Paediatric Abdominal Pain Practice Station

Presenting complaint - Can you show me where it hurts?

Remember that the candidate should be asking questions in a way that can be understood by a 7yr old. If you think they are using too complex words, ask them what they mean. Feel free to frame your responses in a way that you think a 7yr old might answer.

Words that you are unlikely to understand as a 7yr old: abdomen, radiation, migration, urine, stool

Site – Points to right iliac fossa

Quality – ‘Comes in waves’

Intensity – severe 8/10

Timing – Started 3 days ago, has gotten progressively worse

Associated features: Feels nauseous, been sick twice

Exacerbating/relieving factors – Feels worse after eating

Radiation/Migration – Started centrally around belly button

System review – When you do a wee is it ever red? Does it ever burn or sting?

Urinary – no haematuria, no frequency, no dysuria, no foul smelling urine

GI – No constipation, no diarrhoea, no PR bleeding, no melena, vomited twice, no abdominal distension, bowels last open this morning

Infection – Fever started this morning, no recent coryzal symptoms, tonsillitis 2/52 ago treated with antibiotics

Red flags

No testicular pain or trauma – testicular torsion can present as abdominal pain!

Has not vomited bile – bile is dark green, NOT yellow

Reduced fluid intake, not eaten for two days – clarify if they have eaten ANYTHING as the timing may be important if they need surgery

PMHx

Medical conditions – asthma, does NOT have diabetes (asking as considering DKA)

Past surgeries – hydrocele repair at 4yrs old

Medications – salbutamol

Allergies – penicillin (anaphylaxis)

Immunisations – up to date

Social History

No social services input at home

Younger sister – present as single parent

No-one at home unwell – important question that can hint at an infectious cause such as viral gastroenteritis

Family History

Dad has ulcerative colitis

Third cousin had appendix removed

ICE

Ideas – Could this be appendicitis?

Concerns – Will he need surgery?

Expectations – Reassurance then can go home

Uncomfortable child, pale and appears unwell

Obs – RR 25, HR 135, Sats 100% RA, T 38.4, BP 102/78

Children often struggle to localise pain and articulate their symptoms as well as an adult – all children presenting with symptoms that could be secondary to infection should get a top to toe exam.

Ears – normal

Throat and tongue – normal

No raised cervical lymphadenopathy

HS I + II + 0

Chest clear

Central cap refill 4 seconds

Abdomen – guarding and rebound tenderness in RIF, normal bowel sounds, no hernias, no masses.

In practice it is incredibly important to try to examine the child while distracting them from what you are doing. Sometimes the anticipation of pain can give confusing examination findings.

Testicular exam – both testes in scrotum, normal lie, surgical scar noted, non-tender

All boys with abdominal pain should have their testes examined to exclude torsion.

Most likely differentials?

1. Appendicitis – migratory pain from umbilicus to RIF, pain started before fever, pain getting progressively worse, guarding on examination.
2. Mesenteric adenitis – can mimic appendicitis, had infection 2/52 ago.
3. Gastroenteritis – Unlikely as no one else at home unwell and no diarrhoea, vomiting is usually a more prominent symptom.

What are this patient’s main problems and why?

Biological – abdominal pain and underlying pathology

Psychological – worry of both child and father that may need surgery

Social – need to consider childcare arrangements for sister if Reese is admitted

What investigations would you request for this patient and why?

Bedside – Urine dip – looking for leukocytes/nitrites in UTI, blood/protein in renal issues

Laboratory – Urine culture, stool culture – infective cause

Laboratory – Bloods

FBC – raised WCC and neutrophils in inflammatory response

U&Es – raised creatinine and urea in renal pathology eg obstruction

CRP – raised in inflammatory response

amylase – raised in pancreatitis

Note that a group and save is not needed for appendicectomy

Imaging – USS abdomen – looking at size of appendix, free fluid in abdomen, reactive nodes in abdomen

Special tests – diagnostic laparoscopy

If this patient was female, older or younger, what other differentials might you consider when taking your history?

Female - Ovarian torsion / cyst, UTI

Older (teenager) – ulcerative colitis, crohn’s, IBS

Younger (toddler) – intussusception, constipation

Younger (infant/baby) – NEC, reflux, cow’s milk allergy

Given a diagnosis of appendicitis, how would you manage this patient?

Conservative – Nil by mouth, refer to surgical team

Medical – Analgesia, IV fluids, intraoperative and post op antibiotics

Surgical – laparoscopic appendicectomy

Are there any special examination findings (eponymous signs) for appendicitis? How would you elicit them?

Rosving’s sign – Palpation of LIF increases pain felt in RIF

Psoas sign – Flexing hip causes pain in RIF

McBurney’s sign – Deep tenderness at McBurney’s point