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ABDO PAIN

ABDO PAIN . Dr Thomas McAvoy GPST1 ( Paeds ). The history. PC: 4 years 8m male, attended A+E Vomiting and abdominal pain HPC: Vomiting 2-3 days on and off (since new years), no blood/bile Few episodes of diarrhoea (no blood/mucus), but BNO properly for 1-2 days

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ABDO PAIN

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  1. ABDO PAIN Dr Thomas McAvoy GPST1 (Paeds)

  2. The history PC: • 4 years 8m male, attended A+E • Vomiting and abdominal pain HPC: • Vomiting 2-3 days on and off (since new years), no blood/bile • Few episodes of diarrhoea (no blood/mucus), but BNO properly for 1-2 days • Over day developed central abdo pain • Pain on PU • Reduced UO (but had PUd) • No pyrexia • No rashes • More sleepy than usual • 2 sisters had similar episodes • No travel/injury

  3. The history PMH: • Nil (no previous attendances) Birth history: • Full term delivery, NVD Family history: • Parents separated • 2 sisters aged 7 Developmental history: • No concerns

  4. Examination • Alert, PAWS 0 • CVS - HS normal, CRT <2s • RESP - Chest clear, equal AE, Some intercostal recession, sharp/short breaths • ABDO – Soft, no-masses, tender over lower abdomen, no guarding/rebound, BS +ve, testes high riding but non-tender

  5. Any thoughts?

  6. Investigations Bloods: Hb 128, WCC 8.8, Plts 316, MCV 82, Neuts 4.59, Na 127, K 3.3, Bicarb 15.1, Urea 8.1, Creat 28, Cl- 92, CRP 384 BM: 9.1 Urinalysis: Glucose –ve, nitrites +ve, leucocytes +ve, Protein ++, Ketones ++ CXR: NAD ABDO XR: normal bowel gas pattern, some evidence of faecal loading, no obstruction

  7. Management • Admitted to ward ?UTI: • Urine MC+S • IV abx • IV fluids • Examination on ward: • Abdomen mildly distended, generalised tenderness, no rebound/guarding, BS difficult to hear • Breathing slightly more erratic

  8. Management • Surgical opinion: • Flushed. Abdomen soft generally, no specific area of tenderness, no guarding/rebound • IMP: intestinal colic +muscular pain secondary to vomiting • Advised suppository

  9. Management • Uncomfortable overnight, not OB • Abdo more distended, flushed, still generalised tenderness (no rebound/guarding), reduced bowel sounds • Further surgical input asked for (FY2) • Continue with plan

  10. Management • Later seen by surgical reg: • Vague picture, but in absence of progress: CT abdo • Reviewed on WR: • RR 25, HR 121, Temp 37.5, SATs 96% OA (PAWS 5) • Still not OB, lethargic, flushed • Sighing resps • Metranidazole added IV • Surgical consultant seen: • Laparotomy

  11. Management • “Gross mucopurulent peritonitis, washout required. Retrocoecal appendix, perforated tip” • IV abx, NG, Aspirates regularly, NBM, TPN early

  12. Abdominal Pain and Surgical Abdomen • In nearly ½ children admitted to hospital, pain resolves undiagnosed • Appendicitis by far most common surgical- important not to delay diagnosis • Easy to belittle clinical signs of abdo tenderness in young children

  13. Causes Causes of acute abdo pain Extra-abdominal Intra-abdominal Medical: NSAP GE Urinary tract (UTI/pyelonephritis, Renal calculus) HSP DKA IBD Gastritis/PU Constipation Recurrent abdo pain of childhood Gynae in pubertal females Psych Unknown Surgical: Acute appendicitis Intestinal obstruction (inc intussusception) Hernia Peritonitis Meckel’s Pancreatitis Trauma URTI LRTI Torsion Hip and spine

  14. Appendicitis • Commonest cause of abdo pain in childhood • Can occur at any age (uncommon under 3 years) • Symps: • Abdo pain: Central then RIF in <60% • Vomiting (usually a few times) • Anorexia, • Diarrhoea atypical • Signs: • Flushed face + oral fetor, • low grade fever (severe after perf- still not common) • Persistent tenderness +/- guarding (+ aggrevated by movement)

  15. Appendicitis • Neonate: • May only be irritability • Preschool: • Diagnosis more difficult • Perforation rapid as omentum less well developed + fails to surround appendix (signs easy to underestimate) • Retrocaecal (15%): • guarding can be absent • can be pain in psoas/flank/RUQ, • delay in pain • Can present with vomiting 1st • Pelvic: • few abdo signs, symptoms in rectum/bladder (pain on voiding/OB) • ?Obturator sign

  16. Appendicitis Becker et al found that 44% of patients diagnosed with appendicitis presented with 6 or more of the following atypical features: • No fever • Absence of Rosving sign • Normal or increased bowel sounds • No rebound pain • No migration of pain • No guarding • Abrupt onset of pain • No anorexia • Absence of maximal pain in the RLQ • Absence of percussive tenderness • Scoring systems available but not widely used (Kharbanda, Samuel, Alvarado) • No investigation or imaging consistently helpful: • WCC often within reference range for 1st 24h • AXR – Helpful in setting of severe constipation, faecaliths • White cells/organisms in urine not uncommon

  17. Mesenteric adenitis Concomitant or antecedent upper respiratory tract infection Fever, malaise, anorexia Nausea and vomiting Mesenteric lymph node inflammation caused by various agents (B-haem strep, staph, Yersinia) Abdo pain RLQ (can be more diffuse) – 20% with normal appendix • Management – quickly identify those who need surgical intervention for ?appendicitis • Diagnosis only definitive if appendix normal/large mesenteric nodes Diarrhoea

  18. Intussusception - Invagination of prox bowel into distal - Usually ileum into caecum - Commonest cause of obstruction after neonatal period (2m-2years) Redcurrent jelly stool- blood stained mucus (late) Severe colicky pain, pallor, drawing up legs Sausage shaped mass - Distended small bowel on XR (+absence of gas in distal colon/rectum) - Air insufflation 75% - Operative reduction 25% - Recurrence <5% Abdominal distension and shock

  19. Meckel’s Diverticulum - 2% have remnent of vitellointestinal duct in form of meckel’s - Ectopic gastric mucosa/pancreatic tissue - Can also present with intusussception, volvulus around a band or diverticulitis (can mimic appendicitis) - Treatment through surgical resection - Most asymptomatic - May present with severe rectal bleeding (not bright red, no malena)

  20. Intestinal non-rotation/mal-rotation around SMA (or failure of caecum to rotate) + anomalies of intestinal fixation (Ladd’s Bands) • May arise during foetal development • Acute midgut volvulus (obstruction with bilious/blood-stained vomits, peritonitis) • Chronic midgut volvulus (malabsorption and pain) • Duodenal obstruction • Herniation Malrotation • Younger = higher rate of mortality • 40% in first week of life (50% diagnosed at 1m, 75% by 1 year) • May present at any age • Corrected through untwisting, mesentery broadened • Sometimes appendix removed to avoid confusion later

  21. Recurrent abdominal pain • Sufficient to interrupt normal activities for at least 3 months • 10% school children • Characteristically central, otherwise well • Usually one of three distinct symptom constellations: • IBS • Non-ulcer dyspepsia • Abdo migraine • ½ become rapidly free of symps • ¼ take months to resolve • ¼ continue into adulthood • Experiences?

  22. THANKYOU FOR LISTENING!

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