Murtagh - Abdominal pain cont. in children

Question 1

probability diagnosis of acute abdomen in children

Answer 1

infant colic
gastroenteritis (all ages)
mesenteric adenitis

Question 2

serious causes not to be missed for acute abdomen in children

Answer 2

intussusception (peaks at 6-9 months)
acute appendicitis (mainly 5-15 years)
bowel obstruction/strangulated hernia

Question 3

when is the most likely time for a child to have intussusception

Answer 3

peaks at 6-9 months

Question 4

when is the most likely time for a child to have acute appendicitis

Answer 4

peaks at 5-15 years

Question 5

pitfalls for acute abdomen in children

Answer 5

child abuse
constipation/faecal impaction
torsion of testes
lactose intolerance
peptic ulcer
infections: mumps, tonsillitis, pneumonia (especially right lower lobe), EBM, UTI
adnexal disorders in females e.g. ovarian

Question 6

rare causes of acute abdomen in children

Answer 6

meckel’s diverticulitis
hence-schonlein purpura
sickle crisis
lead poisoning

Question 7

seven masquarades checklist for acute abdomen in children

Answer 7

diabetes mellitus
drugs
UTI

Question 8

Hx of infant colic

Answer 8

a well baby with regular, unexplained periods of inconsolable crying and fretfulness, usually in the late afternoon and evening
especially between 2 and 16 weeks of age
no cause for the abdominal pain can be found and it lasts for a period of at least 3 weeks

Question 9

how common is infant colic

Answer 9

very common and occurs in one third of infants

Question 10

clinical features of infant colic

Answer 10

baby between 2 and 16 weeks old
prolonged crying - at least 3 hours
occurrence at least three days per week
crying worst at around 10 weeks of age
crying during late afternoon and early evening
child flexing legs and clenching fists as if severe stomach ache
normal physical examination

Question 11

management of infant colic

Answer 11

advise the parents:
- use gentleness (such as subdued lighting, soft music, speaking softly, quiet feeding times)
avoid quick movements that may startle the baby
make sure the baby is not hungry
if the baby is breastfed, express the watery fore milk before putting the baby to breast
provide demand feeding
make sure the baby is burped and give posture feeding
provide comfort from a dummy or pacifier
provide plenty of gentle physical contact
cuddle and carry the baby around

Question 12

how to assist parents with baby with infant colic

Answer 12

a carrying device allows baby to be carried around at the time of crying
make sure the mother gets plenty of rest during this difficult period
do not worry about leaving a crying child for 10 minutes or so after 15 minutes of trying consolation

Question 13

drugs fro infant colic

Answer 13

drugs are not generally recommended, but for severe problems some preparations can be helpful e.g. simethicone (infacol wind drops)

Question 14

Hx of intussusception

Answer 14

child usually between 3 months and two years
sudden onset severe colicky pain, coming at intervals of about 15 minutes and lasting for 2-3 minutes

Question 15

how quickly should intussusception be diagnosed

Answer 15

early diagnosis within 24 hours of onset is essential, as there is a significant rise in morbidity and mortality after this point

Question 16

what causes intussusception in children

Answer 16

due to telescoping og segment of bowel into the adjoining distal segment resulting in intestinal obstruction
usually idiopathic but can have a pathological lead point (e.g. polyp, meckel’s diverticulum)

Question 17

typical clinical features of intussusception

Answer 17

male babies > female
birth to school age usually 5-24 months
sudden onset acute pain with shrill cry
vomiting
lethargy
pallor with attacks
intestinal bleeding - redcurrant jelly

Question 18

pain distribution and abdominal mass of intussusception

Answer 18

Question 19

pale child with severe colic and vomiting is likely

Answer 19

intussusception

Question 20

signs on examination of a child with intussusception

Answer 20

pale, anxious and unwell
sausage shaped mass in high upper quadrant anywhere between the line of colon and umbilicus, especially during attacks (difficult to feel)
signe de dance (i.e. emptiness in RIF to palpation)
alternating high pitched active bowel sounds with absent sounds
rectal examination may show blood or hard lump

Question 21

what might be found on rectal examination of a child with intussusception

Answer 21

blood or hard lump

Question 22

how do you diagnose a child with intussusception

Answer 22

ultrasound
oxygen or barium enema (with caution) is also used for diagnosis and treatment

Question 23

treatment for a child with intussusception

Answer 23

hydrostatic reduction by air or oxygen from the ‘wall’ supply (preferred) or barium enema
surgical intervention may be necessary

Question 24

how to tell acute gastroenteritis from intussusception

Answer 24

usually attacks of pain are of shorter duration for gastroenteritis
there is loose watery stool, fever and no abdominal mass
if doubtful, refer as possible intussusception

Question 25

differential diagnosis for intussusception

Answer 25

acute gastroenteritis
impacted faeces can lead to spasms of colicky pain - usually an older child with a Hx of constipation
other causes of intestinal obstruction eg. irritable inguinal hernia, volvulus, intra-abdominal band

Question 26

at what ages is acute appendicitis more likely in children

Answer 26

more common in children of school age (10-12 years) and in adolescence, and uncommon in children under 3 years of age

Question 27

presentation of a child with acute appendicitis

Answer 27

vomiting in 80%
diarrhoea in 20%
usually only very slightly elevated temperate

Question 28

how do you tell mesenteric adenitis and acute appendicitis apart in a child

Answer 28

sometimes indistinguishable
mesenteric adenitis has a more vague localisation of pain
rigidity is less of a feature in mesenteric adenitis

Question 29

features of mesenteric adenitis vs. acute appendicitis in children

Answer 29

Question 30

recurrent abdominal pain in children

Answer 30

three distinct episodes of pain over 3 or more months
very few cases are able to determine an organic cause

Question 31

possible causes of recurrent abdominal pain in children

Answer 31

constiptaion
childhood migraine equivalent (pain with extreme pallor)
lactose intolerance (symptoms related to milk ingestion)
intestinal parasites (may disturb child about 60 minutes after falling asleep)