The Child with Vomiting/Abdominal Pain

Question 1

What are the characteristics of childhood vomiting caused by GORD?

Answer 1

• Regurgitation of food - after feed, can be forceful but usually effortless. Never bile-stained
• Noisy breathing (acid irritation and secretions)
• May have signs of pain (arched back etc.) if acid irritation
• Irritability
• Failure to thrive

Question 2

When does childhood GORD normally resolve? What measures may be needed?

Answer 2

• Normally resolves by 9-15 months
• Diet changes - thickened feeds, smaller and more frequent
• Posturing - in cot with head up (supine) rather than sitting
• “Tummy time” - prone positioning aids gastric emptying
• Medications rarely used
  
  • Antacids/H2 - if reflux associated with distress
  • PPIs - if reflux oesophagitis
• Surgery - if severe, persistent, refractory to medical treatment

Question 3

What are some of the classic presetning features of intussusception? What investigations should you order?

Answer 3

• Spasms – screaming and pallor with legs drawn up. 10-15 minutely for 2-3 minutes
• Vomiting - early symptom
• Passage of blood/slime/red-currant jelly PR (late feature)
• Investigations
  
  • CXR +/- US
  • Barium enema (also treatment) - air enema more common now

Question 4

What are the classic presenting features of hypertrophic pyloric stenosis?

Answer 4

• 2-6 weeks after birth (regardless of prematurity)
• Progressive milky/curdled vomits becoming projectile
• Continual hunger, even after feeds
• Ex - visible gastric peristalsis, hypertrophic pylorus is sometimes felt below right costal margin (olive-sized)

Question 5

What are the classic presenting features of appendicitis?

Answer 5

• Flushed, febrile, tachycardic
• Migratory pain from poorly localised cramping central abdominal pain (midgut colic) to well-localised peritonitic pain
• Peritonism (guarding, tenderness and inflammatory signs e.g. percussion)

Question 6

What is the pathophysiology of volvulus? How does it present?

Answer 6

• Condition where the DJJ and the ileocaecal junction are close together, predisposing to volvulus of the shortened mesentery (which may overlay the duodenum)
• Bilious vomiting at day 1-3
• Late signs: abdominal distension

Question 7

What is the diagnostic test if considering volvulus? The management?

Answer 7

• Diagnosis
  
  • Upper GI contrast study
• Management
  
  • Surgery

Question 8

What is the definition of functional abdominal pain?

Answer 8

• Generally recurrent umbilical/peri-umbilical pain occurring in the absence of other red-flag features (vomiting, tenderness, waking from sleep, fever, weight loss, urinary symptoms)

Question 9

Describe the prognosis of childhood functional abdominal pain

Answer 9

• Reassurance and explanation
• 50% resolve quickly and spontaneously
• 25% take months to resolve
• 25% symptoms return or continue as adults as migraine, IBS

Question 10

What is an abdominal migraine? What treatment might be appropriate?

Answer 10

• Recurrent abdominal pain in children with a family history of migraine
• Usually midline, associated with vomiting and pallor, headache
• Treatment
  
  • Reassurance, trigger avoidance
  • Simple analgesia, antiemetics
  • Cyproheptadine (prophylaxis)