| Abdominal pain depends on.... | - Type of stimuli
• Type of nociceptors
• Way of conduction
• Patient’s personality
• Cultural patterns
• Other |
| Etiology of abdominal pain | Diseases of digestive tract
• Diseases of other intraabdominal organs (kidney, urinary tract)
• Disease of organs, systems located outside the abdomen (pleura, lung)
• Systemic diseases (endocrine, metabolic)
• Effect of drugs
• Effect of toxic substances
- organic diseases
- functional disorders |
| Acute abdominal pain – surgical | - Acute pain
• Vomiting
• Abdominal distention
• No gases, no stool, bloody stool
• Fever
• Severe general state
• Peritoneal symptoms |
| Acute abdomen causes | Acute appendicitis
• Ileus
• Intussusception
• Volvulus
• Incarceretion of hernia
• Peritonitis
• Perforation
• Meckel’s divericulitis
• Acute pancreatitis
• Trauma |
| Location and radiation of abdominal pain | Esophageal diseases – pain behind sternum,radiating to back and left shoulder
• Peptic ulcer disease – epigastrium, radiating to back
• Small bowel –around the umbilicus
• Colon – abdominal pain, radiating to back
• Hepatomegaly (stretching of hepatic capsule) – right epigastrium
• Gall bladder – right subcostal region
• pancreas – epigastrium, radiating to back
• Kidneys – costo-vertebral angle, back, side
• Ureter – radiation to testicle, to thight
• Small pelvis – subgastrium, back |
| Factors affecting abdominal pain | Meal – alleviates (duodenal peptic ulcer disease), intensifies (gastric peptic ulcer
disease, pancreatitis, ileus)
• Alcalising drugs, hydrochloric acid reducing drugs (gastric and esophageal
disease)
• Milk – dyscomfort, abdominal distention – lactose intolerance
• Supine position – intensifies, contaction of the legs - alleviates
• Abdominal massage – alleviates in functional pain
• Bowel opening (stool, gase) – alleviates in functional pain |
| What are the accompaninig symptoms of accute abdomen | From gastrointestinal tract
• Nausea
• Vomiting
• Diarrhoea
• Gastrointestinal bleeding
• anorexia
From other systems:
• Fever, weight loss, icterus, painful micturition, cough artritis, eye changes, genital bleeding, fatigue |
| Etiology of vomiting | - Gastrointestinal diseases
• Urinary tract diseases
• Infections
• Central nervous system diseases
• Metabolic diseases
• Functional diseases |
| Accompanying symptoms of vomiting | - Nausea
• Sweating, salivation, chills, paleness, tachycardia, abdominal pain |
| Nausea and vomiting – questions from history | - Since when they occur, intensification
• Time of day, meals
• Projectile vomiting
• Vomit content: food content, bile, blood, coffee grounds vomiting, stagnant
vomiting, fecal vomiting
• Accompanying symptoms: headache, abdominal pain, fever, diarrhoea
• Epidemiological history: contact with people with contagious diseases, similar symptoms in other members of family |
| What can the appearance of vomit tell us? | coffe ground: internal bleeding in upper GI
green: bile present in vomit |
| Vomiting – clinical examples | •Non-forceful, regurgitation – gastroesophageal reflux
- Bile vomiting, stagnant, green vomiting, no gases, no stool, abdominal tenderness – ileus (intestinal obstruction), surgical abdomen
•Morning vomiting, headache, bulging fontanelle, seizures – brain tumor
•Vomiting and loose stools – acute diarrhoea
•Forceful vomiting – pyloric stenosis
•Vomiting and hepatosplenomegaly – chronic liver disease, inborn error of metabolism
•Vomiting and blood in stool – intussesception, bacterial gastroenteritis |
| Stools | Number
• Consistence
• Content: mucus, fresh blood, melena (dark black, tarry feces, caused by
hemoglobin in the blood being altered by digestive enzymes and intestinal
bacteria), pus
• Colour: yellow, green, brown, black (melena), acholic (white, lack of bile,
cholestasis) |
| How do we divide GI bleeding? | into upper and lower |
| Upper GI bleedding causes | - blood from respiratory system
- esophageal varices
- varices of cardia in stomach
- Mallory Weiss syndrome
- peptic ulcer
- haemorrhagic esophagitis
- dudodenal ulcer |
| Upper gastrointestinal bleeding - history | - Is it blood? – contents: dyes, tea, juice, beetroot
• Coffee grounds vomiting – peptic ulcer,
• Fresh blood – esophageal varices
• Blood clot – esophageal varices
• Small pieces of blood
• Stool – melena?, bloody stool – in massive upper gastrointestinal bleeding
• Other sources of blood – swallowed blood in breast fed infants, upper respiratory
tract bleeding, sinuses, tooth, bleeding gums
• How plentiful bleeding |
| What are the different causes of upper Gi bleeding in neonates? | Apparent bleeding
(swallowed blood in brest fed children, mother’s nipple with wound)
•Cow’s milk protein allergy
•Trauma (nasogastric tube)
•ulcer
•esophagitis
•Coagulopathies (congenital, acquired)
•Vascular malformation |
| What are the different causes of upper Gi bleeding in infants? | •Gastroesophageal reflux
•Vomiting
•Hemorrhagic gastritis
•Peptic ulcer
•Vascular malformation
naczyniowe
•Duplication of digestive tract
•Ileus
•coagulopathy |
| What are the different causes of upper Gi bleeding in older children? | Vomiting
•Gastro-esophageal reflux
•Drug-induced (NSAID,
salicylates)
•Peptic ulcer
•Chemical inflammation
•Vascuar malformation
•Cogulopathy
•Crohn’s disease |
| Causes of lower GI bleeding? | - vascular changes
- necrotising enterocolitis (Crohns disease)
- Meckels diverticulum
- polyps
- colitis
- anal varices |
| Lower gastrointestinal bleeding - history | Anal bleeding – small bloody fragments, vessels, red colured mucus
• Melena
• Stool with fresh blood
• Loose
• Formed
• constipated
• Admixture of blood, covered in blood |
| What are the ethiology of lower GI bleeding in children younger than 2 years? | •Cow’s milk allergy
•Bacterial gastroenteroclitis (EPEC,
Salmonella)
•Intussusception, volvulus (ileus)
•Necrotising enterocolitis (neonates)
•Meckel’s diverticulitis
•Coagulopathies (congenital, acquired) |
| What are the ethiology of lower GI bleeding in children older than 2 years? | •Bacterial gastroenterocolitis
(Campylobacter, EPEC, Salmonella,
Yersinia, Cl.difficile)
•Inflammatory bowel diseases
•Meckel’s diverticulum
•Polyp
•Vascular malformation
•Duplication of digestive tract
•Gastrointestinal lymphoma
•Anal varices
•Anal fissure
•Foreign body |
| Ascites | Rare symptom in children
• Fluid in peritoneal cavity
• Patophysiology: hypoalbuminemia, sodium retention, renal failure, fluid retention,
portal hipertension, obstruction of the outflow of lymph
• Diagnosis: end stage liver failure, hepatic cirrhosis, nephrotic syndrome, heart failure, tuberculosis, neoplasm |
| Jaudice etiology | • Overproduction of bilirubin (hemolysis, massive hematoma, rhabdomyolisis)
• Disrupted metabolism - hepatatis – viral, alcoholic, postdrug, other, Gilbert’s
syndrome (inherited, genetic liver disorder, affecting ability to process
bilirubin)
• obstructed excretion (mechanical bile obstruction – cholelithiasis, tumor near
bile duct, pancreatic tumor), cholestasis - condition where bile cannot flow
from the liver to the duodenum (hepatitis, drug-induced) |
| Constipation | infrequent bowel defacation, difficult passage of stools that persists for several
weeks or longer
• Stool: dry, hard
• Accompanying symptoms: abdominal pain, painfull defecation, anal bleeding,
loose stools, underwear staing
• The most frequent habitual constipation
• Frquency of defecation:
• First week: 4 a day
• Breast feeding: 4-7 a day, but also 1 per 7 days
• 1 year – 2 daily
• Older – 1 a day |
| Failure to pass meconium within 24 houts of life, diagnostic concern | Hirschsprung disease |
| Faltering growth/growth failure, diagnostic concern | Hypothyroidism, coeliac disease, other |
| Gross abdominal distension, diagnostic concern | Hirschsprung disease, gastrointestinal dysmotility |
| Abnormal lower limb neurology or deformity, e.g.
talipes or secondary urinary incontinence, diagnostic concern | Lumbosacral pathology |
| Sacral dimple above natal cleft, over the spine –
naevus, hairy patch, central pit, or discoloured
skin, diagnostic concern | Spina bifida occulta |
| Abnormal appearance/position/patency of
anus, diagnostoc concern | Abnormal anorectal anatomy |
| Perianal bruising or multiple fissures, diagnostic concerne | Sexual abuse |
| Perianal fistulae, abscesses, or fissures, diagnostic concerne | Perianal Crohn’s disease |
| Oropharyngeal (upper, pre-esophageal) dysphagia - difficulty swallowing | CNS diseases, prematurity, cerebral palsy, metabolic diseases, long term
tube feeding |
| Esophageal (lower) dysphagia - difficulty passing through the esophagus | - Post-inflammatory stricture of the esophagus
• Esophageal stricture with scarring (after atresia, burns)
• Esophageal neoplasms (rare in children) |
| Anal itching | Anal skin infections (bacterial, fungal)
• Anal fissure
• Haemorrhoids
• Rectal prolapse
• Gastrointestinal parasitic diseases |
| Urinary tract symptoms | Pain
• Urinary incontinence
• Haematuria / Haematuria
• Swelling of the penis / scrotum |
| When do children acuire voiding controll? | 5 y.o. |
| Classification of urinary incontinence | nocturnal
day + night time incontinence
day time incontinence |
| How do we define haematuria / haematuria? | the presence of 5 or more erythrocytes in the field of
view on microscopic examination of the urine sediment in all 3 urine samples taken
at least 1 week apart |
| Osteoarticular system | Edema
• Reddening
• Warming
• Traffic restriction
• Pain
- Number of joints involved
• Symptoms from other organs |
