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Abdominal Presentation in Infants and Children

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1 Abdominal Presentation in Infants and Children
Angie Green RGN, RN ( Child) BSc ( Hons).

2 Objectives Discussion of age specific abdominal presentation in infants and children Red flags

3 Causes Medical DKA IBS Gastroenteritis ( bacteria or viral)
Constipation Flatulence Mesenteric lymphadenitis GI bleed UTI Ureteric calculi Hepatitis Cholecystitis Pancreatitis Sickle cell anaemia/crises Henoch-Schönlein purpura Surgical Bowel obstruction Trauma Appendicitis Hernia Peritonitis Testicular torsion Referred Pain Drugs/toxins Gynae Obstetric

4 Neonatal Period 3/52 baby girl Breast fed Feeding well
Episode of fresh blood in small vomit after feed

5 Blood in vomit Breast fed Well baby No co-morbidity
Thorough assessment Reassurance Advice to mum Risk of mastitis Midwife Safety netting

6 1 day old baby boy Refusing feeds Dribbling saliva Choking/cyanotic episodes when feeding

7 Oesophageal atresia +/- fistula
1 in births

8 Diagnosis of OA Unable to pass NGT
Pass a radio-opaque tube and order AP and lateral XRays of the chest and upper abdomen Prognosis Dependant on anomalies- 97% with no other anomalies, 22% with major cardiac anomalies Contrast- pouch visible

9 Newborn Bile stained vomits Continued vomiting long after feeds Absent bowel movements Absent urination after first voidings

10 Duodenal Atresia 1:10,000 live births Plain abdominal xray
“double-bubble” sign of gas in the stomach with a distended duodenum Approx 8% of infants with Down’s have DA Surgery

11 Meconium Ileus Abdominal distension Failure to pass meconium
Obstruction of the dital ileum from inspissated meconium Usually a manifestation of CF ( and the earliest) Meconium normally passed within 6 hours post delivery Bath- seen in hospital if no meconium after 24 hrs Sweat test for CF- high levels of sodium

12 What is the possible diagnosis?
                  

13 Hirschsprung’s Disease
Affects 1:5000 Boys more than girls 98% diagnosed in newborns Abdominal distension Vomiting- may be bilious Not passing stool 20% of babies will have associated abnormality

14 Hirschsprung’s in an 8 year old

15 Not feeding/gaining weight
Evidence of ? Pneumonia Decreased unilateral AE Increasing resp distress and cyanosis

16 Congenital Diaphragmatic Hernia
Antenatally Late presentation (5%) Incidental finding on CXR Mediastinal shift Shift of cardiac impulse Surgical intervention

17 Infants Volvulus Intussusception Pyloric stenosis GORD
Hernia presentation

18 Inguinal Hernia Majority of cases male
Incidence in full term newborn 3.5% Pre-term incidence as high as 60% Risk of developing intestinal incarceration and strangulation 70% of cases- able to reduce hernia and convert to elective procedure May only be evident when infant crying or straining Rt side more than left Risk of incarceration is higher in pre-term infants and girls

19 Inguinal Hernia

20 Umbilical hernia Occurs in about 10 % of all babies.
More often in girls than in boys. More often in premature babies. Develops when muscle layers around umbilicus do not meet and close after birth Majority will have closed without surgery by age 5 yrs

21 GORD Usually commences in first six weeks Majority resolves by 1yr
Non forceful Coughing, hiccups Swallowing, gulping Discomfort during or after feeding Diagnosis made clinically- effortless regurgitation If not clear may require investigation

22 Management of GORD Feeding in upright position
Left lateral after feeding Smaller more frequent feeds Raising head end of cot Feed thickener Pre-thickened formula Gaviscon Ranitidine Omeprazole Domperidone Simple measures for 2 weeks- baby gaining weight. Left lateral- contents settle away from LES

23 Pyloric Stenosis More common in boys than girls
First born most commonly affected Family history in 10% patients Unexplained hypertrophy of the circular muscles of the pylorus develops Short history of forceful vomiting in a baby of 2-8weeks of age Vomit may contain altered blood, non bile stained Upper abdo may be distended, visible gastric peristalsis may be seen after feed Olive-sized mass palpable at pylorus

24 Pyloric stenosis

25 Bilious vomiting Clinical signs of shock

26 Intussusception Affects more boys than girls Presentation 6 months-2rs
1:1000 live births May be associated with- weaning, gastroenteritis, URTI Caused by telescoping of the bowel usually at the ileocaecal region Colicky pain and vomiting, may be bile stained ‘red-currant-jelly stool’ Paucity of abdo contents in RIF, mass felt in R hypochondriac or epigastrium Reocurrence in less than 5% The ileocecal region consists of the last few inches of the small intestine (the ileum), which moves digesting food to the beginning portion of the large intestine (the cecum).

27 Intussusception

28 Volvulus Malrotation of bowel may predispose infant to volvulus
Bowel become twisted Up to 90% in children younger than 1yr ( up to 60% in 1st month of life) Male: female presentations 2:1 Babies who present in first week of life tend to have more severe obstruction Bilious vomiting, apnoeic episodes, bloody stool, abdo pain, shock Time critical referral Mid gut- superior mesenteric artery

29 Immediate referral for upper GI contrast
Surgical management

30 Toddlers/Pre-school Diarrhoea and Vomiting Constipation
Meckels Diverticulum Wilm’s Tumour GI bleed Appendicitis

31 Diarrhoea and Vomiting
10% of children under 5 years with gastroenteritis present to healthcare services 16% of medical presentations to major paed ED Diagnosis Assessment of dehydration and shock Fluid management Nutrition management Advice

32 Constipation Affects 5-30% of all children
Underestimation of the impact on child and family- poor clinical outcome Presents normally as AAP and/or anal bleeding Diagnosis made on Hx May be able to palpate a loaded descending colon, full rectum Consistency not frequency Grunting in infants, clenching buttocks, rocking up and down on toes, turning red in the face Anal fissure 1in 3 children who become constipated may develop idiopathic constipation

33 Idiopathic Constipation
Hx- Soiling Excessive flatulence Foul smelling wind and stools Irregular consistency of stools Withholding Lack of energy Irritable mood Do not request AXR for diagnosis of idiopathic constipation Treatment not dietary intervention alone Treatment will be needed for several months Children who are not toilet trained to remain on treatment until toilet training well established May need to consider behavioural referral Factors that may impact- fever, dehydration, dietary, psychological, toilet training, medicines, family Hx Movicol, add in stimulant laxative eg dulcolax Need to reassure that is of unknown cause…Some neurological conditions. Hypothyroidism (an underactive thyroid gland). Cystic fibrosis. Rare diseases with abnormal development of the bowel, such as Hirschsprung's disease. As a side-effect of certain medications that a child has to take for another condition

34 Acute GI Bleed History PMH Examination Investigations Management
Quantity Vomit largely blood or contained streaks of blood Clots? PR bleed- fresh or tarry PMH NSAI’s FH Examination ENT Bowel sounds++ may be indication of ongoing bleed PR Investigations bloods Management IV access Fluid Refer NBM Epistaxis, nasal polyps, evidence of ingestion Most common mallory weiss tear, peptic ulcer, oesohageal varices Peptic ulcer- helicobacter pylori- interferes with normal protection of stomach lining.

35 Meckel’s Diverticulum
Most common GI defect ( 2% of all infants) Contains stomach/pancreatic tissue Peak age for symptoms prior to 2 yrs boys: girls 3:1 PR bleed Blood in stool, mucous Abdo pain Sepsis/ peritonitis/bowel obstruction Surgical intervention

36 Wilms’ Tumour Childhood cancer of the kidney (nephroblastoma)
One of the most common types of childhood cancer 1:10,000 70 per year in UK Children under 5 years More girls than boys Anterior presentation

37 Wilm’s Tumour Painless swelling in abdomen Haematuria, unwell,
hypertension, weight loss, loss of appetite USS, CT, biopsy Staging Radiotherapy, chemo, nephrectomy,

38 School age/teenage Constipation Appendicitis Chronic abdominal pain
Mesenteric adenitis Torsion Gynae/obstetric related

39 Acute Appendicitis Peak incidence at 12 years of age
4:1000 children aged 5-14yrs Viral infection, constipation, dehydration may precede presentation The classic history of anorexia and vague periumbilical pain, followed by migration of pain to RLQ and associated fever and vomiting is observed in fewer than 60% of patients.

40 Acute onset of severe pain Vomiting prior to pain Diarrhoea High fever
Atypical Acute onset of severe pain Vomiting prior to pain Diarrhoea High fever Considerations The progression from obstruction to perforation usually takes place over 72 hours. A delay in the diagnosis of appendicitis is associated with rupture and associated complications, especially in young children.

41 Examination Mc Burney’s point Rovsing sign Psoas sign Obturator sign
Try to avoid eliciting rebound tenderness Cough Predicted value of hopping?

42 Mesenteric Adenitis Poorly defined symptoms
MA is self limited inflammatory process that affects the mesenteric lymph nodes in RLQ Thought that inflammation of mesenteric lymph nodes leads to peritoneal reaction Association with strep URTI Site of tenderness may shift when child moves position ‘active observation’ useful Leucocytosis is common Diagnosis is one of exclusion Ultrasound A persisting localized tenderness lasting more than 3-6hrs may warrant surgical exploration

43 Testicular Torsion Teenage boys
May occur from strenuous exercise or injury, or no apparent cause Sudden and severe pain. Swelling and tenderness on the side of scrotum that is affected (more often on the right side). The testicle becomes sore and extremely tender. Associated nausea and vomiting The scrotum may also become red and inflamed Surgery needed within 6 hours Bi-lateral tethering Cremasteric reflex

44 Recurrent Abdominal Pain
Apley (1958) -Waxes and wanes -Occurs with three episodes within a three-month period of time -Is severe enough to affect a child's activities Age group 4-12 yrs Significant because… One of the most common symptoms of childhood Morbidity, lost school days Health resources Chronic- increasing anxiety Organic and functional disorders Apley- Bristol paediatrician Girls more than boys

45 Clinical features Organic Non organic Site of pain Flanks, suprapubic, RUQ, RLQ Central, epigastric Family History- particularly of abdo pain, headache and depression Less likely, but take note of IBS Likely Psychological factors – particularly anxiety Less likely Likely, especially anxiety Headache More likely Alarm symptoms Vomiting generally equally likely but beware persistent or significant vomiting. Chronic severe diarrhoea more likely. Unexplained fever. Gastrointestinal blood loss. Alarm symptoms less likely Abnormal signs Present Absent Abnormal growth/ and or weight loss Abnormal investigations Expected Not found

46 Abdominal presentations in children
Not small adults Assessment difficult Age related Exclusion criteria Red Flags

47 Top tips It is vital that the initial contact with the child is not painful Useful to ascertain child's baseline level of response With repeated episodes of AP over prolonged period always consider child protection issues Examination, examination, examination!

48 What is the Diagnosis?

49 References Aspenuld, G. Langer, J. (2007) Current Management of hypertrophic pyloric stenosis Seminars in Pediatric Surgery 16,p Banez,G (2008) Chronic abdominal pain in children: what to do following the medical evaluation Current Opinion in Pediatrics. 20(5):p571-5. Berger et al (2007)Chronic abdominal pain in children. BMJ. May 12;334(7601):p Craig WR, Hanlon–Dearman A, Sinclair C, et al. Metoclopramide, thickened feedings, and positioning for gastro-oesophageal reflux in children under two years. In: The Cochrane Library, Issue 2, 2006. Dhroove G. et al ( 2010) A Million Dollar work up for abdominal pain- is it worth it? Journal of Pediatric Gastroenterology & Nutrition. 51(5):p579-83, Dixon, M. crawford, D. Teasdale, D. Murphy, J. (2009) Nursing the Highly Dependent Child or Infant Blackwell Publishing Ltd, Oxford. Dufton et al (2009) Anxiety and Somatic complaints in children with recurrent abdominal pain and anxiety disorders Journal of Pediatric Psychology. 34(2):p El-Matary et al (2004)Irritable bowel syndrome: the commonest cause of recurrent abdominal pain in children. Eur J Pediatr.163(10)p584-8.

50 Epsein et al (2008) Clinical Examination Fourth Edition Elsevier Ltd, London.Hennely, K. Bachur, R. ( 2011) Appendictis Update Current Opinion in Pediatrics 23,(3) p 281–285 Hysia, R (2010) Pediatrics, Gastrointestinal bleeding Kanto, W. (2002) Bilious vomiting- Is it That Bad? Journal Watch Pediatrics and Adolescent Medicine August 12. Kessmann J. Hirschsprung's Disease: Diagnosis and Management. Am Fam Phys. 2006;74: Minks, R. Pediatric Appendicitis Clinical Presentation NICE (2010) Constipation in Children and Young People NICE (2009) Diarrhoea and Vomiting in Children Ramchandani, P. et al ( 2011) An Investigation of Health Anxiety in families where Children have Recurrent Abdominal Pain Journal of Pediatric Psychology. 36(4):409-19, 2011 Wyllie R. (2007) Intestinal atresia, stenosis, and malrotation. In: Kliegman RM, Behrman RE, Jenson HB, Stanton BF, eds. Nelson Textbook of Pediatrics. 18th ed. Philadelphia, Pa: Saunders Elsevier


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