WK 2 CASE 2

The differential for acute abdominal pain is extremely broad, and the possible causes should be considered as you take your history in order that you elicit the appropriate information.

You could try using the acronym VITAMIN CDEF.

Vascular: GI bleed is rare but can occur in children - could be secondary to a number of pathologies such as gastric ulcer, angiodysplasia (more commonly painless bleeding). Vasculitides can affect the GI tract, such as henoch-Schonlein purpura, which can cause abdominal pain in itself or can act as a lead point for intusussception.

Infection/inflammatory: gastroenteritis is a common cause of abdominal pain in children. Urinary tract infection is not uncommon. Hepatitis can occur in children, but is not common. Infections outside the GI tract can present as abdominal pain, particularly in younger children who may find pain more difficult to describe/ localise- classically lower respiratory tract infection can present as abdominal pain. Inflammatory bowel disease should be considered. Acute appendicitis should be considered and ruled out.

Trauma: if trauma is reported, then this is an obvious cause to be considered, however when assessing a child, non-accidental injury should be considered as a possible cause of pain. Features which could suggest non-accidental injury as a cause of pain should be considered during the history/ examination.

Autoimmune: Systemic autoimmune conditions could include abdominal pains as a presenting feature- these conditions are rare

Metabolic: DKA can present with abdominal pain- you may elicit a history of weight loss/ polyuria/ polydipsia but the presenting symptoms may be vague. All children with acute abdominal pain should have a BM check.

A child who looks very unwell or who has an abnormal PEWS (particularly with tachycardia/ tachypnoea) needs careful assessment.

Iatrogenic/idiopathic: Iatrogenic causes may be deliberate poisoning (eg deliberate self harm in an older patient, induced illness in a younger child), or excessive medication use may be linked with the pain (eg excessive NSAID use could lead to secondary complications). Idiopathic causes include constipation which is extremely common in the paediatric population and should be actively considered in the history taking, pancreatitis (rare). Intussusception can occur as either an idiopathic phenomenon in young children, or secondary to a condition which gives rise to an area which can act as a lead point (eg HSP, lymphoma).

Neoplasm: abdominal pain could be one of the presenting features of neuroblastoma- there would likely be other systemic features and often a palpable mass on palpation.

Congenital: Meckel’s diverticulum more usually causes painless PR bleeding, but could present with abdominal pain if there is perforation/ intussusception.

Degenerative: children with chronic degenerative diseases could develop any of the acute causes of abdominal pain, and may be more difficult to assess so care must be taken, and carer concerns must be closely considered.

Endocrine/environmental: DKA as above.

Functional: Children with functional GI disorders could present with an exacerbation of their chronic pain.

You need to get a detailed history of the pain - you could use any appropriate mnemonic (e.g. SOCRATES: site, onset, character, radiation, association, time course, exacerbating/relieving factors, severity), but need to accurately characterise the pain and any associated features.

With this, mum tells you that:

Jenny has had severe abdominal pain for the last 24 hours. The pain is in her lower abdomen. She cannot accurately describe it, but mum feels it seems to be a crampy pain, which comes on suddenly and lasts up to 30 minutes. No exacerbating factors noted, but appears to be relieved by opening bowels.

She had some nausea initially and a couple of vomits.

The vomiting has now settled, but she is passing frequent loose stools. 

It is important to elicit specific information about each symptom, as this will help you to narrow down the differential.

Vomiting: any blood? Any bile? (haematemesis is uncommon in children, and when it does occur often due to Mallory-Weiss tear but other causes need to be considered; bilious vomiting is always abnormal and indicates a surgical pathology) - Jenny has had no blood or bile in the vomits.

Stools: details of bowel habit needed including:

Frequency - need to be specific- how many stools?, during both night and day? (opening bowels at night makes a colitis more likely)

Consistency - Consistency of each stool- are they variable? Are they mixed? Patients may describe stools as ‘normal’ which means different things to different people - can be helpful to use pictures to clarify e.g. Bristol Stool chart.

Bristol Stool Chart

Presence of blood - if fresh blood is present is it on the outside of a hard stool? (possible constipation), is it just on wiping? (possible constipation, possible other local cause), is it mixed through a soft stool? (possible infection- more likely bacterial if blood in stool, possible colitis).

Presence of mucus - may indicate inflammation.

Jenny’s mum tells you that she has passed 8 stools in the last 24 hours, they are brown and very watery (type 7), there has been no blood/ mucus in the stools

·          Inflammatory bowel disease

.

The history is too short for a diagnosis of IBD to be reached.

·          Infectious gastroenteritis - viral

.

Correct answer.

·          Infectious gastroenteritis - bacterial

.

There are no particular features suggestive of a bacterial infection (such as bloody stools) and this is less common than a viral cause but risk factors for bacterial infection should be sought in the history.

·          Acute appendicitis

.

Acute appendicitis could present with a similar history, and should be considered as you proceed on with the assessment.

·          Urinary tract infection

.

Urinary tract infection is less likely in absence of urinary symptoms, and the pain is in the lower abdomen and consistent with colicky pains associated with bowel movements.  However, urinary tract infection can present in a number of ways and if the abdominal pain on examination was significant you may want to consider checking a urine dip test.

·          Intussusception

.

Intussusception is unlikely at this age unless there is a predisposing condition.

You need to elicit other possible features of infection - has there been a temperature?

You need to consider whether she is at risk of dehydration - is she still eating and drinking? Is she still passing urine?

You need to consider whether there are risk factors for any specific infections/ bacterial illnesses or if there is a history of contact with viral gastroenteritis, making that more likely. Ask about - infectious contacts, foreign travel, contact with farm animals, eaten any foods out of the ordinary, any contacts with similar symptoms.

Mum tells you that she felt a bit warm earlier today but no temperature was recorded. She has not eaten much but still drinking well and is still passing normal volumes of urine.

There are no known infectious contacts, no recent contact with farm animals, no recent foreign travel.

·          Blood in the stools

.Correct answer.

·          Symptoms regularly waking child from sleeep

.Correct answer.

·          Weight loss

.Correct answer.

·          Poor growth

.Correct answer.

·          Age <5 years

.Correct answer.

Jenny's early warning score is as follows:

HR: 102 = 0
RR: 22 = 0
Saturations: 99% in air = 0
CRT: <2seconds = 0
Conscious level: alert = 0

TOTAL SCORE = 0

Need to assess her general appearance - is she alert and responsive? Are there any signs of dehydration or shock? (e.g. reduced skin turgor, prolonged capillary refill, moist mucous membranes)

Are there any signs of chronic illness? (e.g. mouth ulcers, finger clubbing, jaundice)

Are there any features consistent with a surgical pathology?

In younger children, observation of their general behaviour (both in the department and described by the parents) can be very informative, particularly if the child is worried about the examination or they are in pain as may find it difficult to cooperate with formal examination.

When observing Jenny, you notice that she is able to walk around and climb onto the bed without obvious abdominal pain. She is able to jump without pain.

This is most likely infectious gastroenteritis.

She is tolerating oral fluids, and there is no suspicion of dehydration.

You decide that there is no indication for further investigation at this time.

You consider sending a stool culture, but you feel that, as she does not require hospital admission, and there is no clinical suspicion of a bacterial cause, and there is no foreign travel, that this would not alter the management at this time.

You explain your diagnosis to mum and explain the expected course of the illness. You advise mum to bring Jenny back if she deteriorates or is no longer tolerating oral fluids, or if the illness does not follow the expected course.

RR: 24 = 0
HR: 125 = 1
BP: 98/62 = 0
CRT: Saturations: 99% in air = 0
Conscious level: alert = 0

TOTAL SCORE = 0

Still green - She is now scoring just into amber for heart rate. This could be for a wide variety of reasons including: pain, anxiety, pyrexia… the trend of the heart rate over time is likely to be more informative than a one-off measurement.

The aspects of the history which are particularly concerning and indicate that further investigation is required are:

· blood in stools

· weight loss

Getting up at night to open bowels makes an inflammatory pathology more likely.

The drop in school attendance is a significant concern - in itself, this would not discriminate between a physical/psychological problem, however in this case the other features make an organic cause more likely.

·          Coeliac disease

.This doesn’t present with blood in stools (unless with constipation), but could cause loose stools and weight loss.  Can send blood test to exclude, but fits with clinical picture less well than IBD.

·          Infectious gastroenteritis - bacterial

.Can have some types of infection which can become chronic- would need to send a stool sample, but this is uncommon and given lack of foreign travel, a less likely diagnosis.

·          Appendicitis

.History is too long

·          Lactose intolerance

.Lactose intolerance can occur following an infectious gastroenteritis.  This is usually temporary, and can be treated with a lactose exclusion diet for up to 6-8 weeks.  In this case, the blood in the stools, and weight loss make this an unlikely diagnosis.

·          Constipation

.Can cause blood on the outside of a hard stool, but there is no history here of any hard stool.  Mucus, weight loss, systemic upset do not fit with this as a diagnosis.

·          Inflammatory bowel disease

.Correct answer.

The history of the loose, frequent stools with blood and mucus, passing stool overnight, weight loss especially in the context of a family history of IBD makes this the most likely diagnosis.

·          Intussusception

.Not likely with this length of history

·          Infectious gastroenteritis - viral

.History is too long

· U&E - normal

· LFT - normal other than a borderline albumin of 30

· CRP - 54

· ESR - 62

· Hb - 105

· WCC - 7.8

· Plt - 542

· Coagulation screen - normal

· Coeliac screen (IgA anti tissue transglutaminase) - negative

Stool: MC&S- negative, calprotectin - 1200 

These bloods indicate active inflammation, stool is negative on culture and, as the calprotectin is high, this provides further evidence of likely bowel inflammation. The results are consistent with likely IBD.

Further investigation for IBD would include OGD and colonoscopy (this would be carried out under general anaesthesia in a child of this age), and she may also need small bowel imaging such as a barium study. Small bowel MR enterography can be used in place of a barium study, but can be technically challenging in young children.

At first presentation, the most likely diagnosis is still infectious gastroenteritis. Further investigation would not be indicated at this stage with this history/ examination. It may have been that she had an infectious illness which ‘unmasked’ the IBD, or a first presentation of IBD. Investigation was warranted once the history was no longer consistent with a simple infectious illness (i.e. prolonged duration, weight loss, blood in stools). It is important to explain clearly the expected course of an illness when giving a diagnosis to a patient, in order that they can seek advice if there is deterioration or the illness does not follow the expected course- ‘safety netting’.