Peads - Acute Abdominal Pain Flashcards
1
Q
How common is haematemesis in children?
A
Uncommon
(often due to Mallory-Wiss tear but need to consider other causes)
2
Q
What questions are important regarding vomiting & stool?
A
Vomit:
- Frequency, volume, triggers, timeline
- Blood?
- Haematemesis
- Bile?
- Bilious vomiting = always abnormal
Stool:
- Frequency, consistency / form, timeline, Bristol stool chart
- Blood?
- Stool - fresh on wiping (?peri-anal pathology), on outside of hard stool (?constipation), mixed in with soft stool (?infection - likely bacterial blood in stool)
- Mucus - possible infection
3
Q
What are functional GI disorders?
A
Functional GI disorders are common disorders characterised by persistent & recurring GI symptoms due to ‘abnormal functioning’ of the GI tract
(I.e. NOT due to structural or biochemical abnormalities - thus scan and blood tests often appear normal)
Examples:
- Irritable Bowel Syndrome (IBS)
- Functional dyspepsia
- Functional abdominal pain
- Functional constipation or diarrhoea
4
Q
In a paediatric GI case what ‘red flag’ features can you name that would prompt further investigation?
A
History:
- Age < 5yrs
- Systemic symptoms: weight loss, fever, dysphagia, vomiting (?blood, bilious)
- Nocturnal symptoms - that wake child from sleep
- Persistent RU or RL abdo pain
- Dysuria / haematuria / flank pain
- Chronic NSAID use
- FHx of IBD / coeliac / peptic ulcer disease
Examination:
- Growth deceleration
- Delayed puberty
- Jaundice or Pallor
- Rebound / guarding / organomegaly
- Perianal disease
- Blood in stool
Investigations:
- ↑ WCC
- ↑ inflammatory markers
- anaemia or hypoalbuminaemia
5
Q
Abdominal tenderness / pain can be difficult to evaluate when examining a child, what other observation can provide information as to whether the child is in pain?
A
Behaviour
- Walking normally / normal play / climb onto bed without discomfort = likely not in serious pain
6
Q
What are some common causes of malaena in children?
A
- Infection - e.g. bacterial diarrhoea ( e.g. campylobacter, salmonella)
- IBD - Crohn’s or UC
- Tearing of anal vein
- Polyp
- Intussusception - child will be acutely unwell
7
Q
What investigation can be done on stool if suspecting IBD?
A
Faecal Calprotectin Test
- Faecal calprotectin ↑↑ (up to 10 times) in IBD
- Not specific for IBD!! - can be ↑ due to polyps or infection
- Faecal calprotectin = normal in IBS
8
Q
How does the Faecal Calprotectin Test work?
A
- Calprotectin = complex of proteins, which in the presence of Ca2+ can sequester metals; iron, manganese and zinc –> this gives antimicrobial properties
- Calprotectin comprises up to 60% of soluble content of cytosol of neutrophils –> which secrete it during inflammation
- IBD –> causes migration of neutrophils into intestinal mucosa –> which secrete calprotectin, which moves into the intestinal lumen = faecal calprotectin –> thus faecal calprotectin is ↑ inflammatory bowel diseases (UC and Crohn’s can have 10x ↑ in faecal calprotectin)
9
Q
What features are common to both UC and Crohn’s, including ‘extra-intestinal’ symptoms?
A
- Abdominal pain
- Diarrhoea
- Fever
- Weight loss (more so in Crohn’s)
- Arthralgia / arthritis in large joints (most common extra-instestinal features of both UC and Crohn’s)
- Ulcers in mouth and vagina - (more common in Crohn’s)
- Anterior uveitis - inflammation of iris (pain, photophobia, redness, irregular pupil)
- Skin:
- Erythema Nodosum - painful itchy raised round lumps (1-5cm), commonly on legs (more common in UC)
- Pyoderma gangrenosum - dead black pus necrotic tissue, commonly on legs or around stoma
- Primary sclerosing cholangitis (more common in UC)
10
Q
What are the key features of Ulcerative Colitis?
A
Define:
- UC is a relapsing-remitting disease characterised by;
- Colon inflammation (lead-pipe appearance on barium enema)
- Rectal bleeding
- Ulcers interspersed with preserved mucosa –> producing pseudo-polyps
Signs/Symptoms:
- Bloody diarrhoea
- Mucus in stool
- Tenesmus - feeling of incomplete defecation
- Feacal urgency
- Abdominal pain (particularly LLQ)
- Extra-intestinal features
Physiology of Inflammation:
- Inflammation is worse/starts distally in the rectum and can progress proximally BUT rarely passes ileocecal valve
- No inflammation beyond submucosa (confined to mucosa + submucosa)
- Neutrophils migrate into glandular lumens forming ‘crypt abscesses’
-
40-50% Proctitis = inflammation of anus/rectum (only first 6 inches of rectum)
- Proctosigmoiditis = inflammation of rectum + sigmoid colon
- 30-40% Left-sided colitis = Inflammation can spread in proximal direction i.e. from rectum/sigmoid backwards through descending colon
- 20% extensive colitis = Inflammation can spread further proximally to involve transverse colon
- Pancolitis = inflammation of entire colon
Prognosis:
- NO ↓ in mortality, 10-30% need colectomy (within 10yrs post onset)
11
Q
Flares of Ulcerative Colitis can be classified as; Mild, moderate and severe - what are the features of each?
A
-
Mild:
- < 4 stools / day (with/without blood)
- No systemic disturbance
- Normal ESR + CRP
-
Moderate:
- 4-6 stools / day (with/without blood)
- Minimal systemic disturbance
-
Severe:
- > 6 stools / day - contains blood
- Evidence of systemic disturbances e.g.
- Fever
- ↑ HR (tachy)
- ↑ ESR
- Abdo pain, distension or reduced bowel sounds
- Anaemia
- Hypoalbuminaemia
12
Q
What tests might you want to do in a patient with UC?
A
Beside:
- Obs - ↑ temp, ↑ HR, ↑ RR in severe flare of UC
- Abdominal exam - LLQ pain, clubbing, erythema nodosum, pyoderma gangrenosum, iritis
- PR exam - may show blood on glove
- Stool sample - ↑ WBCs suggestive of infective cause
Bloods: - in flare
- FBC:
- ↑ WCC
- ↑ platelets
- ↓ Hb (iron-deficient anaemia)
- ↑ ESR
- ↑ CRP
- pANCA - may be positive in UC (usually negative in Crohn’s)
Other tests:
- Flexible sigmoidoscopy - often shows inflammation, ulceration and bleeding mucosa (is rare rectum/sigmoid are clear in UC)
- AXR - may show air in colon + colonic dilation (often only needed in acute emergency presentations)
-
Barium Enema: - in UC:
- Loss of haustrations
- Superficial ulceration
- Long standing UC: shortened + narrow colon ‘leadpipe’
- Colonoscopy:
- Should not be used during actue attacks of IBD
- Can be used during remission to assess; extent of IBD, perform biopsies to rule out malignancy
13
Q
What are 4 potential complications associated with UC?
A
- Bleeding
- Perforation
- Toxic megacolon
- Colorectal cancer
14
Q
What drugs are used to induce remission of UC and which are used for maintiaining remission?
A
Induce Remission:
- Acute mild:
- 1st line = Topical (suppository or enema) mesalazine
- 2nd line = Topical (suppository or enema) mesalazine + oral prednisolone
- Acute moderate:
- Topical (suppository or enema) mesalazine (aminosalicylate anti-inflammatory) + oral prednisolone
- Acute Severe:
- 1st line = IV steroids e.g. hydrocortisone
- 2nd line = Ciclosporin (immunosuppresant) or Infliximab (monoclonal antibody - not advised due to lack of evidence but is more effective in Crohn’s)
- 3rd line = surgery (colectomy)
Maintaining Remission:
- Oral aminosalicylates e.g. Mesalazine
- Thiopurines e.g. azathipurine or mercatopurine (immunosuppresants)
15
Q
What are the key features of Crohn’s Disease?
A
Define:
- Relapsing-remitting disease
- Can affect any part of GI tract (mouth-anus) often present as ‘skip lesions’ = areas of pathology with gaps of healthy GI tract in-between
- Often involves all layers of bowel + pattern of inflammation gives cobblestone appearances
- Rectum is rarely affected BUT anus often is (fistulae + perianal abscesses)
Signs/symptoms:
-
Diarrhoea (usually non-bloody)
- Can cause constipation if blockage forms e.g. stricture
- Weight loss - crohn’s often affects small intestine (failure to thrive in children)
- Abdominal pain (can mimic appendicitis i.e. umbilical –> LRQ)
- Right iliac fossa mass - 70% of Crohn’s affects the terminal ileum - can produce an abscess
- Fistulae + Abscesses - results from full thickness ulceration of GI tract
- Perianal disease - e.g. skin tags or ulcers
- Non-necrotising granulomas
- Gallstones + renal stones - more common in Crohn’s secondary to reduced bile acid reabsorption (Crohn’s affects small intestine)
- Fat wrapping - mesentery becomes thickened and wraps around bowel to anti-mesenteric border
- Extra-intestinal symptoms
Physiology of Inflammation:
- 40% ileocecal area (ileum + cecum)
- 30-40% small intestine - inflammation appears in segments (skip lesions)
- 20% Crohn’s Colitis = skip lesions in colon (large intestine)
- <10% Perianal inflammation
Prognosis:
- Slight ↓ mortality
- ~50% need surgery (within 10yrs post diagnosis)
16
Q
What are the 4 main complications of Crohn’s Disease?
A
- Stricture - can cause obstruction, presents as ‘acute abdomen’ can mimic appendicitis
- Fistulas = abnormal connnection between 2 organs e.g. bladder-bowel
- Adhesions
- GI cancer - commonly adenocarcinomas of terminal ilieum
17
Q
What test might you do for a patient with Crohn’s Disease?
A
Bedside:
- Abdominal exam - acute abdomen, LRQ pain/mass, clubbing, erythema nodosum, pyoderma gangrenosum, mouth ulcers, iritis
- PR exam - may have blood on glove, identify perianal abscess / skin tags
- Stool samples - to exclude infective diarrhoea (↑ WBCs)
Bloods:
- FBC:
- ↑ WCC (if disease active)
- ↓ Hb (anaemia)
- Serum Iron + B12 if anaemic on FBC - ↓ B12 anaemia
- ↑ CRP
- ↑ ESR
- LFTs - may be deranged if gallstones are present
- U+Es - may be deranged if renalstones are present
Other tests:
- Faecal calprotectin test
- CT - can show fistuals, fistulas and bowel wall changes
- Barium swallow - shows; strictures, mucosal changes and fistulas and picture of skip lesions
18
Q
How is smoking advice potentially different in UC vs Crohn’s?
A
- Potentially don’t stop smoking in UC –> protective in UC, stopping smoking ↑ risk of relapse
- Stop smoking in Crohn’s –> it can be enough to maintain remission
19
Q
How is Crohn’s Disease managed?
A
Crohn’s is NOT treated if asymptomatic (unlike UC)!!
Lifestyle:
- Low residue diet (↓ high-fibre foods e.g. nuts, seeds, fruit and veg) is advised in those with stricture
Pharmacological:
- Acute flares:
- 1st line = Glucocorticoids
- 2nd line = aminosalicylates (5-ASA drugs) e.g. Mesalazine
- Adjunct: Thiopurines e.g. azathipurine or mercatopurine (immunosuppresants) or Methotrexate
- Last line prior to surgery: Infliximab (monoclonal antibody)
- Surgery
- Maintaining remission:
- Stop smoking!!
- Azathipurine or mercatopurine
20
Q
If you were to draw the colon and small intestine to demonstrate affected areas in UC vs Crohn’s how would each look?
A
35
Q
How is intussusception investigated & managed?
A
Investigation:
- Ultrasound - showing ‘target’ or ‘doughnut’ sign (investigation of choice)
Management:
- 1st line = air sufflation (most cases) - involves rectal tube which shoots air into GI tract to force prolapse to correct
- 2nd line = surgery (if air sufflation fails or child has signs of peritonitis)
50
Q
What is Duodenal Atresia?
A
Congenital absence or complete closure of the lumen of the duodenum
Features:
- More common in Down’s syndrome
- Causes polyhydramnios (↑ amniotic fluid) during pregnancy
- occurs because fetus can’t swallow amnitoic fluid & absorb it via digestive tract
- Intestinal obstruction in newborns (few hrs after birth)
- Abdominal distension (absent in proximal atresia)
- Vomiting - bilious / non-bilious (depending on atresia proximal / distal to Ampulla of Vater)
- AXR shows:
- ‘double bubble’ sign - due to distended stomach + dueodenum (seperated by pyloric valve)
- absence of gas distal to obstruction
