Abdomen

Question 1

Localizing Pain (3)

Answer 1

1. 1-finger test: show me where the pain is with 1 finger
2. If pain is all over, the cause is more functional
3. The closer the pain is to the umbilicus = the more likely it is to be functional EXCEPT for in the first hours of the initiation of appendicitis (which will localize to RLQ later)

Question 2

Anatomy Review (4)

Answer 2

1. LUQ: pancreas, spleen
2. RUQ: Gallbladder, liver
3. LLQ: Colon, intestine, L ovary
4. RLQ: Intestine appendix, R ovary

Question 3

Kidney Palpation (5 steps)

Answer 3

1st: Place left hand posteriorly just below the right 12th rib. Lift upwards trying to displace the right kidney anteriorly.
2nd: Palpate deeply with right hand on anterior abdominal wall.
3rd: Have the patient take a deep breath.
4th: Feel for lower pole of kidney as it descends and try to capture it between your hands.
5th: Have the patient release breath. Slowly release the kidney and feel it slide back into place.
* Try the same on the left kidney, but is seldom palpable.

Question 4

How to palpate for CVA tenderness

Answer 4

With patient seated upright, place palm of left hand over each CVA and strike back left hand with ulnar surface or right fist

Question 5

What does CVA tenderness indicate?

Answer 5

Suggests kidney infection such as pyelonephritis or perinephric abscess.

• pyelonephritis: Inflammation of kidney substance and pelvis.
• perinephric abscess: Abscess formation in the peritoneal membrane surrounding the kidney

Question 6

Guarding may indicate…(3)

Answer 6

1. Peritonitis
2. Appendicitis
3. Cholecystitis

Question 7

Point tenderness may indicate (2)

Answer 7

1. Appendicitis
2. Cholecystitis

Point tenderness: mcburney’s point at right lower quadrant below inguinal fold)

Question 8

Asymmetry indicates (2)

Answer 8

1. Appendiceal abscess

2. Tumor

Question 9

No bowel sounds indicates (2)

Answer 9

1. Peritonitis

2. Infarcted bowels

Question 10

Palpable m ass indicates (3)

Answer 10

1. Tumor
2. Cyst
3. Intussusception

Question 11

Nutritional Status is indicated by…

Answer 11

Weight, height

Edema – lack of protein

Anemia

Question 12

Extraintestinal features that are red flags

Answer 12

1. Arthritis
2. Ciliary injection
3. Skin (edema)
   * Think about Crohn’s and inflammatory bowel disease with extraintestinal features

Question 13

Abdominal distention indicates (2)

Answer 13

1. perotinitis

2. obstruction

Question 14

visible bowel loops indicates (2)

Answer 14

1. Intussusception

2. Obstruction

Question 15

High pitched bowel sounds indicates

Answer 15

Obstruction

Question 16

Chronic Abdominal Pain (6)

Answer 16

1. Onset may be associated with an event that the child does not want- test, gym, recess
2. Cannot be localized
3. Does not waken the child
4. Resolves spontaneously when the child has something to do that he likes
5. Pain is out of proportion to physical exam findings
   - May have hyperactive gut (high level of autonomic reactivity, associated with type A child)
6. Lab findings are normal

Question 17

Causes of Epigastric Pain (6)

Answer 17

a. Peptic Ulcer disease
b. GERD
c. Gallbladder disease
d. Pancreatitis
e. Trauma
f. Idiopathic

Question 18

Causes of Periumbilical Pain (7)

Answer 18

Usually a functional cause….

a. Functional abdominal pain
b. Abdominal migraine
c. Streptococcal pharyngitis
d. Gastroenteritis
e. Appendicitis
f. Carbohydrate intolerance
g. Lactase deficiency

Question 19

Pain in RLQ (8)

Answer 19

a. Ovarian torsion
b. Appendicitis
c. PID
d. Ectopic pregnancy
e. Mittelschmerz
f. Right lower lobe pneumonia
g. Inguinal hernia
h. Iliopsoas abscess

Question 20

Pain in LLQ (2)

Answer 20

1. Constipation

2. Right ovarian or testicular pain

Question 21

Pain in Suprapubic area (4)

Answer 21

1. UTI
2. Constipation
3. Urinary retention
4. Hydrometrocolpos; blood stuck in ovaries

Question 22

Characteristics that are NOT worrisome with abd pain (4)

Answer 22

1. Undigested food in stool
2. Green stool
3. Child sleeps through the night
4. Pain occurs in morning and disappears with passing of school bus and tends not to occur on the weekend

Question 23

5 Types of Malformations of the Cecum

Answer 23

1. Non rotation and therefore cecum is found in the left part of the abdominal cavity
2. Malrotation and the cecum remains below the pylorus
3. Subhepatic cecum and therefore the cecum is below the liver
4. Mobile cecum: not fixed to the retroperitoneum
5. Hyperrotation in which the cecum lies directly at the left colic flexure

Question 24

Appendicitis Presentation (6)

Answer 24

1. Pain that precedes vomiting
   - Pain starts as periumbilical pain then localizes to lower quadrant
   - Pain is sharp and constant
2. N/V
3. Tenderness at McBurney’s point
4. Fever
5. Leukocytosis
6. Tachycardia*

Question 25

Signs of appendicitis in toddler (3)

Answer 25

1. Fever and vomiting 2. Pain may be intermittent and referred to right hip with limp 3. Abdominal pain may be localized or generalized

Question 26

Signs of appendicitis in school aged (5)

Answer 26

1. Abdominal pain and vomiting common 2. Pain with walking or movement 3. Fever 4. Abdominal wall tenderness that tends to be focal to RLQ (unless appendix is displaced) 5. Involuntary guarding

Question 27

Appendicitis MANTREL

Answer 27

``` Migration of pain Anorexia N/V Tenderness on RLQ Rebound tenderness Elevated temperature Leukocytosis ```

Question 28

Psoas Sign

Answer 28

1st: Have child in supine position 2nd: Place hand above right knee 3rd: Direct child to raise leg against pressure * Positive sign: pain in RLQ when pushing down on leg or: Have child drop right leg over exam table *Positive finding: this will be painful Positive- indicates appendicitis extending the thigh of a patient lying on his side with knees extended, or asking the patient to actively flex his thigh at the hip. If abdominal pain results, it is a "positive psoas sign".

Question 29

Obturator Sign

Answer 29

Flex child’s right thigh at the hip with the knee bent, Rotate leg internally at the hip then externally Pain occurs when there is internal and external rotation of the flexed thigh = positive sign and indicator of appendicitis

Question 30

Rovsing's Sign

Answer 30

Pain in RLQ with left-sided pressure (press on left side and get pain on right side)

Question 31

Markle Jar Heel Test

Answer 31

Up on toes, down hard on heels Have patient jump op and down *pain in the right lower quadrant of the abdomen is elicited by dropping from standing on the toes to the heels with a jarring landing.

Question 32

Rebound Tenderness (3)

Answer 32

1. Only do this once and with older children; do not do with young child! 2. Firmly and slowly push in, hold, then quickly withdraw - There will be pain as you withdraw 3. Take hand, put it on McBurney’s point, distract child, keep hand there for 30 seconds, let go and the removal causes pain *Occurs with appendicitis

Question 33

Pneumonic for Pancreatitis Causes

Answer 33

``` Idiopathic Gallstones Ethanol Trauma Spider/scorpion Mumps/malignancy Autoimmune Steroids Hyperlipedemia/hypercalcemia/hyperparathryodism ERCP Drugs (HIV, furosemide, methanol, salicylates, valproac acid, organophosphates) ```

Question 34

Signs of Pancreatitis (4)

Answer 34

1. Lipase and amylase elevations 2. Pain in upper abdomen towards right side or periumbilical pain radiating to back 3. Hypercalcemia 4. Ileus, distension, ascites

Question 35

Murphy' Sign

Answer 35

Temporary inspiratory arrest with palpation of right subcostal margin Patient takes deep breath and you cup under the right side and ask them to exhale; they will feel pain in gallbladder *Indicates cholecystitis

Question 36

Nonalcoholic Steatophepatitis (NASH) and Nonalcoholic Fatty Liver Disease (NAFLD) (4)

Answer 36

1. Strong association with obesity 2. Elevation of liver enzymes (AST, ALT) 3. NASH - Fat in the liver, along with inflammation and damage - Leads to cirrhosis 4. NAFLD - Fat in liver without inflammation

Question 37

Mallory Weiss Tear

Answer 37

tear in the mucosal layer at the junction of the esophagus and stomach *Can get it from vomiting

Question 38

Signs/Symptoms of Eosinophilic Esophagitis in Children and Adolescents (11)

Answer 38

i. Recurrent vomiting ii. Abdominal pain iii. Dysphagia iv. Pain with swallowing (odynophagia) v. Vomiting often but not always occur in association with eating vi. Some accompanying nausea. vii. Intense feeling of discomfort as a swallowed food bolus slowly moves down the esophagus. viii. Often patients will try to drink liquids to help bring the foods down ix. Episodes may last for only a few seconds or can be more prolonged and severe, and occasionally result in food becoming stuck in the esophagus ‐ that is food impaction. x. Severe and chronic symptoms, significant weight loss can also occur. xi. Heartburn, cough, chest pain, or epigastric (upper abdominal) pain, which does not respond to anti‐reflux therapy.

Question 39

Causes of Watery diarrhea (2)

Answer 39

i. Infection: viral, bacterial, parasitic | ii. Appendicitis with perirectal abscess

Question 40

Cause of hard or large stools

Answer 40

constipation

Question 41

cause of decrease in stool frequency (2)

Answer 41

1. constipation | 2. obstruction

Question 42

Cause of mucous containing stool

Answer 42

colitis (but also can be normal)

Question 43

cause of bright red blood in stool (small volume) (2)

Answer 43

1. fissure | 2. hemorrhoids, suggesting constipation

Question 44

Current jelly stool indicates

Answer 44

Intussusception

Question 45

Melena stool indicates (2)

Answer 45

1. Gastric ulcer | 2. Duodenal ulcer

Question 46

Alcoholic/white stool indicates (2)

Answer 46

1. biliary disease | 2. hepatic disease

Question 47

Diagnosing Childhood Functional Abd Pain

Answer 47

Must include all of the following criteria at least once a week for at least two months prior to diagnosis: 1. Continuous or episodic abd pain 2. Insufficient criteria for other functional GI disorders 3. No evidence of an inflammatory anatomic, metabolic, or neoplastic process that explains the symptoms

Question 48

Diagnostic Criteria for IBS

Answer 48

Must Include both of the following criteria, fulfilled at least once pet week for two months prior to diagnosis. Abdominal pain or discomfort associated with two of the following: 1. Improvement with defecation * Gets better when child poops 2. Onset associated with a change in frequency of stool 3. Onset associated with change in form of stool * Will have alternating diarrhea and constipation (there are changes in the form of the stool)

Question 49

Functional Dysplesia (3)

Answer 49

1. Persistent or recurrent pain or discomfort centered in the upper abdomen 2. Not relieved by defecation or associated with the onset of a change in stool frequency or stool form 3. No evidence of an inflammatory, anatomic, metabolic, or neoplastic process to explain symptoms

Question 50

Bilious Emesis (4)

Answer 50

1. Bilious emesis is a mechanical obstruction unless proven otherwise! 2. Bilious emesis = green vomit 3. In infancy the obstruction can result from: - Feeding problems with transient episodes of bilious vomiting - Failure to thrive with feeding intolerance (Malrotation with volvulus) 4. In school-aged child, obstruction can result from adhesions from previous surgeries!!

Question 51

Pyloric Stenosis (6)

Answer 51

1. Familial with 5:1 male predominance 2. Non bilious, projectile vomiting and hungry 30-60 minutes later 3. Hypochloremic metabolic alkalosis 4. Not a mechanical obstruction; Narrowing of pylorus valve causing difficulty getting milk from mouth to stomach 5. Generally presents at 3rd-6th week of life 6. Comes into ER with non-bilious vomit; child will be puking and dehydrated

Question 52

Malrotation of Volvulus (6)

Answer 52

1. Abnormal fixation of bowel mesentery with twisting around mesenteric artery - May be due to perineum not attached well, so the gut twists 2. Painful distended abdomen 3. Bilious vomiting present 4. Blood in stool 5. Abdominal Pain 6. May be lethargic on presentation

Question 53

Classic Triad Sign of Intussusception (and dance's sign)

Answer 53

1. Jelly like stool 2. Vomiting 3. Intermittent abdominal pain with palpable sausage-shaped mass 4. Dance’s sign: concavity in RLQ and RUQ where intestine telescoped in -Empty right lower quadrant

Question 54

Other Clinical Features of Intussusception (6)

Answer 54

1. Colicky abdominal pain 2. Infant pulls knees up to chest while crying 3. Normal between episodes of pain 4. Altered mental status 5. Palpable sausage shaped mass during crying 6. Dance’s sign: concavity in the right lower quadrant due to absence of underlying bowel

Question 55

Newborn Hirschsprung's Disease physical exam (9)

Answer 55

1. Newborn: well constipated with distended soft abdomen with normal or hyperactive bowel sounds 2. Rectal exam: slight pressure on examining finger with no stenosis or obstruction 3. Ampulla is empty: on removal explosive evacuation of stool or gas Ill newborn will present with.... 1. More distention without peritoneal signs unless perforation 2. React minimally to examiner 3. Can be lethargic 4. Fever 5. Tachycardia 6. Ominous hypotension

Question 56

Older infant and child with Hirschsprung's presentation (4)

Answer 56

1. Chronically distended, non-tender abdomen with large fecal masses ON LEFT SIDE 2. Rectal exam: ampulla is empty 3. Anal tone is normal 4. Explosive stool will also occur after examining finger is withdrawn

Question 57

Hematochezia

Answer 57

maroon stools which indicated distal GI source or short transit time from briskly bleeding proximal source

Question 58

Melena

Answer 58

dark or black tarry stools when the bleeding is from | upper tract

Question 59

Hematemesis (3)

Answer 59

1. vomiting of blood or blood per rectum - Appearance of coffee grounds or bright red 2. Can occur if newborn swallows maternal blood during delivery 3. Esophagitis will occur secondary to reflux (bleeding can occur due to reflux)

Question 60

APT Test

Answer 60

Dx whether newborn hematemesis is from swallowing maternal blood during delivery Mix emesis with 1% sodium hydroxide * Fetal blood remains pink or bright red * Maternal hemoglobin turns brown

Question 61

Upper GI Bleed Causes (8)

Answer 61

1. Stress 2. Vascular malformaiton 3. Gastric/esophageal duplication 4. Hemorrhagic gastritis 5. Esophagitis 6. Varices from portal HTN 7. Vascular malformations 8. Bleeding diathesis from such hemorrhagic disease of the newborn

Question 62

Lower GI Bleed Causes (3)

Answer 62

1. Juvenile polyps (may be from Gardner's syndrome) 2. Anal fissure 3. Meckel Diverticuli

Question 63

Meckel Diverticuli (4)

Answer 63

1. Most common source of significant lower GI bleeding in children 2. Preschooler bleeding is the result of - HCL secreted from ectopic gastric mucosa within diverticulum - Ulceration forms on ileal mucosa 3. Painless but can be massive 4. Part of stomach mucosa in the small intestines because mucosa secrets HCL and they get massive GI bleed

Question 64

Manifestations of Ulcerative Colitis (12)

Answer 64

1. Most diagnosed between 15-30 years old 2. Acute bloody diarrhea 3. Cramping 4. Tensemus 5. Pallor 6. Growth retardation Extraitestinal manifestations: 7. Arthralgia 8. Uveitis 9. Oral ulceration: aphthous ulcers 10. Liver disease by fatty infiltration or sclerosing cholangitis (15%) Skin manifestations: 11. Erythema nodosum 12. Pyoderma granulosum (non-healing ulcer)

Question 65

Where do ulcerative colitis ulcers occur? (2)

Answer 65

1. Diffuse, continuous superficial inflammation 2. Edema and shallow ulceration and small pseudopolps in rectum, descending colon as far as ileocecal juncture (limited to colon)

Question 66

Where do Crohn's Disease ulcers occur? (2)

Answer 66

1. Focal asymmetrical inflammation anywhere on GI tract (from anus to mouth) 2. Most common in terminal ileum proximal colon and ileocecal junction

Question 67

Crohn's Disease Manifestations (8)

Answer 67

1. WEIGHT LOSS (90% of the time) 2. Abdominal pain, typically in RLQ since inflamed edematous terminal ileum (70%) 3. Diarrhea (67%) 4. Fever (25%) 5. Bloody diarrhea*** 6. Anal skin tag 7. Perianal ulceration*** 8. Same extraintestinal manifestations as ulcerative colitis

Question 68

Neuroblastoma History (7)

Answer 68

1. Hx of vasoactive intestinal peptide 2. Watery diarrhea with abdominal distention and electrolyte imbalance 3. Opsoclonus-myoclonus (dancing eyes with myoclonic jerks w/ or w/o cerebellar ataxia) Catecholamine excess (More common if renal in origin) 1. Flushing 2. Tachycardia 3. Headache 4. HTN

Question 69

Neuroblastoma head and neck exam and thoracic exam signs (7)

Answer 69

Head and Neck: 1. Visual changes 2. Exopthalmos 3. Horner’s syndrome: ptosis, meiosis, anhydrosis 4. Cerebellar ataxia 5. Periorbital ecchymosis – raccoon eyes 6. Heterochromia iridis – different color iris’ Thoracic exam 1. If dumb bell extension into spine- neurological abnormalities, cough, SOB

Question 70

Signs and Symptoms of Wilm's Tumor

Answer 70

1. Abdominal mass that is firm, flank, non-tender, minimally mobile and doesn’t usually cross midline 2. Well appearing 3. Asymptomatic mass 4. Pain rarely reported 5. HTN and micro-hematuria