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2H Pedia > MOD4 Abdominal pain > Flashcards

MOD4 Abdominal pain Flashcards

OUTLINE •Case Scenario •Types of Abdominal Pain •History: Clues to Ask About •Examination: Signs to Look For •Investigations •Management

1
Q

What are the clues?

A
  1. Persistent Crying
  2. Refusal of feeding
  3. Irritability
  4. Flexion of thighs on the abdomen
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2
Q

What are the types of abdominal pain?

A
  1. Visceral pain
  2. Somatic pain
  3. Reffered pain
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3
Q

– results when nerves within the gut
detect injury
- vague, dull, poorly localized
- slow in onset

A

VISCERAL PAIN

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4
Q

– overlying body structures are injured
- includes parietal peritoneum,
fascia, muscles, skin of the
abdominal wall

A

SOMATIC PAIN

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5
Q

– painful sensation in a body or region distant from the source of pain

A

REFERRED PAIN

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6
Q

Intra-abdominal Causes

A

•GIT
•Liver and Gallbladder
•Pancreas
•Kidney and Urinary Tract
•Spleen
•Internal Genitalia

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7
Q

Extra-abdominal Causes

A
  • URT
  • Lungs
  • Heart
  • Nervous System
  • Hematologic
  • Metabolic
  • Functional/Psychogenic
  • Miscellaneous (eg. Poisoning)
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8
Q

What are the causes of acute abdominal pain?

A
  1. Mesenteric Adenitis
  2. Intussuception
  3. Diabetes
  4. Lower Lobe Pneumonia
  5. Peptic ulcer
  6. Renal Calculi
  7. GIT obstruction
  8. Gastroenteritis
  9. Constipation
  10. UTIs
  11. Henoch Schonlein Purpura
  12. Acute Appendicitis
  13. IBD
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9
Q
  • Recent Viral infection
  • No peritonism
  • Pain can mimic Appendicitis
A

Mesenteric Adenitis

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10
Q
  • Intermitten screaming / colic
  • Shock/ pallorl
  • Recurrent jelly/ stool
  • Usually 3-24 months old
A

Intussupception

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11
Q
  • Signs of Pneumonia
  • Referred abdomina pain
A

Lower lobe pneumonia

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12
Q
  • Pain at night
  • relief with milk
  • helicobacter pylori
A

peptic ulcer

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13
Q
  • hydronephrosis
A

Renal calculi

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14
Q
  • Bile-stained vomiting
  • abdominal distention
A

Intestinal obstruction

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15
Q
  • vomiting and diarrhea
A

gastroenteritis

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16
Q
  • hard or infrequent stools
  • mass in left iliac fossa
  • faecal loading on x-ray
A

Constipation

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17
Q
  • Dysuria, frequency
  • bedwetting
  • back pain
  • vomiting
  • evidentce of infection on urinalysis or microscopy
A

UTI

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18
Q
  • Purpuric rash on legs
  • Joint pain
A

Henoch-Schonlein purpura

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19
Q
  • Anorexia
  • pain central-> right iliac fossa
  • peritonism in right iliac fossa
  • tachycardia
A

acute appendicitis

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20
Q
  • blood/ mucus in stools
  • family history diarrhea
  • weight loss and poor growth
A

inflammatory bowel disease

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21
Q

0-3 mo

Vomiting- Nonbilious

A

GERD reflux

Hypertrophic pyloric stenosis

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22
Q

Vomiting- Bilious

A

Malrotation and volvulus

Hirschsprung’s disease

Hernias

Meningitis or other sepsis

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23
Q

0- 3 mos

Abdominal mass

A

Renal or ovarian masses

Neuroblastoma

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24
Q

3 mos - 3 yr

Pain and lethargy

A

Intussusception

Wilm;s’ tumor

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25
Q

Older than 3 yr

Pain- persistent and lateralized

A

appendicitis

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26
Q

Onset

A

Sudden or gradual,

prior episode,

associated with meals,

history of injury
Acute vs. Chronic

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27
Q

Nature

A

Sharp versus dull, colicky or constant, burning

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28
Q

Pain that interferes minimally with activity or Pain associated with a known benign cause, such as viral AGE

A

MILD

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29
Q

Pain that interferes with activity or Associated signs of bacterial infection (respiratory distress, UTI, Streptococcus pyogenes) A history of prior abdominal surgery or NEC

A

MODERATE

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30
Q

Signs of peritonitis or intestinal obstruction or intussusception or Alterations in mental status (delirium, confusion, lethargy) or Signs of moderate or severe dehydartion

A

SEVERE

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31
Q

Signs of sepsis or septic shock with altered mental status or Poor or peripheral perfusion, hypotension or Respiratory distress (adult respiratory distress syndrome)

A

VERY SEVERE

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32
Q

Location

A

Epigastric,

periumbilical,

generalized,

right or left,

upper or lower quadrant,

change in location over time

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33
Q

Epigastric Pain

A
  • Peptic Ulcer Disease
  • Hiatal hernia
  • Gastroesophageal Reflux
  • Esophagitis
  • Pancreatitis
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34
Q

Signs of Ulcer Disease

A

Recurrent abdominal pain
–Often epigastric
–Relieved by food or antacids
–Awaken the patient from sleep
•Associated with
–Nausea
–Vomiting
–Hematemesis or melena

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35
Q

RUQ Pain

A
  • Hepatitis
  • Liver abscess or tumor
  • Cholecystitis
  • Cholangitis
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36
Q

Mild Abdominal Pain:

Diffuse, Periumbilical or Left sided

A
  • Constipation
  • Mesenteric adenitis
  • Food poisoning
  • Muscle strain
  • Gastroenteritis
  • Psychogenic pain
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37
Q

Associated symptoms

A
  • Dysuria, frequency (UTI)
  • Fever
  • Vomiting
  • Diarrhea
  • Rectal bleeding
  • Jaundice
  • Weight loss
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38
Q

Mild Abdominal Pain: Diffuse, Periumbilical or Left sided

Precipitating Factors and Predisposing Conditions

A
  • Constipation
  • Trauma
  • Medications
  • Menses
  • Pregnancy
  • Prior abdominal surgery
  • Inflammatory bowel disease
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39
Q

Extraintestinal Symptoms

A

Cough,

dyspnea,

dysuria,

urinary frequency,

flank pain

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40
Q

Course of symptoms

A

Worsening or improving,

change in nature

or location of pain

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41
Q

Physical Examination

General

A

: growth and nutrition,

appearance,

degree of discomfort,

body position

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42
Q

Signs of peritoneal irritation

–Psoas sign
–Obturator test

A
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43
Q

Psoas sign

A

(iliopsoas rigidity)

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44
Q

Obturator test

A

(pain with external thigh rotation)

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45
Q

Signs of intestinal obstruction

A

–abdominal distention
–decreased bowel sounds
–persistent vomiting

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46
Q

Signs of peritonitis

A

–rigidity of the abdominal muscles
–rebound tenderness
–decreased bowel sounds
–abdominal distention
–shock

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47
Q

Signs that suggest systemic disease or infection

Jaundice

A

 Hepatitis

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48
Q

Signs that suggest systemic disease or infection

Perianal lesions, weight loss, bloody stools

A

 IBD

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49
Q

Bloody stools with antibiotic use

A

 Pseudomembranous colitis

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50
Q

Bloody stools, hematuria, anemia, renal failure

A

 HUS

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51
Q

Bloody diarrhea, fever, no vomiting

A

 Bacterial enteritis

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52
Q

Palpable purpura, arthritis, hematuria

A

 HSP

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53
Q

Prolonged fever, conjunctivitis, mucosal lesions, rash

A

 Kawasaki disease

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54
Q

Vaginal discharge

A

 Pelvic inflammatory disease

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55
Q

Fever, weight loss, lymphadenopathy, hepatosplenomegaly

A

 Malignant neoplasm

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56
Q

Anemia

A

 Sickle cell disease

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57
Q

Cough, rales, decreased breath sounds

A

 Lower lobe pneumonia

58
Q

Bruises, fractures, abdominal distention

A

 Non-accidental trauma

59
Q

Cost-effective diagnostic technique
•May identify appendicitis, intussusception, gallbladder disorders, biliary tract disease, pelvic masses, and renal disorders

  • Often fails to identify pelvic inflammatory disease, hepatitis, pancreatitis
  • A negative sonogram does not exclude appendicitis or abscess
A

Ultrasonography

60
Q

Abnormal Radiographic Findings

Fecaliths

A

 Appendicitis

61
Q

Abnormal Radiographic Findings

Pneumatosis intestinalis

A

 NEC

62
Q

Abnormal Radiographic Findings

Free air

A

 Perforation

63
Q

Obstructive patterns

A

 Mechanical and Functional

64
Q

Abnormal Radiographic Findings

A

•Fecaliths  Appendicitis
•Pneumatosis intestinalis  NEC
•Free air  Perforation
•Obstructive patterns
 Mechanical and Functional
•Air in an abscess
•Abdominal mass
•Abdominal calcifications
•Renal stones
•Pneumonia

65
Q

•Radiates to the back or RUQ
•May be associated with
–Ascites
–Abdominal distention
–Peritoneal signs

  • Associated with vomiting
  • Elevated serum amylase and lipase or radioimmune assay of pancreatic trypsinogen
A

Pancreatitis

66
Q

What is the mgt of pancreatitis?

A

Management:
–Gastric suction
–IVF
–Bed rest
–Adequate pain management
–Oxygen
–TPN
–Antibiotics
–Surgery

67
Q

Fever, vomiting, pain over Mc Burney point, and signs of peritoneal irritation

A

Appendicitis

68
Q

In diagnosing appendicitis, the Absence of fever and vomiting suggests an ______________

A

alternative diagnosis

69
Q

In the DRE: appendicitis is palpable where?

A

tender RLQ mass

70
Q

Can Diarrhea and pyuria occur in appendicitis?

A

YES

71
Q

Can leukocytosis occur in appendicitis?

A

Leukocytosis – common but nonspecific

72
Q

What can precipitate appendicitis?

A

Can be precipitated by fecaliths or parasitic infections

73
Q

Perforation most likely if treatment delayed more than _____________

A

36 hours or if patient < 8 years old

74
Q

Ultrasonography sensitivity for appendicitis is

A

75-93%

75
Q

Intermittent crampy abdominal pain

  • Associated with vomiting, abdominal distention, or bloody stools •Epigastric sausage-shaped mass
  • May cause alteration in mental status that suggests CNS disease
A

Intussuception

76
Q

Intussusception commonly occurs in what age group?

A

Most commonly occurs in 4-24 months of age

77
Q

Mostly in idiopathic intussusception occurs

A

Idiopathic –
–75% of ileocolic intussusception
–More likely in children < 5
•Proximal bowel telescopes into distal

78
Q

Causes of intussusception

A

•Leading point
–Hyperplasia of Peyer patches in terminal ileum
–Structural: small bowel lymphoma, Meckel diverticulum
–Systemic: cystic fibrosis, Henoch-Schönlein, Crohn disease

79
Q

What are the structural causes of intussuception?

A

–Structural: small bowel lymphoma, Meckel diverticulum

80
Q

What are the systemic cause of intussusception?

A

–Systemic: cystic fibrosis, Henoch-Schönlein, Crohn disease

81
Q

Epidemiology of intussusception

male female ratio

A

•Male:female – 3:2

82
Q

Epidemiology of Intussuception

age

A

•Age –
–3 months to 6 years with 80% < age 2

83
Q

Epidemiology of Intussuception

peak of age is

A

–Peak at 6-12 months

84
Q

Most common site of Intussusception?

A

•Most common - ileocolic

85
Q

What are the clinical manifestation of Intussusception?

A

Clinical manifestations
•Intermittent, severe, crampy abdominal pain with loud cry and in curled up position
•Vomiting
•Appear normal between attack
•Currant-jelly stool

86
Q

What are the laboratory procedures done?

A

Laboratory Procedures
•Chemistry – dehydration, electrolyte imbalance
•CBC – infection
•X-ray: plain film & contrast or air enema
•Ultrasound
•CT scan – only if other tests are negative

87
Q

When UTZ is done in a suspected intussusception, what can be seen?

A

Could detect ileoileal intussusception

88
Q

What is the management in intussuscepion?

A

Management

•Air or contrast reduction
–Air is better than barium reduction – less perforation <1%
–Not very successful if symptoms > 24 – 48 hours or with bowel obstruction
–Successful rate – 75-90% with ileocolic intussusception

•Surgery
–Persistent filling defects
–Failed nonoperative reduction
–Prolonged intussusception

89
Q

In the mgt of intussusception using
•Air or contrast reduction
–Air is better than barium reduction in ?

A

– less perforation <1%

90
Q

When is air contrast reduction not successful?

A

–Not very successful if symptoms

> 24 – 48 hours or with bowel obstruction

91
Q

When is air reduciton successful?

A

–Successful rate – 75-90% with ileocolic intussusception

92
Q

When is surgery indicated in intussusception?

A

Surgery
–Persistent filling defects
–Failed nonoperative reduction
–Prolonged intussusception

93
Q

What is the problem in intestinal malrotation?

A

•Mesentery is not fixed properly so that midtransverse colon may be twisted around a narrow base and occlude the arterial blood supply, causing a volvulus

94
Q

How do neonates present with intestinal malrotation?

A

•Neonates present with bilious vomiting and other signs of small bowel obstruction
•Assess for associated anomalies such as cardiac defects

95
Q

Pyloric Stenosis
Causes

A

Unknown Associations

Abnormal muscle innervations

Erythromycin use in neonates

hypergastrinemia

96
Q

What drug is associated with Pyloric Stenosis?

A

Erythromycin

97
Q

What is the epidemiology of pyloric stenosis?

A

Prevelance – 3/1000

More common in white northern European descents

Male:female = 4:1 to 6:1

( MORE IN MALES)

98
Q

What is the age onset of pyloric stenosis?

A

Age – 1 week – 5 months

but usually 3 to 6 weeks

99
Q

WHat is the Clinical presentation of pyloric stenosis?

A

•Abdominal pain
•Nonbilious vomiting after feeding and with 91% having projectile emesis
–Hungry after feeding
–Weight loss
–Progressive symptoms
• Jaundice 5% of affected patients Indirect hyperbilirubinemia due to decreased level of glucuronyl transferase

100
Q

What is the PE in pyloric stenosis?

A

•Abdominal distension
•Olive mass – RUQ, after feeding

101
Q

What are the lab procedures done in pyloric stenosis?

A

Laboratory Procedures
•Chemistry
•Plain abdominal x-ray
•Ultrasound
•UGI

102
Q

What is the abdominal xray finding in pyloric stenosis?

A

Abdominal x-ray
Increased gastric air or fluid suggestive gastric outlet obstruction

103
Q

What is this finding?

A

Increased gastric air or fluid suggestive gastric outlet obstruction

104
Q

What is found in the UTZ of pyloric stenosis?

A

Ultrasound
Shoulder sign - indentation of pylorus into the stomach

105
Q
A

UGI
•String sign
•Pyloric spasm may mimic the string sign

106
Q

What is seen in the UGI of Pyloric stenosis?

A

UGI
•String sign
•Pyloric spasm may mimic the string sign

107
Q

what exactly is the difference? Why is pyloric stenosis non-bilious but duodenal atresia bilious? Where does it exactly occur that’s making the difference?

A

Bile duct drains into second part of duodenum via ampulla of Vater. So, obstruction proximal to 2nd part of duodenum will have non-bilious vomiting and obstruction distal to it will have bilious vomiting.

108
Q

What is the mgt in pyloric stenosis?

A

Management:
•Medical resuscitation first
–IVF hydration with potassium
–Correction of alkalosis because of postoperative apnea associated with general anesthesia
•Pyloromyotomy
•Endoscopically-guided balloon dilation – surgery is contraindicated or incomplete pyloromyotomy

109
Q

What is the first thing that yolou should do in pyloric stenosis?

A

Management:
•Medical resuscitation first

–IVF hydration with potassium
–Correction of alkalosis because of postoperative apnea associated with general anesthesia

110
Q

What is the clinical presentation of Volvulus

A

Clinical presentation
•Bilious emesis
•Abdominal distension

111
Q

What are the procedures done for volvulus?

A

Procedures

  • *• UGI**- duodenum not crossing the midline
  • *• Barium ene**ma – malposition of cecum
112
Q
  • Suggested by a positive history or associated bruises or fractures
  • Causes traumatic pancreatitis, intramural duodenal hamaturia, and lacerations of the liver, spleen or bladder
A

Abdominal Trauma

113
Q
  • Signs of acute abdomen
  • When right ovary involved

similar to acute appendicitis

  • *•Ultrasonography**
  • *•Early diagnosis and surgery** are necessary to save the ovary and fallopian tube
A

Acute Ovarian Torsion

114
Q
  • Often considered a benign disease
  • Major cause of morbidity and mortality
A

Gastroenteritis

115
Q

___________ remain the most common cause of acute gastroenteritis in children:

A

viruses

116
Q

What virus remains to be the most common cause of gastroenteritis in children?

A

Rotavirus

117
Q

How will you differentiate if the cause of gastroenteritis is bacterial; or viral in stool exam?

A

Watery – viral gastroenteritis
•Bloody or mucoid - bacterial

118
Q
  • one of the most common pediatric infections
  • first-time symptomatic UTI: highest in boys and girls during the first year of life
  • history and clinical course of a UTI vary with the patient’s age and the specific diagnosis. -No one specific sign or symptom
A

Urinary Tract Infection

119
Q

Whats are the symptoms of UTI in neonates ( 0 to 2 months)

A

Jaundice

fever

failure to thrive

poor feeding

vomiting

irritability

120
Q

What are the symptoms of UTI in aged 2 mos to 2years old?

A

Poor feeding

fever

vomiting

strong smelling urine

abdominal pain

irritability

121
Q

Symptoms of UTI in childrean aged 2- 6 years old

A

Vomiting

Abdominal pain

FEver

Storng-smelling urine

Enuresis

Urinary symptoms( Dysuria, urgency and frequency)

122
Q

What is the criteria of UTI by AMerican Academy of Pediatrics

A

children 2-24 months are the presence of pyuria and/or bacteriuria on urinalysis and of at least 50,000 colony-forming units (CFU) per mL of a uropathogen from the quantitative culture of a properly collected urine specimen

123
Q

What are the most commonly isolated bactera in PHIL in urine specimen?

A
  1. Escherichia coli
  2. Klebsiella sp
  3. Enterobacter sp
124
Q

Urine specimen collection

A

A midstream, clean-catch specimen may be obtained from children who have urinary control

125
Q

Suprapubic aspiration is the method of choice for obtaining urine from the following patients:

A
  1. Uncircumcised boys with a redundant or tight foreskin
  2. –Girls with tight labial adhesions,
  3. –Children of either sex with clinically significant periurethral irritation
126
Q

When does a culture of a urine specimen has a false-positive rate?

A

Culture of a urine specimen from a sterile bag attached to the perineal area has a false-positive rate
–a negative culture is strong evidence that UTI is absent

127
Q

What is the management of UTI

A

Most cases are treated on OPD basis with appropriate antibiotic
•A Cochrane review concluded that children with acute pyelonephritis can be treated effectively with either oral antibiotics or with 2-4 days of IV therapy followed by oral therapy

128
Q
A
129
Q

How to define chronic abdominal pain?

A

Defined as three or more episodes of pain, severe enough to affect activities occuring over a period of three months.
-Affects about 10-15% of school-age children

130
Q

How to say if it is a recurrent abdominal pain ( RAP )

A

Commonly occuring in more than 10% of pre-school and school aged children
-In younger than 2 yo, associated with an organic cause
-

131
Q

RAP w/o organic cause is often called ___________________

A

“functional” abdominal pain

132
Q

What are the differential diagnosis of recurrent abdominal pain?

A

NON-ORGANIC

organic

133
Q

What are the two possible causes of Non organic?

A
  1. Functional abdominal pain
  2. Irritable Bowel Syndrome
134
Q

________________ -pain almost daily -not associated with meals or relieved with defecation

-Symptoms often result from stress in school or in novel social situations

A

Functional Abdominal pain

135
Q

_______________– characterized by onset of pain at the time of a change in stool frequency or consistency

  • a stool pattern fluctuating between diarrhea and constipation and relief of pain with defecation
  • Linked to gut motility
  • Linked with anxiety of imagined causes, disordered peer relationship
A

Irritable bowel syndrome

136
Q

What are the organic causes?

A

Chronic pancreatitis
•Gallstones
•Peptic disease
•Lactose intolerance
•Fructose malabsorption
•Inflammatory bowel disease
•Congenital intestinal malformation
•Parasitic infection
•Abdominal migraine
•Lead poisoning

137
Q

Warning signs of Underlying Illness in Recurrent Abdominal Pain

A
  • Vomiting
  • Abnormal screening laboratory study
  • Fever
  • Bilous emesis
  • Growth failure
  • Pain awakening child from sleep
  • Weight loss
  • Location away from periumbilical region
  • Blood in stool or emesis
  • Delayed puberty
138
Q

SUGGESTED EVALUATION OF RECURRENT ABDOMINAL PAIN

A

Initial Evaluation Complete history and PE

Ask about “warning signs”

Deterrmine degree of functional impairment

CBC,ESR

Amylase

Urinalysis

Abdominal UTZ

Trial of lactose free diet

139
Q

What are the followup evaluation in RAP?

A

Follow-up Evaluation
CT scan
Upper GI series
Endoscopy
Colonoscopy

140
Q
A

2H Pedia (9 decks)

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