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Paediatrics - Gastrointestinal History (Other features (Abdominal pain…
Paediatrics - Gastrointestinal History
Diarrhoea
Blood in stool
Intussusception
Intermittent crying and clutching stomach, pale during episodes, increasing lethargy, refusing feeds
Blood stained mucous in stool
Treatment - resuscitation, air enema if no peritonitis, surgical reduction
Diagnosis: clinical suspicion, distended small bowel on CXR, 'target sign' on USS
Gastroenteritis
Bacterial
Campylobacter, shigella, salmonella, e. coli
Viral (most common)
Adenovirus, norovirus, coronavirus, astrovirus, rotavirus
Management
Prevent dehydration (ORS), IV fluids if persistent vomiting/ shock
Higher risk groups
Infants under 6 months/ low birth weight
6+ diarrhoeal stools in 24 hours
3+ vomits in 24 hours
Unable to tolerate extra fluids
Malnourished
IBD
Crohn's
Cramping pain, potential fistulas/ abscesses/ obstruction, only slight increase in colon cancer risk
Treatment: polymeric diet (whole protein feeds) for 6-8 weeks, systemic steroids, immunosuppressants to maintain remission
Terminal ileum, skip lesions, transmural
May require enteral nutrition or surgery in severe disease
Ulcerative Collitis
Bloody diarrhoea, potential haemorrhage or toxic megacolon, marked increase in colon cancer risk
Treatment: aminosalicylates (mesalazine) for induction and maintenance, topical steroids/ immunomodulators
Rectum, continuous lesions, submucosal
Watery, mucousy diarrhoea, crampy abdominal pain relieved by defaecation, tiredness, weight loss
Investigations: upper/ lower endoscopy, histological findings
Vomiting
Projectile vomiting
first few weeks of life
Pyloric stenosis
Investigations: test feed, USS, blood gas (metabolic alkalosis, hypochloraemic, hypokalaemic)
Management: fluid resuscitation if required (20ml/kg), correct fluid/ electrolyte balance, NG tube to reduce air pressure in stomach, pyloromyotomy
Pyloric muscle hypertrophy causing gastric outlet obstruction
Signs: visible gastric peristalsis, palpable abdominal mass, dehydration
Haematemesis
Oesophagitis, peptic ulcers, oral/ nasal bleeding, varices
Bile-stained vomit
Intestinal obstruction
With coughing
Pertussis - Vomiting at the end of paroxysmal coughing
Gastroenteritis, appendicitis
Other features
Abdominal pain
Surgical abdomen
Pain on movement
IBD (Crohn's)
Cramping pain, worse after certain foods
UTI, gastroenteritis, DKA, hepatitis, constipation, gynaecological, psychological, inguinal hernia, peritonitis, inflamed meckel diverticulum, pancreatitis, torsion, intusussception
Appendicitis
Soft abdomen, Rovsing's positive
Most common cause of abdominal pain requiring surgery, uncommon in under 3s
Vomiting, off food, limping with pain/ crying when moved
Non-specific
Resolves in around 48 hours with no clear cause
Often mimics appendicitis
Usually accompanied with cervical lymphadenopathy and recent or current viral illness
"Mesenteric adenitis"
Malrotation
Upper GI contrast study, surgical correction
Predisposition to obstructive volvulus due to mesentery not being fixed during foetal life
First few days of life - bilious vomiting, possible peritonitis/ shock
Recurrent (3 months+)
Abdominal migraine
Long periods of no symptoms, then 12-48 hours with
Personal/ family history of migraine
Midline pain with pallor and vomiting
IBS
Modulated by stress/ anxiety
Loose mucousy stools, bloating, feeling of incomplete defecation, constipation
Altered gastrointestinal motility, abnormal sensitivity to intra-abdominal events
Must exclude coeliac
Abdominal distension
Obstruction/ strangulated hernia
Hepatosplenomegaly
Chronic liver disease
Severe dehydration
Severe gastroenteritis/ DKA
Bulging fontanelle
Raised ICP
Faltering growth
Gastro-oesophageal reflux
Vomiting and irritable after feeds
Factors: fluid diet, horizontal posture, short intra-abdominal length
Occurs in normal infants, often spontaneously resolves by 12 months
GORD
Recurrent pulmonary aspiration - pneumonia, cough, wheeze or apnoea
Dystonic neck posturing, oesophagitis
Investigations (if complicated) - 24hr oesophageal pH, 24hr impedence monitoring, endoscopy + biopsies, contrast studies
Feed thickener, smaller more frequent feeds, PPIs if significant, CMPA if no response, surgical if unresponsive
Coeliac disease
Other History