GI - Recurrent Abdominal Pain Flashcards
School-aged child presents to you with recurrent abdominal pain that occurred at least 4 times in the past month. They complain of not being able to go to sleep well but it has no effect on sleep they are asleep. What is the most likely diagnosis. What are some differentials? (5)
Functional recurrent abdominal pain (RAP)
Crohn’s disease
Ulcerative colitis
Celiac disease
Peptic ulcer disease
Esophagitis (eosinophilic)
Pancreatitis (central pain radiating to the back)
Pelvic-ureteric junction obstruction
What are the main clinical features of functional recurrent abdominal pain?
What are the main psychosocial features of the disease?
Constant central pain, typically diagnosed as constipation. May change in location and is distractible
Pain prevents child from sleeping but does not wake him up in the middle of sleep (red flag)
Retching vs vomiting (red flag). For RAP, the vomit should be either limited to retching or effortless regurgitation.
Systematic symptoms: Anorexia (!!but maintains body weight within normal centiles!!), lethargy, headaches.
Psychosocial: Typically misses school, bullied.
Personality: Worrier/anxious/internalizes stress or conscientious, high achieving and empathetic.
Previous trauma/surgery: e.g. Past hx of surgery or infection
What are findings expected on examination of RAP?
Normal centiles, looks well but in pain
Excruciating central tenderness that is distractable!
Check stigmata of IBD (apthous ulcers, perianal area)
What investigations would you like to perform for a patient with RAP?
How would you manage this patient?
We must avoid any investigations to reassure without any findings.
Instead, noninvasive screening techniques such as urinalysis and blood screening for IBD and celiac disease as well as an US abdomen would be good
Management: This typically goes away on its own with time. This is not a diagnosis of exclusion and hence in the absence of findings, you must reassure parents and child via: (on ipad)
Validating pain
explaining how common it is and that there is genuinely no actual cause that we can find
Biopsychosocial model of pain
Give red flags for RAP (5)
Non-central abdominal pain (flank = PUJ obstruction)
Non-effortless vomiting
Reflux and dysphagia (Eosinophilic oesophagitis)
Pain waking up from sleep
Weight loss, growth faltering, Constipation/bloody diarrhea in school (IBD)
Hematemesis (Duodenal ulcer)
Dysuria or enuresis (UTI)
What does the biopsychosocial model of pain entail?
Biopsychosocial model of pain (Visceral hypersensitivity, altered motility, physical causes, and psychological stress)
Visceral hypersensitivity refers to how a sensitizing medical event such as infection, allergy, surgery etc. may cause slight pains to become excruciating and that can lead to altered motility. This in conjunction with a psychosocial event/personality such as depression, anxiety, bullying, maltreatment can add to it.
You have received a positive test confirming the presence of helicobacter pylori. what would you do to manage?
Only if they are symptomatic because the majority of people have it colonizing the stomach but unless there is an ulcer (which is exceptionally rare in children), it shouldn’t cause any symptoms.
Give PPI (esomeprazole)
What IBD is more common in children?
Crohn’s disease
What areas of the gut can Crohn’s disease affect? Where is the most common area?
Anywhere from the mouth (apthous ulcers) to the anus
Most common location is the terminal ileus
What main characteristic findings would you find on biopsy for Crohn’s? (2) vs. UC? (1)
non-caseating granulomas and transmural inflammation
UC: Cryptitis
What main characteristic findings would you expect on colonoscopy for crohn’s? (1) vs UC (1)
Skip lesions
UC: Pancolitis
What are some extraintestinal and systemic features of Crohn’s disease. Give 3 by 2
Erythema nodosum (red rash on the distal tibia), arthritis, Pyoderma Gangrenosum (really bad ulcer), Apthous ulcers, vomiting…
Systemic: fever, tachycardia, !anemia!
What is the typical presentation of IBD?
Weight loss, diarrhoea, and abdominal pain (+faltering growth in paeds!!!)
A patient presents with Weight loss, bloody diarrhoea, and abdominal pain. What is the most likely diagnosis
Bloody diarrhoea and common presentation of IBD => ulcerative colitis most likely. Crohn’s also has bloody stool but usually not as obvious.
What is the gold standard diagnostic tool(s) for IBD?
What other investigations would you conduct?
How would you manage a patient with confirmed IBD? Give names of medication.
How would you manage an acute relapse
Gold Standard = Biopsy and Colonoscopy
Other: FBC for anemia!, CRP and ESR (inflammatory BD), stool cultures for infective causes of colitis
Management:
Anti-inflammatories: Sulfalazine
Immunosuppressants: Azathioprine
Disease-modifying drugs: Infliximab
Acute relapse Steroids: Hydrocortisone
