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What is the most common cause of appendicitis in children?
What is the most common cause of appendicitis in children?
Which scoring system is used to assess the likelihood of appendicitis?
Which scoring system is used to assess the likelihood of appendicitis?
What additional finding can be considered a late sign of appendicitis?
What additional finding can be considered a late sign of appendicitis?
How is abdominal ultrasound primarily utilized in diagnosing appendicitis?
How is abdominal ultrasound primarily utilized in diagnosing appendicitis?
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What is a significant characteristic of irritable bowel syndrome (IBS)?
What is a significant characteristic of irritable bowel syndrome (IBS)?
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Which symptom is NOT typically associated with appendicitis?
Which symptom is NOT typically associated with appendicitis?
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Which of the following conditions is a common extra-abdominal cause of acute abdominal pain in childhood?
Which of the following conditions is a common extra-abdominal cause of acute abdominal pain in childhood?
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What is the necessary treatment for a confirmed case of appendicitis?
What is the necessary treatment for a confirmed case of appendicitis?
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What is the primary goal of maintenance therapy in managing functional constipation?
What is the primary goal of maintenance therapy in managing functional constipation?
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Which symptom distinguishes infantile dyschezia from true constipation?
Which symptom distinguishes infantile dyschezia from true constipation?
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Which diagnostic test is considered definitive for Hirschsprung disease?
Which diagnostic test is considered definitive for Hirschsprung disease?
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What is a hallmark symptom of infantile hypertrophic pyloric stenosis (IHPS)?
What is a hallmark symptom of infantile hypertrophic pyloric stenosis (IHPS)?
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What is commonly seen in lab findings of infantile hypertrophic pyloric stenosis due to excessive vomiting?
What is commonly seen in lab findings of infantile hypertrophic pyloric stenosis due to excessive vomiting?
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What effective intervention for GERD is commonly performed to avoid complications?
What effective intervention for GERD is commonly performed to avoid complications?
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Which condition is characterized by the failure of neural crest cells to migrate, causing constipation?
Which condition is characterized by the failure of neural crest cells to migrate, causing constipation?
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What dietary change is recommended to manage functional constipation effectively?
What dietary change is recommended to manage functional constipation effectively?
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What describes the stool appearance commonly seen in mild cases of Hirschsprung disease?
What describes the stool appearance commonly seen in mild cases of Hirschsprung disease?
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What is the first step in the management of functional constipation in children?
What is the first step in the management of functional constipation in children?
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Which symptom is NOT considered a red flag for ruling out organic GI disorders in a patient suspected of having IBS?
Which symptom is NOT considered a red flag for ruling out organic GI disorders in a patient suspected of having IBS?
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What is the primary goal of treatment for functional constipation?
What is the primary goal of treatment for functional constipation?
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Which diagnosis would NOT be a primary consideration when assessing a child with constipation?
Which diagnosis would NOT be a primary consideration when assessing a child with constipation?
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What characteristic change occurs in malrotation of the GI tract during development?
What characteristic change occurs in malrotation of the GI tract during development?
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In IBS patients, which diagnostic test is specifically performed to exclude celiac disease?
In IBS patients, which diagnostic test is specifically performed to exclude celiac disease?
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What is NOT a characteristic of functional constipation according to the Rome IV criteria?
What is NOT a characteristic of functional constipation according to the Rome IV criteria?
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Which presentation is most typical for malrotation with midgut volvulus during the first month of life?
Which presentation is most typical for malrotation with midgut volvulus during the first month of life?
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What is the primary diagnostic tool for confirming malrotation with midgut volvulus?
What is the primary diagnostic tool for confirming malrotation with midgut volvulus?
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What is an expected finding during the examination of a child with functional constipation?
What is an expected finding during the examination of a child with functional constipation?
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Which of the following options describes a potential consequence of chronic constipation in children?
Which of the following options describes a potential consequence of chronic constipation in children?
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What initial management is recommended for a patient with malrotation and midgut volvulus?
What initial management is recommended for a patient with malrotation and midgut volvulus?
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Which finding on an abdominal X-ray is indicative of duodenal obstruction?
Which finding on an abdominal X-ray is indicative of duodenal obstruction?
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Which condition is considered an organic cause of constipation?
Which condition is considered an organic cause of constipation?
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Which of the following symptoms would NOT typically signal a need for further evaluation beyond IBS?
Which of the following symptoms would NOT typically signal a need for further evaluation beyond IBS?
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What surgical procedure is typically performed to address malrotation with midgut volvulus?
What surgical procedure is typically performed to address malrotation with midgut volvulus?
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What is a typical triggering event for functional constipation in children?
What is a typical triggering event for functional constipation in children?
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What complication may arise from Ladd bands in malrotation with midgut volvulus?
What complication may arise from Ladd bands in malrotation with midgut volvulus?
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What treatment may be necessary for patients in shock due to malrotation with midgut volvulus?
What treatment may be necessary for patients in shock due to malrotation with midgut volvulus?
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Which statement about irritable bowel syndrome (IBS) is FALSE?
Which statement about irritable bowel syndrome (IBS) is FALSE?
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Which of the following is a common psychological impact of chronic constipation in children?
Which of the following is a common psychological impact of chronic constipation in children?
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In the context of IBS, what role does fecal calprotectin play?
In the context of IBS, what role does fecal calprotectin play?
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What is the most common object ingested by children?
What is the most common object ingested by children?
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At what age range are children most at risk for foreign body ingestion?
At what age range are children most at risk for foreign body ingestion?
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Which complication is associated with the ingestion of button batteries in children?
Which complication is associated with the ingestion of button batteries in children?
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What is a characteristic sign of intussusception in older children?
What is a characteristic sign of intussusception in older children?
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Which imaging technique is both diagnostic and therapeutic for intussusception?
Which imaging technique is both diagnostic and therapeutic for intussusception?
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What percentage of children with Henoch-Schonlein Purpura (HSP) experience GI involvement?
What percentage of children with Henoch-Schonlein Purpura (HSP) experience GI involvement?
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Which of the following describes the 'Rule of 2’s' related to Meckel’s diverticulum?
Which of the following describes the 'Rule of 2’s' related to Meckel’s diverticulum?
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What laboratory finding is indicative of acute glomerulonephritis in HSP?
What laboratory finding is indicative of acute glomerulonephritis in HSP?
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What is the first-line treatment for asymptomatic foreign body ingestion that is distal to the esophagus?
What is the first-line treatment for asymptomatic foreign body ingestion that is distal to the esophagus?
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Which imaging study can show a target sign for diagnosing intussusception?
Which imaging study can show a target sign for diagnosing intussusception?
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Which condition is a potential complication arising from foreign body ingestion involving magnets?
Which condition is a potential complication arising from foreign body ingestion involving magnets?
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What is a common initial symptom of foreign body ingestion in children?
What is a common initial symptom of foreign body ingestion in children?
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Indications for rigid bronchoscopy include foreign bodies located where?
Indications for rigid bronchoscopy include foreign bodies located where?
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What percentage of patients with HSP may develop arthritis?
What percentage of patients with HSP may develop arthritis?
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Study Notes
Appendicitis
- Most common surgical cause of abdominal pain in childhood
- Peak incidence in the second decade of life
- Lumen of the appendix is obstructed, typically by a fecalith, also viral-induced mesenteric lymphadenitis or tumor
- Trapped bacteria multiply and invade the appendix wall
- Appendix swells and becomes ischemic
- Appendix ruptures, usually within 48 hours of symptom onset
Appendicitis - Scoring
- Alvarado Score or MANTRELS score are used to help rule out appendicitis
- 0-4 points = appendicitis unlikely
- >4 points = consider appendicitis
-
Score factors:
- Migration of pain from periumbilical area to RLQ (1 point)
- Anorexia (1 point)
- Nausea/vomiting (1 point)
- Tenderness in RLQ (2 points)
- Rebound tenderness (1 point)
- Elevated temperature ≥37.3˚C (1 point)
- Leukocytosis with WBC >10,000 per uL (2 points)
- Shift of leukocytes with neutrophils ≥75% (1 point)
Appendicitis - Diagnosis & Management
- Often diagnosed clinically
-
Imaging:
- Abdominal ultrasound is preferred
- Contrast-enhanced CT or MRI if ultrasound equivocal
- Management includes:
- NPO (nothing by mouth)
- IV fluids
- Broad-spectrum IV antibiotics
- Appendectomy
Community Acquired Pneumonia
- Most common extra-abdominal cause of acute abdominal pain in children
- The pleura of the lungs connects with the parietal peritoneum of the diaphragm, allowing pain from the lower lung lobes to be referred to the abdomen
- Other extra-abdominal causes of acute abdominal pain in youth include:
- Group A streptococcal pharyngitis
- Urinary tract infection
- Sexually transmitted infection
- Pregnancy
Irritable Bowel Syndrome (IBS)
- One of several functional GI disorders (no structural or biochemical cause)
- Diagnosed using the Rome IV criteria:
- Recurrent abdominal pain and at least two of the following:
- Related to defecation
- Associated with a change in frequency of stool
- Associated with a change in stool form or appearance
- Present at least one day per week for the past three months, with symptom onset at least six months prior to diagnosis
- Not due to another medical cause
- Recurrent abdominal pain and at least two of the following:
IBS - Red Flags
- If red flag symptoms present, an organic GI disorder must be ruled out.
- Red flag symptoms include:
- Involuntary weight loss
- Deceleration of linear growth
- Delayed puberty
- Blood in the stool
- Nocturnal, bloody, or chronic diarrhea (3+ loose stools daily for 2+ weeks)
- Bilious, protracted, or projectile vomiting
- Oral ulcerations
- Perianal abnormalities
- Hepatosplenomegaly
- Unexplained fevers
- Urinary symptoms
- Back pain
- Skin changes, e.g., rashes, eczema, hives
- Family history of inflammatory bowel disease, celiac disease, or peptic ulcer disease
IBS - Diagnostic Testing
- If no red flag symptoms present, consider evaluating for IBS with diarrhea:
- Celiac disease antibody panel: to rule out celiac disease
- Fecal calprotectin: to rule out inflammatory bowel disease
IBS - Pathophysiology
- Dysregulation of the enteric nervous system and CNS signaling results in:
- Visceral hyperalgesia (increased sensitivity to pain)
- Reduced pain threshold
- Abnormal referred pain from rectal distension
- Impaired gastric relaxation response to meals
IBS - Treatment
- Mainstays of treatment for IBS:
- Educating and reassuring the patient & family
- Forming a therapeutic alliance with the patient & family
- Normalizing the patient's daily routine to minimize focus on "being sick"
- Identifying and modifying dietary, environmental, and behavioral triggers
- Managing symptoms with medication as needed
Constipation
- Affects 30% of the pediatric population
- Accounts for 5% of pediatric office visits
-
Common etiologies:
- Functional constipation - most common
- Developmental disabilities - difficulty with potty training
- Hirschsprung disease
- Spinal cord anomaly
- Hypothyroidism
- Drugs
- Lead poisoning
- Metabolic or muscular disorders
Functional Constipation
-
Rome IV criteria:
- At least two of the following for the last three months, with symptom onset at least six months prior:
- Fewer than 3 spontaneous bowel movements per week
- Straining with >25% of defecations
- Lumpy or hard stools with >25% of defecations (Bristol 1 or 2)
- Sensation of incomplete evacuation with >25% of defecations
- Sensation of anorectal blockage with >25% of defecations
- Manual maneuvers needed with >25% of defecations (e.g., digital evacuation)
- All of the following must also be present:
- Loose stools are rarely present without laxatives
- Does not meet Rome IV criteria for Irritable Bowel Syndrome with constipation
- Symptoms are not explained by another medical condition
- At least two of the following for the last three months, with symptom onset at least six months prior:
Functional Constipation - Presentation
-
Common times it presents:
- When solid foods are introduced during infancy
- During potty training
- When children first start school
Functional Constipation - Exam Findings
- Abdominal exam: Palpable stool in LLQ
-
Perirectal exam:
- Normal or reduced anal sphincter tone
- Enlarged rectum from stool accumulation
- May have anal fissure
Functional Constipation - Diagnosis & Treatment
- Usually diagnosed clinically, though abdominal X-ray is helpful for quantifying stool burden
-
Treatment:
- "Bowel retraining" - daily soft stools to regain colon tone
-
Step 1: Disimpaction
- Enema, stimulant laxative, and stool softener
- Manual disimpaction in OR and/or continuous stool softener by NG tube if severe
- Step 2: Maintenance therapy with a daily stool softener
-
Step 3: Behavioral and dietary changes
- Regularly scheduled toilet sits
- Increased water and fiber intake
- Exercise
- Decreased milk intake
- Stool tracking
- Step 4: Gradual tapering of stool softener
Infantile Dyschezia
- Not constipation
- Straining and crying with passage of soft stool in an otherwise healthy infant under 6 months old
- Crying generates intra-abdominal pressure to pass stool
- Resolves spontaneously with age
Hirschsprung Disease (Congenital Aganglionic Megacolon)
- Organic cause of constipation
- Failure of neural crest cells to migrate to part or all of the large intestine
- The aganglionic segment spasms and causes a functional obstruction
- Can be associated with Down Syndrome and other anomalies
- Typically presents in newborns as failure to pass meconium within 48 hours of birth and/or acute abdomen
Hirschsprung Disease - Presentation & Diagnosis
-
Mild Cases: Present later in life as refractory constipation
- Skinny ribbon-like stools
- No encopresis
- Failure to thrive
-
Diagnosis:
- Barium enema shows a transition zone
- Anorectal manometry shows lack of internal anal sphincter relaxation
- Rectal suction biopsy shows absence of ganglion cells in the rectal submucosal plexus
Hirschsprung Disease - Treatment
- Surgical resection of the aganglionic segment
Infantile Hypertrophic Pyloric Stenosis (IHPS)
- Progressive hypertrophy/hyperplasia of the pyloric sphincter leading to gastric outlet obstruction
- Characterized by forceful, non-bilious emesis that progressively worsens
- Baby is constantly hungry
- Baby will develop dehydration, weight loss, and eventually hypovolemic shock if untreated
IHPS - Exam Findings
- Possible "palpable olive" in LUQ
IHPS - Lab Findings
- Hypochloremic hypokalemic metabolic alkalosis: due to vomiting gastric hydrochloric acid
- Prerenal acute kidney injury: elevated BUN due to dehydration
IHPS - Diagnosis & Treatment
- Pyloric ultrasound: study of choice
-
Upper GI series: if pyloric US is equivocal
- Barium creates a "string sign" as it passes through the elongated and narrowed pyloric sphincter
-
Treatment:
- Correct vomiting, dehydration, and electrolyte abnormalities: NPO, NG tube to suction, IV fluids
- Ramstedt pyloromyotomy: Pyloric sphincter incision longitudinally, leaving the mucosal layer intact, to release the constriction
Physiologic GER (Spitting Up) v. GERD
-
Physiologic GER: Effortless regurgitation of stomach contents in infants who are otherwise feeding and growing well
- Decreased lower esophageal sphincter tone, improves with age
- Starts around 1 month old, peaks at 4-6 months, and resolves by 12 months
- "Happy spitters"
-
GERD: Regurgitation of stomach contents and excess stomach acid causes gastric and esophageal inflammation. Requires treatment to avoid complications
- Interventions may include: upright feeding position, thickened feedings, exclusion of dairy and soy, and/or acid-reducing medications
- Refractory cases should be referred to pediatric GI
Foreign Body Ingestion
- Children at risk: 6 months to 3 years, developmental disabilities, psychiatric conditions
- Most common objects ingested:
- Coins
- Food
- Toys
- Pills
- Button batteries
- Magnets
- If a patient may have swallowed a button battery, call the National Battery Ingestion Hotline 24/7 for guidance: 1-800-498-8666
Foreign Body Ingestion - Complications
- Button batteries: Can cause mucosal injury within 1 hour and involve all esophageal layers within 4 hours
- Magnets: Attract through the bowel wall causing bowel ischemia and perforation
Foreign Body Ingestion - Location
- Esophagus: Thoracic inlet or lower esophageal sphincter
- Tracheobronchial tree: Especially the right mainstem bronchus
Foreign Body Ingestion - Presentation
- 30% of patients are asymptomatic
- Initial choking, gagging, and coughing, followed by excess salivation, dysphagia, food refusal, emesis, and pain
- Stridor, wheezing, cyanosis, and dyspnea can occur if the trachea is being compressed
Foreign Body Ingestion - Diagnosis
- Radiopaque objects: AP and lateral X-rays of neck, chest, and abdomen
-
Radiolucent objects:
- Inspiratory & expiratory AP chest X-ray
- Bilateral decubitus X-ray
- Fluoroscopy
- Rigid bronchoscopy (airway) or endoscopy (GI tract)
Foreign Body Ingestion - X-Ray Findings
- Coin position in the trachea vs. esophagus can be distinguished by tracheal cartilage ring orientation
Foreign Body Ingestion - Treatment
- If the object is distal to the esophagus, weekly X-rays are obtained until passed
-
Endoscopic removal is warranted if:
- Object is lodged in the esophagus
- The object does not pass out of the stomach within 3-4 weeks
- The object is a button battery, multiple magnets, or sharp
- Rigid bronchoscopy is warranted for objects anywhere in the tracheobronchial tree
Henoch-Schönlein Purpura (HSP)
- Small vessel vasculitis involving IgA deposits
- Most common systemic vasculitis of childhood
- Most common cause of non-thrombocytopenic purpura
- Affects children ages 3-15 years
HSP - Presentation
- Prodrome: Fever, headache, anorexia
- Rash: Dependent areas, progressing from macules to palpable purpura and ecchymosis
- Arthritis: Ankles and knees, with swelling and refusal to bear weight
- GI involvement: 50% of patients, during the acute phase of illness
- Acute glomerulonephritis: 33% of patients, up to 3 months after rash
HSP - GI Manifestations
- Crampy abdominal pain due to intestinal wall ischemia
- Intussusception: Telescoping of proximal bowel into distal bowel
- Occurs spontaneously in infants
- Caused by a "lead point" in older children - e.g., purpuric lesion of the bowel wall
Intussusception
-
Presentation:
- Sudden onset colicky abdominal pain
- Bilious emesis
- Currant jelly stools
- Sausage-shaped mass palpable in RUQ or epigastrum
-
Treatment:
- NPO, NG tube to suction, IV fluids
- Barium enema with air contrast is diagnostic & therapeutic
- Surgery if enema unsuccessful, patient is unstable, or a pathological lead point is suspected
Intussusception - Diagnosis
- Ultrasound: Diagnostic, showing the intussuscepted bowel as a target sign or pseudokidney sign
Meckel's Diverticulum
- Can be a lead point for intussusception
- Outpouching of the distal ileum from incomplete obliteration of the omphalomesenteric duct during weeks 5-6 of gestation
-
Rule of 2's:
- 2% of the population
- 2:1 males to females
- 2-foot proximity to the ileocecal valve
- 2 inches in length
- 2 types of heterotopic GI mucosa
- 2 years of age or younger
Meckel's Diverticulum - Diagnosis & Presentation
-
Diagnosis:
- Meckel scan: Technetium radiolabeled heterotopic gastric mucosa
- Other imaging or surgical exploration
-
Presentation (in order of occurrence):
- Asymptomatic - Incidental finding
- Painless lower GI bleeding
- Appendicitis-like episode
- Small bowel obstruction
Meckel's Diverticulum - Treatment
- Surgical excision
Malrotation with Midgut Volvulus
- Deviation from the normal rotation and fixation of the GI tract during fetal development
Malrotation with Midgut Volvulus - Anatomy
- Normal rotation and fixation: Broad mesenteric root extending from the cecum to the duodenojejunal junction
-
Abnormal rotation and fixation:
- Narrow mesenteric root predisposed to twisting
- Formation of Ladd bands (abnormal peritoneum) that partially obstruct the duodenum
Malrotation with Midgut Volvulus - Presentation
- 60% present in first month of life with bilious emesis
- Remaining 40% present later with acute abdominal pain, bilious emesis, bloody stools, acute abdomen, sepsis
Malrotation with Midgut Volvulus - Diagnosis & Treatment
-
Diagnosis:
- Upper GI series is diagnostic
- Abdominal X-ray is not diagnostic, but helpful : General signs of obstruction, Double bubble sign
-
Treatment:
- Decompress the stomach: NPO, NG tube
- Correct dehydration and electrolyte abnormalities: IV fluids
- Patients in shock may require vasopressors and blood products
- Ladd procedure: Reduction of volvulus, division of Ladd bands, placement of small intestine on the right and large intestine on the left, resection of necrotic bowel, appendectomy
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Test your knowledge on appendicitis in children with this quiz. Explore common causes, diagnostic methods, and treatments for appendicitis in the pediatric population. Perfect for medical students and healthcare professionals alike.
