8Diagnosis of OA Unable to pass NGT Pass a radio-opaque tube and order AP and lateral XRays of the chest and upper abdomenPrognosisDependant on anomalies- 97% with no other anomalies, 22% with major cardiac anomaliesContrast- pouch visible
9NewbornBile stained vomitsContinued vomiting long after feedsAbsent bowel movementsAbsent urination after first voidings
10Duodenal Atresia 1:10,000 live births Plain abdominal xray “double-bubble” sign of gas in the stomach with a distended duodenumApprox 8% of infants with Down’s have DASurgery
11Meconium Ileus Abdominal distension Failure to pass meconium Obstruction of the dital ileum from inspissated meconiumUsually a manifestation of CF ( and the earliest)Meconium normally passed within 6 hours post deliveryBath- seen in hospital if no meconium after 24 hrsSweat test for CF- high levels of sodium
18Inguinal 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 strangulation70% of cases- able to reduce hernia and convert to elective procedureMay only be evident when infant crying or strainingRt side more than leftRisk of incarceration is higher in pre-term infants and girls
20Umbilical 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 birthMajority will have closed without surgery by age 5 yrs
21GORD Usually commences in first six weeks Majority resolves by 1yr Non forcefulCoughing, hiccupsSwallowing, gulpingDiscomfort during or after feedingDiagnosis made clinically- effortless regurgitationIf not clear may require investigation
22Management of GORD Feeding in upright position Left lateral after feedingSmaller more frequent feedsRaising head end of cotFeed thickenerPre-thickened formulaGavisconRanitidineOmeprazoleDomperidoneSimple measures for 2 weeks- baby gaining weight.Left lateral- contents settle away from LES
23Pyloric Stenosis More common in boys than girls First born most commonly affectedFamily history in 10% patientsUnexplained hypertrophy of the circular muscles of the pylorus developsShort history of forceful vomiting in a baby of 2-8weeks of ageVomit may contain altered blood, non bile stainedUpper abdo may be distended, visible gastric peristalsis may be seen after feedOlive-sized mass palpable at pylorus
26Intussusception Affects more boys than girls Presentation 6 months-2rs 1:1000 live birthsMay be associated with- weaning, gastroenteritis, URTICaused by telescoping of the bowel usually at the ileocaecal regionColicky pain and vomiting, may be bile stained‘red-currant-jelly stool’Paucity of abdo contents in RIF, mass felt in R hypochondriac or epigastriumReocurrence 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).
28Volvulus Malrotation of bowel may predispose infant to volvulus Bowel become twistedUp to 90% in children younger than 1yr( up to 60% in 1st month of life)Male: female presentations 2:1Babies who present in first week of life tend to have more severe obstructionBilious vomiting, apnoeic episodes, bloody stool, abdo pain, shockTime critical referralMid gut- superior mesenteric artery
29Immediate referral for upper GI contrast Surgical management
30Toddlers/Pre-school Diarrhoea and Vomiting Constipation Meckels DiverticulumWilm’s TumourGI bleedAppendicitis
31Diarrhoea and Vomiting 10% of children under 5 years with gastroenteritis present to healthcare services16% of medical presentations to major paed EDDiagnosisAssessment of dehydration and shockFluid managementNutrition managementAdvice
32Constipation Affects 5-30% of all children Underestimation of the impact on child and family- poor clinical outcomePresents normally as AAP and/or anal bleedingDiagnosis made on HxMay be able to palpate a loaded descending colon, full rectumConsistency not frequencyGrunting in infants, clenching buttocks, rocking up and down on toes, turning red in the faceAnal fissure1in 3 children who become constipated may develop idiopathic constipation
33Idiopathic Constipation Hx-SoilingExcessive flatulenceFoul smelling wind and stoolsIrregular consistency of stoolsWithholdingLack of energyIrritable moodDo not request AXR for diagnosis of idiopathic constipationTreatment not dietary intervention aloneTreatment will be needed for several monthsChildren who are not toilet trained to remain on treatment until toilet training well establishedMay need to consider behavioural referralFactors that may impact- fever, dehydration, dietary, psychological, toilet training, medicines, family HxMovicol, add in stimulant laxative eg dulcolaxNeed 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
34Acute GI Bleed History PMH Examination Investigations Management QuantityVomit largely blood or contained streaks of bloodClots?PR bleed- fresh or tarryPMHNSAI’sFHExaminationENTBowel sounds++ may be indication of ongoing bleedPRInvestigationsbloodsManagementIV accessFluidReferNBMEpistaxis, nasal polyps, evidence of ingestionMost common mallory weiss tear, peptic ulcer, oesohageal varicesPeptic ulcer- helicobacter pylori- interferes with normal protection of stomach lining.
35Meckel’s Diverticulum Most common GI defect ( 2% of all infants)Contains stomach/pancreatic tissuePeak age for symptoms prior to 2 yrsboys: girls 3:1PR bleedBlood in stool, mucousAbdo painSepsis/ peritonitis/bowel obstructionSurgical intervention
36Wilms’ Tumour Childhood cancer of the kidney (nephroblastoma) One of the most common types of childhood cancer 1:10,00070 per year in UKChildren under 5 yearsMore girls than boysAnterior presentation
37Wilm’s Tumour Painless swelling in abdomen Haematuria, unwell, hypertension, weight loss, loss of appetiteUSS, CT, biopsyStagingRadiotherapy, chemo, nephrectomy,
38School age/teenage Constipation Appendicitis Chronic abdominal pain Mesenteric adenitisTorsionGynae/obstetric related
39Acute Appendicitis Peak incidence at 12 years of age 4:1000 children aged 5-14yrsViral infection, constipation, dehydration may precede presentationThe 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.
40Acute onset of severe pain Vomiting prior to pain Diarrhoea High fever AtypicalAcute onset of severe painVomiting prior to painDiarrhoeaHigh feverConsiderationsThe 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.
41Examination Mc Burney’s point Rovsing sign Psoas sign Obturator sign Try to avoid eliciting rebound tendernessCoughPredicted value of hopping?
42Mesenteric Adenitis Poorly defined symptoms MA is self limited inflammatory process that affects the mesenteric lymph nodes in RLQThought that inflammation of mesenteric lymph nodes leads to peritoneal reactionAssociation with strep URTISite of tenderness may shift when child moves position‘active observation’ usefulLeucocytosis is commonDiagnosis is one of exclusionUltrasoundA persisting localized tenderness lasting more than 3-6hrs may warrant surgical exploration
43Testicular Torsion Teenage boys May occur from strenuous exercise or injury, or no apparent causeSudden 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 vomitingThe scrotum may also become red and inflamedSurgery needed within 6 hoursBi-lateral tetheringCremasteric reflex
44Recurrent 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 activitiesAge group 4-12 yrsSignificant because…One of the most common symptoms of childhoodMorbidity, lost school daysHealth resourcesChronic- increasing anxietyOrganic and functional disordersApley- Bristol paediatricianGirls more than boys
45Clinical featuresOrganicNon organicSite of painFlanks, suprapubic, RUQ, RLQCentral, epigastricFamily History- particularly of abdo pain, headache and depressionLess likely, but take note of IBSLikelyPsychological factors – particularly anxietyLess likelyLikely, especially anxietyHeadacheMore likelyAlarm symptomsVomiting generally equally likely but beware persistent or significant vomiting. Chronic severe diarrhoea more likely. Unexplained fever. Gastrointestinal blood loss.Alarm symptoms less likelyAbnormal signsPresentAbsentAbnormal growth/ and or weight lossAbnormal investigationsExpectedNot found
46Abdominal presentations in children Not small adultsAssessment difficultAge relatedExclusion criteriaRed Flags
47Top tipsIt is vital that the initial contact with the child is not painfulUseful to ascertain child's baseline level of responseWith repeated episodes of AP over prolonged period always consider child protection issuesExamination, examination, examination!
49ReferencesAspenuld, G. Langer, J. (2007) Current Management of hypertrophic pyloric stenosis Seminars in Pediatric Surgery 16,pBanez,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):pCraig 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):pEl-Matary et al (2004)Irritable bowel syndrome: the commonest cause of recurrent abdominal pain in children. Eur J Pediatr.163(10)p584-8.
50Epsein et al (2008) Clinical Examination Fourth Edition Elsevier Ltd, London.Hennely, K. Bachur, R. ( 2011) Appendictis Update Current Opinion in Pediatrics 23,(3) p 281–285Hysia, R (2010) Pediatrics, Gastrointestinal bleedingKanto, 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 PresentationNICE (2010) Constipation in Children and Young PeopleNICE (2009) Diarrhoea and Vomiting in ChildrenRamchandani, 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, 2011Wyllie 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