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Paediatric Dr Sweatha Ananthalingam (FY1) 2 1 Common 3 Abdo pain & Congenital Vomiting presentations conditions 4 5 6 Surgical Knowledge Practice Questions causes review Abdominal Pain – Causes? Medical Causes Surgical Causes ▪ Constipation ▪ Henoch-Schonlein purpura ▪ Appendicitis ▪ Urinary tract infection▪ Mesenteric adenitis ▪ Bowel obstruction ▪ Abdominal migraine ▪ Pyelonephritis ▪ Testicular torsion ▪ Coeliac disease ▪ Infantile colic ▪ Intussusception ▪ Inflammatory bowel disease ▪ Irritable bowel syndrome ▪ Diabetic ketoacidosis ▪ Ectopic pregnancy RED FLAGS! ▪ Ovarian torsion •Persistent or bilious vomiting ▪ Pregnancy •Severe chronic diarrhoea ▪ Dysmenorrhea •Fever ▪ Pelvic inflammatory disease •Rectal bleeding Functional/Non-organic •Weight loss or faltering growth •Dysphagia •Nighttime pain Vomiting – Causes? • Gastro-oesophageal reflux • Gastritis or gastroenteritis • Pyloric stenosis • Appendicitis • Intestinal obstruction RED FLAGS! • Bilious vomiting • Infections such as UTI, tonsillitis or meningitis, whooping cough • Haematemesis • DKA • Projectile vomiting • Bulimia • Abdominal distension • Blood in the stool • Severe dehydration, shock • Bulging fontanelle or seizures • Faltering growth Constipation  Very common  Idiopathic(+ secondary causes)  Lifestyle factors : low-fibre diet, dehydration, sedentary lifestyle, safeguarding!  Presentation: • Straining and painful passages • < 3 stools a week • Abdominal pain • Hard stools (may be palpable in abdomen) • Retentive posturing • Rabbit dropping stools • Rectal bleeding • Encopresis* • Loss of sensation to open the bowels *Faecal incontinence that is usually not pathological until 4. Large hard stools remain in the rectum and loose stools are able to bypass the blockage causing soiling. Constipation – *Red Flags* • No meconium <= 48 hours of birth - cystic fibrosis or Hirschsprung’s disease • Leg weakness/motor delay - cerebral palsy • Vomiting - intestinal obstruction or Hirschsprung’s disease • Ribbon stool - anal stenosis • Abnormal anus(fistulae, bruising) - anal stenosis, inflammatory bowel disease or sexual abuse • Abnormal lower back or buttocks - spina bifida • Failure to thrive - coeliac disease, hypothyroidism or safeguarding • Acute severe abdominal pain and bloating - obstruction or intussusception • Constipation triggered by introduction of cow’s milk protein Constipation – Management  Rule out red flags!  It is important to provide adequate explanation of diagnosis and management  Correct reversible factors  Laxatives (macrogol is first line)  Encourage visiting the toilet - scheduling visits, a bowel diary, star charts. Caution! •Intestinal obstruction or *Laxatives* perforation •Paralytic ileus. •Crohn's disease or UC •Toxic megacolon 1. Osmotic laxatives - increase the amount of fluid in the large bowel and soften stools •Electrolyte Imbalance • Macrogol(Movicol) – comes in sachets • Lactulose — very sweet liquid. 2. Stimulant laxatives cause peristalsis by stimulating the colonic and rectal nerves. • Senna — many children find the liquid formulation unpalatable; however, the tablets can be taken from 2 years of age (off-label use below 6 years of age) if preferred. • Docusate — has relatively weak stimulant effect, but also stool-softening properties. It is available asboth a liquid formulation and capsules. Only the liquid formulation is licensed for use in children younger than 12 years of age. • Bisacodyl — tablets are licensed for use in children aged 12years and older. • Sodium picosulfate — the liquid formulation is very sweet; the capsules are licensed for use in children aged 4 years and older. GORD  In infants, lower oesophageal sphincter is weaker  It is normal for babies to have some reflux after larger feeds.  Presents with: • Chronic cough • Hoarse cry • Distress, crying or unsettled after feeding • Reluctance to feed • Pneumonia • Poor weight gain > 1-year similar symptoms to adults GORD - Management 1. Reassurance and:-  Small, frequent meals  Burping regularly to help milk settle  Not over-feeding  Keep the baby upright after feeding 2. Altering feeds and Medications  Thickened milk or (specific anti-reflux formulas are available)  Gaviscon mixed with feeds  Proton pump inhibitors 3. Surgical Intervention – (Very severe cases) 2 1 Common 3 Abdo pain & Congenital Vomiting presentations conditions 4 5 6 Surgical Knowledge Practice Questions causes reviewPyloric Stenosis  Progressive hypertrophy of the pyloric muscle, causing gastric outlet obstruction  Risk factors : male, family history  4-6 weeks of age with non-bilious projectile vomiting after feed.  Other symptoms : Feeds hungrily, Weight loss, dehydration*  Examination : Peristalsis + palpable olive size abdominal mass  Investigations : - Blood gas – Hypochloric metabolic alkalosis - USS - Hypertrophy of the pyloric musclePyloric stenosis - Management 1.Peri-operatively:  correct metabolic abnormalities. Fluid boluses for acute hypovolaemia.  Oral feeding to be stopped and a NG tube passed and aspirated at 4 hourly intervals.  Blood gases and U+E’s checked regularly. 2. Surgery : Ramstedt’s pyloromyotomy  Should not be undertaken until electrolyte abnormalities have been corrected.  Post–operative vomiting is common after surgery, due to gastric distension and dysmotility Neonatal Jaundice - 60% of term infants and 80% of preterm infants - unconjugated (physiological or pathological) or conjugated (always pathological) 1. Physiological Jaundice : Starts day 2-3, peaks day 5 and resolves by day 10. Well baby • Increased red blood cell breakdown, Immature liver; 2. Haemolytic disease : less than 24 hours • ? family history • Requires investigation and treatment • haemolytic disease of the newborn (rhesus), spherocytosis 3. Unwell neonate: jaundice as a sign of congenital or post-natal infection 4. Prolonged Jaundice: Jaundice for >14 days in term infants and 21 days in preterm, consider; • Metabolic: Hypothyroid/pituitarism • Breast milk jaundice: well baby, resolves between 1.5-4 months • Biliary atresia *Jaundice in the first 24 hours of life is pathological. This needs urgent investigations and management. Neonatal sepsis is a common cause. Biliary Atresia • Section of the bile duct is either narrowed or absent. • Results in cholestasis, where the bile cannot be transported from the liver to the bowel. • Conjugated bilirubin is excreted in the bile • Management : Surgical - “Kasai portoenterostomy” involves attaching a section of the small intestine to the opening of the liver, where the bile duct normally attaches. Often patients require a full liver transplant to resolve the condition. 2 1 Common 3 Abdo pain & Congenital Vomiting presentations conditions 4 5 6 Surgical Knowledge Practice Questions causes reviewIntestinal Obstruction  Surgical emergency!  Presents with persistent vomiting, abdominal pain, distention, failure to pass stools or flatus.  High pitched and “tinkling” bowel sounds(earlier)  Management – NBM, IV fluids, NG tube for decompression *Causes* •Meconium ileus •Hirschsprung’s disease •Intussusception •Volvulus •Strangulated hernia •Oesophageal atresia •Duodenal atresia •Imperforate anus Intussusception  condition where the bowel “invaginates” into itself.  Associated with : Concurrent viral illness, Henoch-Schonlein purpura, Cystic fibrosis, Intestinal polyps, Meckel diverticulum  Presents with : • Severe, colicky abdominal pain • Pale, lethargic and unwell child • Redcurrant jelly stool – (blood+mucus: sign of ischaemia) • Vomiting • Intestinal obstruction • Right upper quadrant mass on palpation. This is described as “sausage-shaped” Intussusception  Investigations – Uss or contrast enema.  Therapeutic enemas can be used to try to reduce the intussusception.  Surgical reduction may be necessary if enemas do not work.  Complications : obstruction, perforation, gangrenous bowel – SURGERY! Hirschsprung’s Disease  Absent myenteric plexus – stimulates peristalsis  During fetal development parasympathetic ganglion cells migrate down the GI tract.  Hirschsprung’s occurs when these cells do not travel all the way down the colon, and a section is aganglionic – constricted part of the bowel with distention proximally.  Associations : Downs syndrome, Neurofibromatosis, MEN II  Severity of the presentation depends on extent of bowel aganglionosis. • > 24 hours not passing meconium • Chronic constipation • Abdominal pain and distention • Vomiting • Poor weight gain and failure to thrive • Obstruction Hirschsprung’s : Management  Abdominal xray : signs of intestinal obstruction  Rectal biopsy : Diagnostic investigation. Shows absence of ganglionic cells.  Definitive management : surgical removal of aganglionic section of bowel.  Complication? Hirschsprung-associated enterocolitis 20% of neonates with Hirschsprung’s disease in 2-4 weeks of birth Presents with fever, abdominal distention, bloody diarrhoea and sepsis – Life threatening! Management : urgent antibiotics, fluid resuscitation and decompression of bowel. Differentials •Neonatal sepsis •Hirschsprung disease *Necrotizing Enterocolitis* •Intestinal malrotation •Intestinal volvulus •Gastroesophageal reflux •Spontaneous intestinal  Neonatal surgical emergency with significant mortality(20-30%) and morbidity(27%) perforation •Infectious enterocolitis  90% in premature babies  Risk factors : Low birth weight, formula feeding, IUGR, hypoxia;  Inflammation of the intestine leading to cellular damage and death which causes necrosis of the colon and intestine.  Presentation : Intolerance to feeds, Vomiting, Generally unwell, Distended, tender abdomen, Absent bowel sounds, Blood in stools. When perforation occurs signs of peritonitis and shock Necrotizing Enterocolitis*  Investigations : Full blood count - thrombocytopenia and neutropenia CRP - inflammation Blood gas - metabolic acidosis Blood culture - sepsis  A-xray : Dilated bowels loops, Thickened wall; ‘Pneumatosis Intestinalis’  Staged according to the ’Bell scoring system’  Management : NBM, IV fluids, Abx; Surgical removal of necrotic bowel + Stoma; 2 1 Common 3 Abdo pain & Congenital Vomiting presentations conditions 4 5 6 Surgical Knowledge Practice Questions causes review Appendicitis – migratory pain Case 1 Ectopic pregnancy – pregnancy test! Ruptured/twisted ovarian cyst - USS Mesenteric Adenitis – previous URTI?  15- year old with right iliac fossa pain. Differentials? Meckels Diverticulum  Presenting features?  Rovsing's Sign?  Mcburney’s point?  Investigations?  Management : Laparoscopic appendectomyKnowledge review question 1 Investigations for Coeliac disease will only be valid if the patient has been on a diet containinggluten for at least how long? 1. 3 weeks 2. 6 weeks 3. 9 weeks 4. 12 weeksKnowledge review question 1 Investigations for Coeliac disease will only be valid if the patient has been on a diet containinggluten for at least how long? 1. 3 weeks 2. 6 weeks 3. 9 weeks 4. 12 weeksKnowledge review question 2 What pathophysiological change isseen in the villi in classic form Coeliac disease? 1. Hypertrophy 2. Hyperplasia 3. Atrophy 4. Metaplasia 5. DysplasiaKnowledge review question 2 What pathophysiological change isseen in the villi in classic form Coeliac disease? 1. Hypertrophy 2. Hyperplasia 3. Atrophy 4. Metaplasia 5. DysplasiaKnowledge review question 3 What cell mediated autoimmune response occurs in Coeliac disease? 1. T-cell mediated 2. Mediated by phagocytes 3. B-cell medicated 4. Mediated by neutrophilsKnowledge review question 3 What cell mediated autoimmune response occurs in Coeliac disease? 1. T-cell mediated 2. Mediated by phagocytes 3. B-cell medicated 4. Mediated by neutrophils The main characteristics are development of inflammatory anti-gluten CD4 T cell response, anti-gluten antibodies, autoantibodies against tissue transglutaminase, endomysium (connective tissue surrounding intestinal muscle) and the activation of intraepithelial lymphocytesKnowledge review question 4 Which ofthe following features from the history would make a diagnosis of coeliac disease less likely? 1. Fresh blood in the stool 2. Megaloblastic Anaemia 3. Abdominal Distension 4. Weight loss 5. Diffuse Abdominal PainKnowledge review question 4 Which ofthe following features from the history would make a diagnosis of coeliac disease less likely? 1. Fresh blood in the stool 2. Megaloblastic Anaemia 3. Abdominal Distension 4. Weight loss 5. Diffuse Abdominal PainKnowledge review question 5 Which dermatological skin condition is associated with coeliac disease? 1. Erythema Nodosum 2. Erythema Multiform 3. DermatitisHerpetiformis 4. Psoriasis 5. Seborrheic DermatitisKnowledge review question 5 Which dermatological skin condition is associated with coeliac disease? 1. Erythema Nodosum 2. Erythema Multiform 3. DermatitisHerpetiformis 4. Psoriasis 5. Seborrheic DermatitisKnowledge review question 6  A 6-year-old boy is brought to the GP by his mother with a 4-month history of weight loss, abdominal cramping and bloating. The GP suspects coeliac disease and orders an anti-TTG. Which of the following tests does the GP need to order in addition to this to identify a false negative result? 1. Anti-EMA 2. FBC 3. Liver Function Tests 4. Total IgA level 5. CEAKnowledge review question 6  A 6-year-old boy is brought to the GP by his mother with a 4-month history of weight loss, abdominal cramping and bloating. The GP suspects coeliac disease and orders an anti-TTG. Which of the following tests does the GP need to order in addition to this to identify a false negative result? 1. Anti-EMA 2. FBC 3. Liver Function Tests 4. Total IgA level 5. CEA 2 1 Common 3 Abdo pain & Congenital Vomiting presentations conditions 4 5 6 Surgical Knowledge Practice Questions causes reviewPractice Question – 1 A term, exclusively breast fed 6week old infant is brought to his GP with feeding concerns. He often vomits post feed, and appearsuncomfortable filling a feed. Mum has brought him in today as she noticed flecksof red blood in hisstool. On examination he has a mild eczematous rash on his back, but is otherwise well with no signs of dehydration. What is the most likely cause? 1. Pyloric Stenosis 2. Malrotation 3. Rotavirus Infection 4. Cow’s milk protein allergy 5. IntersucceptionPractice Question – 1 A term, exclusively breast fed 6week old infant is brought to his GP with feeding concerns. He often vomits post feed, and appearsuncomfortable filling a feed. Mum has brought him in today as she noticed flecksof red blood in hisstool. On examination he has a mild eczematous rash on his back, but is otherwise well with no signs of dehydration. What is the most likely cause? 1. Pyloric Stenosis 2. Malrotation 3. Rotavirus Infection 4. Cow’s milk protein allergy 5. IntussusceptionPractice Question – 2 Which clinical sign would suggest clinical dehydration? 1. Sunken Eyes 2. Cold Extremities 3. Hypotension 4. Weak peripheral pulses 5. Prolonged central capillary refill timePractice Question – 2 Which clinical sign would suggest clinical dehydration? 1. Sunken Eyes 2. Cold Extremities 3. Hypotension 4. Weak peripheral pulses 5. Prolonged central capillary refill timePractice Question 3  What is the most commonly reported bacterial causative organism for gastroenteritis in the UK? 1. Rotavirus 2. Salmonella Typi 3. Campylobacter 4. E-coli 5. Staph AureusPractice Question 3  What is the most commonly reported bacterial causative organism for gastroenteritis in the UK? 1. Rotavirus 2. Salmonella Typi 3. Campylobacter 4. E-coli 5. Staph AureusPractice Question 4  Which hernia isa risk factor for GORD? 1. Inguinal 2. Femoral 3. Hiatus 4. UmblicalPractice Question 4  Which hernia isa risk factor for GORD? 1. Inguinal 2. Femoral 3. Hiatus 4. UmblicalThank you☺ Resources used: Illustrated book of paediatrics Nice Guidelines Zero-to-finals Teach-me-paediatrics