Case 27: Abdo Pain, 8 Yo

Front 1

DDx of functional of abdominal pain?

Back 1

• Functional dyspepsia
  
• Irritable bowel syndrome
  
• Abdominal migraine or
• Functional abdominal pain syndrome.

Front 2

When to diagnose functional abdominal pain?

Back 2

• no alarming symptoms/signs
  
• PE normal
  
• stool sample tests negative for occult blood
  

may have additional somaticcomplaints, such as headache, difficulty sleeping, or limb pain.

Front 3

Treatment of functional abdo pain?

Back 3

• reassuring parents
  
• psychological eval if appropriate
  

Front 4

How to approach abdo pain in children?

Back 4

• very common, mostly benign
  
• concerning signs are:
  
• involuntary weight loss
  
• decel of linear growth
  
• gastro blood loss
  
• sig vomiting
  
• chronic severe diarrhea
  
• persistent RU or RLQ pain
  
• unexplain fever, FamHx IBD, abnormal PE
  

Front 5

Importance of growth charts

Back 5

plot over time, can pick up subtle changes

Front 6

Rectal exam helpful for what diagnoses?

Back 6

• GI bleed
  
• intussusception
  
• rectal abscess
  
• impaction
  

stool guaiac can be obtained during rectal exam

Front 7

Causes of microcytic anemias

Back 7

MCC is iron deficiency

most commonly due to inadequate iron intake, blood loss may be cause

thal less common

Front 8

"Red flags" for chrons

Back 8

Pain that awakens the child at nightPain that can be localizedInvoluntary weight loss or growth decelerationExtraintestinal symptoms (e.g., fever, rash, joint pain, aphthous ulcers, or dysuria)Sleepiness after attacks of painPositive family history of inflammatory bowel disease (although only positive in about 30% ofpatients)

Front 9

"red flags" for chron's cont

Back 9

Abnormal labs such as guaiac-positive stool, anemia, high platelet count, high ESR, hypoalbuminemia Abnormalities in bowel function (e.g., diarrhea, constipation, incontinence) Vomiting Dysuria

Front 10

How to grade chron's?

Back 10

• # stools per day
  
• daily abdo pain rating and well being rating
  
• symptoms
  
• abdo fullness/palpable mass
  
• hematocrit
  
• height and weight growth velocity
  

Front 11

DDx for abdo pain and bloody stools

Back 11

• IBD
  
• Celiac
  
• bacterial gastro
  
• giardiasis
  
• PUD
  
• HSP
  

Front 12

IBD

Back 12

bloody stools

Front 13

Celiac disease

Back 13

occurs between 6 and24 months of age with chronic abdominal pain, abdominal distention,diarrhea, anorexia, vomiting, and poor weight gain

Front 14

Bacterial gastro

Back 14

bloody diarrhea

Clostridium difficile is another bacterial cause of colonic infection andtypically follows exposure to antibiotics.

Front 15

Giardiasis

Back 15

abdo pain

few other symptoms

travel history

Front 16

PUD

Back 16

While guaiac-positive stools (occult blood) are common with PUD, franklybloody stools (stools with bright red blood) are not consistent with thisdiagnosis.

Front 17

HSP

Back 17

develops within days of rash (palpable purpura)

Half of patients with HSP have guaiac-positive stools; less commonly,patients can have massive GI bleeding.

Front 18

Studies for abdo pain and bloody stools

Back 18

CBC and diff

ESR

Hepatic profile

IgA TTG

Stool ova and parasites

stool culture

Front 19

Hepatic profile

Back 19

Low protein and albumin levels may reflect malnutrition, hepatic disease with poor syntheticfunction, or losses from a protein-losing enteropathy.

Front 20

Evaluation of IBD?

Back 20

Inflammatory bowel disease (IBD) includes both Crohn's disease (CD) and ulcerative colitis (UC).Because the definitions of UC and CD are based on the location and characteristics of theinflammatory process within the gastrointestinal tract, evaluation for IBD involves looking forinflammation in both the upper GI tract and lower GI tract.

Front 21

UC

Back 21

In UC, relatively generalized inflammation is confined to the mucosa, starting in the rectumand involving a variable extent of colon proximally.Crypt abscesses are common.Rarely, patients may have discontinuous inflammation at diagnosis or even relative rectalsparing.Over the course of the illness, however, the inflammation becomes more confluent.

Front 22

Chron's disease

Back 22

The inflammation associated with CD may involve any portion of the alimentary tract, frommouth to anus.Mucosal inflammation may become more generalized or remain patchy and may extendgradually into the submucosa, muscularis, and serosa.Transmural inflammation can result in fistula formation.

Front 23

Definitive diagnosis of CD or UC?

Back 23

radiography and endoscopy

Front 24

When to use CT?

Back 24

help to define the extent of disease or complications. (e.g., may help to evaluate afistula or abscess in complicated CD).

Front 25

Treating chron's?

Back 25

The use of immunomodulators in children who have IBD has become the standard of care.Fifty percent of newly diagnosed children who have UC and 75% of those who have CD aregiven immunomodulators within 2 years of diagnosis.For patients with mild disease at presentation, an aminosalicylate like mesalamine is thefirst-line drug for treatment.For patients with moderate to severe disease, options to induce remission of active diseaseinclude corticosteroids (prednisone, prednisolone, budesonide), or exclusive enteral nutritionwith exclusive liquid formula feeds, and immunomodulators (azathioprine, 6-mercaptopurine,methotrexate) and antitumor necrosis factor inhibitors (infliximab and adalimumab) formaintenance therapy