Paedics Flashcards
What are the major steps in taking paediatric history
Demographics Know who the primary care giver of the child is PC HPC ODQ Systemic enquiry Pregnancy and delivery history Past medical and surgical history Past drug history Past family history Immunization history Developmental history Feeding and nutritional history Dietary recall Social history Summary
What are you looking for in pregnancy and delivery history? And state why you’re looking for it
When asking,document everything you do and everything you asked the patient and if the patient doesn’t know,state that the patient didn’t know true or false
In history taking of a child,a child who is 12 years can be considered and an adult history will be taken for the child instead of paediatric history true or false
If the pregnancy was planned or not
(If pregnancy wasn’t planned,the child may suffer or person won’t get drugs to give the child )
If pregnancy was planned
What’s the duration of the pregnancy (in weeks not months)
Did the mother attend antenatal when prgansnt w the child?
Did she do all the tests asked?
Which tests did she do?(example urine ,blood etc like if patient had a G6PD deficiency)
What were the results of the test?
Did she take all the treatments given during the pregnancy (if person didn’t take tetanus vaccine the child won’t be protected against it)
During the pregnancy did the person get sick or Ill or was there any serious condition the woman had while pregnant?
After how many weeks was the child delivered
How was the child delivered
(If by Cs, ask why the CS was done)
What was the birth weight of the child
Did the child cry at birth or not? Was the cry delayed? (Resuscitation means did the child cry at birth)
Was the child jaundiced,cyanosed at birth?
Did the child pass mucous or stool or urine during the first 24 hours after birth?
Were there complications after delivery?
Was the child admitted after birth?
(State that delivery was uneventful if there were no complications)
In family history what do you ask?
In past med and surgical what do you ask?
In immunization history what do you ask?
In developmental history what do you ask
For developmental history
If the child is 10,11,12,14, you can decide not to ask about the months but if patient has had a problem from birth ,go into details
Fam:
Ask conditions that can be transferable to the child such as SCD, and other diseases
Past med hx and surgical:
If the child had any illness or has had any previous Illnesses or admissions
If Mum has illnesses
If there were blood transfusions
Immunization:
Did child get Al the vaccines
Ask which vaccines the child got
Request for the road to health chart or child health record book
( to report if immunization history is up to date for the age of the child)
Open the book to go through to confirm if the vaccination is up to date or not
Developmental:
What the child can do at his or her age
The milestones: Gross motor development Fine motor development Social development Cognitive and mental development
Gross motor:
At birth was the child moving the limbs or what could the child to that the person was able to see?
Flexed posture
Fine motor: Follows face or light by 2 weeks Follows moving object or face by turning the head (illustrated).
Hearing,speech and language or cognitive and mental ;
Stills to voice
Startles to loud noise
Social, emotional, and behavioural: smiles by 6 weeks
3-4 months: hearing speech and language or mental and cognitive: Vocalises alone or when spoken to, coos and laughs
4-6 months-
Gross motor:what could the child do at this point
Could child sit without support? With the back round?
Fine motor: Palmar grasp
Social: puts food in mouth
7 months- what could child do?
Could child sit without support?
Fine motor:
Could child pick up things?
Transfers objects from hand to hand
Mental and cognitive: Turns to soft sounds out of sight. At 7 months, sounds used indiscriminately.
Social- puts food in mouth
8 months- could child sit without support with back straight?
Could child crawl?
Social:puts food in mouth
9 months- what could child do?
Could child crawl?
10 months- Stands independently Cruises around furniture
Was child in crèche?
Fine motor: Mature pincer grip
Cognitive and mental: At 10 months, sounds used discriminately to parents
Social: Waves bye-bye, plays peek-a-boo
I year- could child walk,could child interact w others?
Walks unsteadily, broad gait, hands apart
Cognitive: Two to three words other than ‘dada’ or ‘mama’
Social: Drinks from a cup with two hands
15 months: Walks steadily
Fine motor: Immature grip of pencil
Random scribble
16-18 months - fine motor: Makes marks with a crayon. Immature grip of pencil,
Random scribble
Congnitive: 6–10 words. Shows two parts of the body
Social: Holds spoon and gets food safely to mouth. Beginning to help with dressing
20-24 months:cognitive: Joins two or more words to make simple phrases
Social: Clean and dry
2.5 to 3 years: cognitive : Talks constantly in 3–4 word sentences
Understands two joined commands
Who is a neonate, an infant,a toddler
A preschooler
2.2 The history must be adapted to the child’s
age. The age when a child first walks is highly relevant when taking the history of a toddler or child with a developmental problem but irrelevant for a teenager in secondary school with headaches.
True or false
Make sure that you and the parent or child mean the same thing when describing a problem. For example, parents may use the word ‘wheeze’ to describe any respiratory sound.
True or false
Neonate (<4 weeks) Infant (<1 year) Toddler Approx 1-2 years Preschool (2-5 years)
What are you looking for in feeding and nutritional history
If mother breastfed the child
How long did she do the breastfeeding
Was it exclusive breastfeeding or it was mixed
If mixed,why?
What month was the child meaned?
How does she breastfeed if she breastfeeds?
Does she put breast milk in a bottle?
How does she clean the bottle?
Does she wash her hands before breastfeeding?
(If she’s still breastfeeding)
If woman uses formula,how does she clean the bottle ?
How many times is the child breastfed a day? (Child should not be fed less than 6-8 times a day)
If child doesn’t take breast milk or takes breast milk and normal food, ask what food the child eats?
Does the child eat adult food?
How many times does the child eat a day(child should eat more than thrice a day w snacks in between )
Components:
Proteins
How many times does the child eat meat or egg or fish in a day or a week
Minerals:
Does child like fruits? What kind of fruits? Do you give child fruits? How many times does child eat fruit in a day or in a week?
Carbs:
What food is given
Water:
How many times does child take after in a day
Dietary recall:
What has the child eaten previously? (24 hours minimum)
What food child eats at home not the hospital if child is admitted
If child has been admitted ask the day before admission what the child ate the whole day?
Ask what child ate and ask for each component w each dish said by woman
Between meals what did the child eat?
Morning afternoon and evening
If she gave Koko, ask if there was milk,sugar and koose or bread w egg ? Were there fruits?
Ask if child was getting balanced diet in each dish?
Find out what was used to make the stew if woman says rice and stew or something and stew?
If the child has malnutrition, do a week or two weeks dietary recall not 24 hours
What are you looking for in drug hx
What about social hx?
How is summary done
Drug: If child is on medications Name of medications What the doses are ? Any allergies to food or medication?
Social hx:
Who is taking care of the child
Who does the child live w?
Where do they stay?
Is it their own home
What’s the ventilation status of where the child sleeps
How is refuse disposed
Source of drinking water and source of water
Average income of primary care giver
What work does he do?
What does mum use to cook cuz charcoal can aggravate asthma in kids
Occupation of parents; if mom is a farmer and stored kerosene ,the child can drink it and present w poisoning
Summary: Who you got the history fromz Name Age or age range(toddler,middle age) Sex All PCs and duration Any negative or positive finding
What is the normal fetal heart rate
110-150bpm
How is examination of the newborn done
What are the nine most common congenital heart lesions
). Polygenic abnormalities probably explain why having a child with congenital heart disease doubles the risk for subsequent children and the risk is higher still if either parent has congenital heart disease. A small number are related to external teratogens.
True or false
Left-to-right shunts (breathless) • Ventricular septal defect 30% • Persistent arterial duct 12% • Atrial septal defect 7% Right-to-left shunts (blue) • Tetralogy of Fallot 5% • Transposition of the great arteries 5% Common mixing (breathless and blue) • Atrioventricular septal defect (complete) 2% Outflow obstruction in a well child (asymptomatic with a murmur) • Pulmonary stenosis 7% • Aortic stenosis 5% Outflow obstruction in a sick neonate (collapsed with shock) • Coarctation of the aorta 5%.
What are the circulatory changes at birth
In the fetus, the left atrial pressure is low, as relatively little blood returns from the lungs. The pressure in the right atrium is higher than in the left, as it receives all the systemic venous return including blood from the placenta. The flap valve of the foramen ovale is held open, blood flows across the atrial septum into the left atrium, and then into the left ventricle, which in turn pumps it to the upper body (Figs 18.1 and 10.8).
With the first breaths, resistance to pulmonary blood flow falls and the volume of blood flowing through the lungs increases six-fold. This results in a rise in the left atrial pressure. Meanwhile, the volume of blood return- ing to the right atrium falls as the placenta is excluded from the circulation. The change in the pressure
Table 18.1 Causes of congenital heart disease
difference causes the flap valve of the foramen ovale to be closed. The ductus arteriosus, which connects the pulmonary artery to the aorta in fetal life, will normally close within the first few hours or days. Some babies with congenital heart lesions rely on blood flow through the duct (duct-dependent circulation). Their clinical condition will deteriorate dramatically when the duct closes, which is usually at 1–2 days of age but occasionally later.
State the causes of congenital heart diseases under maternal disorders ,maternal drugs and chromosomal abnormalities and state the congenital diseases they cause
Maternal disorders: Rubella infection- Peripheral pulmonary stenosis, PDA Systemic lupus erythematosus- Complete heart block (anti-Ro and anti-La antibody)
Maternal drugs: Warfarin therapy- Pulmonary valve stenosis, PDA Fetal alcohol syndrome- ASD, VSD, tetralogy of Fallot
Chromosomal abnormality: Down syndrome (trisomy 21)- Atrioventricular septal defect, VSD
Edwards syndrome (trisomy 18)-
Complex congenital heart disease
Patau syndrome (trisomy 13)-
Complex congenital heart disease
Turner syndrome (45XO)- Aortic valve stenosis, coarctation of the aorta
Chromosome 22q11.2 deletion-
Aortic arch anomalies, tetralogy of Fallot, common arterial trunk
Williams syndrome (7q11.23 microdeletion)- Supravalvular aortic stenosis, peripheral pulmonary artery stenosis
Noonan syndrome (PTPN11 mutation and others)- Hypertrophic cardiomyopathy, atrial septal defect, pulmonary valve stenosis
Congenital heart diseases presents with which signs
At what gestational age is fetal anomaly scan done
Congenital heart disease presents with: • antenatalcardiacultrasounddiagnosis • detectionofaheartmurmur • heartfailure • shock • cyanosis.
18 weeks’ and 20 weeks’ gestation
Features of GiT disorders in kids are of what signs?
What is posseting and regurgitation?
Ehat do they indicate?
What is vomiting ? It is usually benign and is often caused by feeding disorders or mild gastro-oesophageal reflux or gastroenteritis. True or false
In infants, vomiting may be associated with infection outside the gastrointestinal tract, especially
Which systems?
intestinal obstruction, the more proximal the obstruc- tion, the more prominent the vomiting and the sooner it becomes bile stained (unless the obstruction is proxi- mal to the ampulla of Vater). Intestinal obstruction is associated with abdominal distension, more marked in distal obstruction. ‘
True or false
What is the characteristic of vomit in intestinal obstruction,(Oesophagitis, peptic ulceration, oral/nasal bleeding, and oesophageal variceal bleeding),pyloric stenosis,whooping cough or pertussis, what signs are associated with vomiting in surgical abdomen,Intestinal obstruction(including strangulated inguinal hernia), Chronic liver disease, inborn error of metabolism Intussusception, bacterial gastroenteritis
Severe gastroenteritis, systemic infection (urinary tract infection, meningitis), diabetic ketoacidosis) ,
Raised intracranial pressure,
Gastro-oesophageal reflux disease, coeliac disease and other chronic gastrointestinal conditions
Name six causes of vomiting in infants, preschool children, school age and adolescents
What’s a common chronic cause of vomiting in infants?
Over feeding is common in which people?
When will you suspect gastroenteritis in infants but what else should you consider?
If vomit is projectile at 2-8 weeks of age what should you exclude?
If vomit is bile stained it’s a potential emergency so exclude what diseases and assess for what?
• vomiting,abdominalpainanddiarrhoeaa that are transient
(lasting only for a short time)
Posseting and regurgitation are terms used to describe the non-forceful return of milk, but differ in degree. Posseting describes the small amounts of milk that often accompany the return of swallowed air (wind), whereas regurgitation describes larger, more frequent losses. Posseting occurs in nearly all babies from time to time, whereas regurgitation may indicate the pres- ence of more significant gastro-oesophageal reflux.
Vomiting is the forceful ejection of gastric contents. It is a common problem in infancy and childhood
True
urinary tract and central nervous system.
True
Intestinal obstruction:bile stained vomit
Oesophagitis, peptic ulceration, oral/nasal bleeding, and oesophageal variceal bleeding): hematemesis
Pyloric stenosis: Projectile vomiting, in first few weeks of life
Vomiting at the end of paroxysmal coughing: whooping cough
Abdominal tenderness/abdominal pain on movement:surgical abdomen
Abdominal distension: intestinal obstruction
Hepatosplenomegaly : Chronic liver disease, inborn error of metabolism
Blood in the stool: Intussusception, bacterial gastroenteritis
Severe dehydration, shock: Severe gastroenteritis, systemic infection (urinary tract infection, meningitis), diabetic ketoacidosis,
Bulging fontanelle or seizures : Raised intracranial pressure,
Faltering growth: Gastro-oesophageal reflux disease, coeliac disease and other chronic gastrointestinal conditions
Infants Gastro-oesophageal reflux Feeding problems Infection: • Gastroenteritis • Respiratory tract/otitis media • Whooping cough (pertussis) • Urinary tract • Meningitis Food allergy and food intolerance Eosinophilic oesophagitis Intestinal obstruction: • Plyoric stenosis • Atresia – duodenal, other sites • Intussusception • Malrotation • Volvulus • Duplication cysts • Strangulated inguinal hernia • Hirschsprung disease Inborn errors of metabolism Congenital adrenal hyperplasia Renal failure
Preschool children Gastroenteritis Infection: • Respiratory tract/otitis media • Urinary tract • Meningitis • Whooping cough (pertussis) Appendicitis Intestinal obstruction: • Intussusception • Malrotation • Volvulus • Adhesions • Foreign body – bezoar Raised intracranial pressure Coeliac disease Renal failure Inborn errors of metabolism Torsion of the testis
School age and adolescents Gastroenteritis Infection – including pyelonephritis, septicaemia, meningitis Peptic ulceration and H. pylori infection Appendicitis Migraine Raised intracranial pressure Coeliac disease Renal failure Diabetic ketoacidosis Alcohol/drug ingestion or medications Cyclical vomiting syndrome Bulimia/anorexia nervosa Pregnancy Torsion of the testis
Vomiting in infants
• Common chronic cause is gastro-oesophageal reflux.
• Feed volumes should be calculated as overfeeding is common in bottle-fed infants.
• If transient, with other symptoms, e.g. fever, diarrhoea or runny nose and cough, most likely to be gastroenteritis or respiratory tract infection, but consider urine infection, sepsis or meningitis.
• If projectile at 2–8 weeks of age, exclude pyloric stenosis.
• If bile stained, potential emergency – exclude intestinal obstruction, especially intussusception, malrotation and a strangulated inguinal hernia. Assess for dehydration and shock.
What is GER? Which people is it common in? What causes it? Name three things that contribute to GER? While common in the 1st year of life, nearly all symptomatic reflux resolves spontaneously by 12 months of age. True or false and why? Most infants w GER have what? What happens when GER becomes a significant problem? GERD is common in which kids? Name some complications of GERD in kids How do you manage GERD
Gastro-oesophageal reflux
Gastro-oesophageal reflux is the involuntary passage of gastric contents into the oesophagus. It is extremely common in infancy. It is caused by inappropriate relaxation of the lower oesophageal sphincter as a result of functional immaturity. A predominantly fluid diet, a mainly horizontal posture and a short intra- abdominal length of oesophagus all contribute. While common in the 1st year of life, nearly all symptomatic reflux resolves spontaneously by 12 months of age. This is probably due to a combination of maturation of the lower oesophageal sphincter, assumption of an upright posture and more solids in the diet.
Most infants with gastro-oesophageal reflux have recurrent regurgitation or vomiting but are putting on weight normally and are otherwise well, although the mess, smell, and frequent changes of clothes (5% of those affected have 6 or more episodes each day) is frustrating for parents and carers.
Gastro-oesophageal reflux is usually a benign, self- limited condition but when it becomes a significant problem it becomes gastro-oesophageal reflux disease and needs treatment.
Gastro-oesophageal reflux disease is more common in:
• childrenwithcerebralpalsyorother neurodevelopmental disorders
• preterm infants, especially in those with bronchopulmonary dysplasia
• following surgery for oesophageal atresia or diaphragmatic hernia.
-neuromuscular problems or has had surgery to the oesophagus or diaphragm.
Complications of gastro-oesophageal reflux (i.e. gastro-oesophageal reflux disease)
• Faltering growth from severe vomiting
• Oesophagitis – haematemesis, discomfort on
feeding or heartburn, iron-deficiency anaemia
• Recurrent pulmonary aspiration – recurrent
pneumonia, cough or wheeze, apnoea in
preterm infants
• Dystonic neck posturing (Sandifer syndrome)
• Apparent life-threatening events
Management:
Uncomplicated gastro-oesophageal reflux has an excellent prognosis and can be managed by parental reassurance, adding inert thickening agents to feeds (e.g. Carobel), and smaller, more frequent feeds.
Significant gastro-oesophageal reflux disease is managed with acid suppression with either hydrogen receptor antagonists (e.g. ranitidine) or proton-pump inhibitors (e.g. omeprazole). These drugs reduce the volume of gastric contents and treat acid-related oesophagitis. The evidence for the use of drugs that enhance gastric emptying (e.g. domperidone) is poor and as they are associated with significant side-effects their use should be discouraged. If the child fails to respond to these measures, other diagnoses such as cow’s milk protein allergy should be considered and further investigations performed.
Surgical management is reserved for children with complications unresponsive to intensive medical treat- ment or oesophageal stricture. A Nissen fundoplica- tion, in which the fundus of the stomach is wrapped around the intra-abdominal oesophagus, is performed either as an abdominal or as a laparoscopic procedure.
In pyloric stenosis what causes gastric outlet obstruction? When does it present irrespective of gestational age?
It is common in which sec? Particularly which people and there may be a fam history on which side of the family?
What’s re the clinical features?
What occurs as a result of vomiting stomach contents?
In diagnosis of pyloric stenosis unless what is required what is performed?
Gastric peristalsis may be seen as what? The pyloric mass is usually palpable where? If the stomach is overdistended with air what must be done? What exam may be helpful to confirm diagnosis prior to surgery?
What’s the management of pyloric stenosis
What are the signs of pyloric stenosis?
In pyloric stenosis, there is hypertrophy of the pyloric muscle causing gastric outlet obstruction. It presents at 2–8 weeks of age, irrespective of gestational age. It is more common in boys (4 : 1), particularly firstborn, and there may be a family history, especially on the maternal side.
Clinical features are:
• vomiting, which increases in frequency and forcefulness over time, ultimately becoming projectile
• hunger after vomiting until dehydration leads to loss of interest in feeding
• weight loss if presentation is delayed.
A hypochloraemic metabolic alkalosis with a low plasma sodium and potassium occurs as a result of vomiting stomach contents.
Diagnosis
Unless immediate fluid resuscitation is required, a test feed is performed. The baby is given a milk feed, which will calm the hungry infant, allowing examination. Gastric peristalsis may be seen as a wave moving from left to right across the abdomen (Fig. 14.3a). The pyloric mass, which feels like an olive, is usually palpable in the right upper quadrant (Fig. 14.3b). If the stomach is overdistended with air, it will need to be emptied by a nasogastric tube to allow palpation. Ultrasound examination may be helpful (Fig. 14.3c) to confirm the diagnosis prior to surgery.
Management
The initial priority is to correct any fluid and electrolyte disturbance with intravenous fluids. Once hydration and acid–base and electrolytes are normal, definitive treatment by pyloromyotomy can be performed. This involves division of the hypertrophied muscle down to, but not including, the mucosa (Fig. 14.3d). The opera- tion can be performed either as an open procedure via a periumbilical incision or laparoscopically. Postopera- tively, the child can usually be fed within 6 hours and discharged within 2 days of surgery.
• Signs are visible gastric peristalsis, palpable abdominal mass on test feed, and possible dehydration.
• Associated with hyponatraemia, hypokalaemia, and hypochloraemic alkalosis.
• Diagnosis may be confirmed by ultrasound.
• Treated by surgery after rehydration and
correction of electrolyte imbalance.
Crying in healthy babies represents baby’s response to what?
What complain may also be a pointer to potential or actual non-accidental injury.? If there a sudden onset of crying what may it be due to?
Why can cause miserable crying infant?
What is infant colic? Paroxysmal inconsolable crying or screaming often accompanied by what can take place is infant colic? When does it typically occur? If the colic is severe an persistent it may be due to what?
In most, it represents the baby’s response to hunger and discomfort. Reassurance and advice on appropriate feeding will usually suffice.
Some babies cry for prolonged periods in spite of feeding and comforting and this is distressing for all concerned. It can engender a feeling of anxiety, helplessness and depression in parents and carers, par- ticularly if they are inexperienced or poorly supported. It has also been suggested that the emotional climate within a home may be transmitted to a baby, and that in some instances, tense, anxious, or irritable caregivers are more likely to have fretful babies. The complaint that a baby is ‘always crying’ may also be a pointer to potential or actual non-accidental injury.
A cause for the crying is identified in a minority of infants. If of sudden onset, it may be due to a urinary tract, middle ear or meningeal infection; pain from an unrecognized fracture; oesophagitis; or torsion of the testis. Severe nappy rash and constipation may produce a miserable, crying infant. Preterm infants who have spent several weeks in hospital can be difficult to settle, as can infants with a chronic neurological disorder, e.g. cerebral palsy. On the basis of countless reports of parents, eruption of teeth is painful in some infants. However, teething does not cause vomiting, diarrhoea, high fever or seizures.
Acknowledging that troublesome crying is extremely distressing is part of the management. Reducing overstimulation from jigging and winding and encouraging a quiet environment and holding the baby close until the crying stops appear to help many babies.
Infant ‘colic’
The term ‘colic’ is used to describe a common symptom complex that occurs during the first few months of life. Paroxysmal, inconsolable crying or screaming often accompanied by drawing up of the knees and passage of excessive flatus takes place several times a day. There is no firm evidence that the cause is gastrointestinal, but this is often suspected. The condition occurs in up to 40% of babies. It typically occurs in the first few weeks of life and resolves gradually from 3–12 months of age. The condition is benign but it is very frustrat- ing and worrying for parents and may precipitate non-accidental injury in infants already at risk. Support and reassurance should be given. ‘Gripe water’ is often recommended but is of unproven benefit. If severe and persistent, it may be due to a cow’s milk protein allergy and an empirical 2-week trial of a protein hydrolysate formula (cow’s milk protein free) may be considered and continued if symptoms improve. If they do not, then a trial of gastro-oesophageal reflux treatment may be considered.
What are the causes of acute abdominal pain?
Which cause of acute abdominal pain surgically is most common
Which organs must always be checked in acute abdominal pain ?
Although it may occur at any age, it is very uncommon in children of how many years? What are the clinical features of acute uncomplicated appendicitis?(state four signs and four symptoms don’t forget to characterize pain)
What may cause referred pain to the abdomen?
Primary peritonitis is seen in which patients?
What sugar related disease can cause severe abdominal pain? What are two uncommon causes of acute abdominal pain that must not be missed. Why will it be important to test the urine sample ? Pancreatitis may present w acute abdominal pain and what marker should be checked?
Appendicitis is a progressive condition and so repeated observation and clinical review every few hours are key to making the correct diagnosis, avoiding delay on the one hand and unnecessary laparotomy on the other. True or false
Give some signs of complicated appendicitis
In Acute abdominal pain in older children and adolescents wha causes should you exclude? What should you check for in boys ? What is seen when you palpate the abdomen of kids w acute appendicitis? How do you distinguish between acute appendicitis and non-specific abdominal pain ?
When is laparotomy indicated?
Surgical: Acute appendicitis Intestinal obstruction including intussusception Inguinal hernia Peritonitis Inflamed Meckel diverticulum Pancreatitis Trauma
From surgical to Intra-abdominal to medical : Non-specific abdominal pain Gastroenteritis Urinary tract: • urinary tract infection • acute pyelonephritis • hydronephrosis • renal calculus Henoch–Schönlein purpura Diabetic ketoacidosis Sickle cell disease Hepatitis Inflammatory bowel disease Constipation Recurrent abdominal pain of childhood Gynaecological in pubertal females Psychological Lead poisoning Acute porphyria (rare) Unknown Extra-abdominal:
Upper respiratory tract infection Lower lobe pneumonia
Torsion of the testis
Hip and spine
Appendicitis
The testes, hernial orifices and hip joints must always be checked.
- lower lobe pneumonia may cause pain referredto the abdomen
- primary peritonitis Is seen in patients with ascites from nephrotic syndrome or liver disease
- diabeticketoacidosismaycausesevereabdominal pain
- urinary tract infection, including acute pyelonephritis, is a relatively uncommon cause of acute abdominal pain, but must not be missed. It is important to test a urine sample, in order to identify not only diabetes mellitus but also conditions affecting the liver and urinary tract
- pancreatitismaypresentwithacuteabdominal pain and serum amylase should be checked.
Acute appendicitis
Acute appendicitis is the most common cause of abdominal pain in childhood requiring surgical inter- vention .Although it may occur at any age, it is very uncommon in children under 3 years of age. The clinical features of acute uncomplicated appen- dicitis are:
• Symptoms
– Anorexia
– Vomiting
– Abdominal pain, initially central and colicky (appendicular midgut colic), but then localizing to the right iliac fossa (from localized peritoneal
• inflammation)
Signs
– Fever
– Abdominal pain aggravated by movement, e.g.
on walking, coughing, jumping, bumps on the
road during a car journey
– Persistent tenderness with guarding in the right
iliac fossa (McBurney’s point). However, with a retrocaecal appendix,localized guarding may be absent, and in a pelvic appendix there may be few abdominal signs.
Appendicectomy is straightforward in uncompli- cated appendicitis. Complicated appendicitis includes the presence of an appendix mass, an abscess, or perforation. If there is generalized guarding consistent with perforation, fluid resuscitation and intravenous antibiotics are given prior to laparotomy. If there is a palpable mass in the right iliac fossa and there are no signs of generalized peritonitis, it may be reasonable to elect for conservative management with intravenous antibiotics, with appendicectomy being performed after several weeks. If symptoms progress, laparotomy is indicated.
Acute abdominal pain in older children and adolescents
• Exclude medical causes, in particular lower lobe
pneumonia, diabetic ketoacidosis, hepatitis, and
pyelonephritis.
• Check for strangulated inguinal hernia or
torsion of the testis in boys.
• On palpating the abdomen in children with
acute appendicitis, guarding and rebound tenderness are often absent or unimpressive, but pain from peritoneal inflammation may be demonstrated on coughing, walking or jumping.
• To distinguish between acute appendicitis and non-specific abdominal pain may require close monitoring, joint management between paediatricians and paediatric surgeons and repeated evaluation in hospital.
