which can be seen on fluoroscopy
Care not to apply to high a pressure which may lead to bowel perforation
Should only be performed is hx is <24hrs and no evidence of peritonism or severe dehydration
When may a laparotomy be required in an intussusception?
If an air or barium enema fails to reduce it, or if there is evidence of peritonism
Surgical reduction then performed
What may an abdo exam show reveal in intussusception?
Sausage shaped mass in the right side of the abdomen
What should be considered if a child experiences repeated intussusception?
A polyp
What is the prognosis of intussusception?
Good with prompt diagnosis
Risk of death if diagnosis missed
1% mortality with treatment
Post reduction recurrence 5-15%
