Abdominal Presentation in Infants and Children

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

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

7. Oesophageal atresia +/- fistula 1 in 2500-3000 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

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. MeconiumIleus • Abdominal distension • Failure to pass meconium • Obstruction of the dital ileum from inspissatedmeconium • Usually a manifestation of CF ( and the earliest)

12. What is the possible diagnosis?

13. Affects 1:5000 Boys more than girls 98% diagnosed in newborns Abdominal distension Vomiting- may be bilious Not passing stool Hirschsprung’s Disease

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. 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 Inguinal Hernia

19. Inguinal Hernia

20. 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 Umbilical hernia

21. GORD • Usually commences in first six weeks • Majority resolves by 1yr • Non forceful • Coughing, hiccups • Swallowing, gulping • Discomfort during or after feeding

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

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%

27. Intussusception

28. 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 Volvulus

29. Immediate referral for upper GI contrast • Surgical management

30. Toddlers/Pre-school • Diarrhoea and Vomiting • Constipation • MeckelsDiverticulum • 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. 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 Constipation

33. 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 Idiopathic Constipation

34. Acute GI Bleed • History • 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

35. 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 Abdopain Sepsis/ peritonitis/bowel obstruction Surgical intervention Meckel’sDiverticulum

36. 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 Wilms’ Tumour

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

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

39. 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. Acute Appendicitis

40. 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. 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 Testicular Torsion

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

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 27-33. • 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):p997-1002. • 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 PediatricGastroenterology & 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):p176-86. • 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 http://emedicine.medscape.com/article/802064-overview • 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;74:1319-1322. • Minks, R. Pediatric Appendicitis Clinical Presentation http://emedicine.medscape.com/article/926795-clinical • 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