Which of the following is LEAST likely to cause abdominal pain in children?
Answer: B: Congenital adrenal hyperplasia is a broad term for deficiencies in enzymes responsible for the production of aldosterone and or cortisol. Each is an autosomal recessive disorder.
The most common form of congenital adrenal hyperplasia is 21–hydroxylase deficiency, accounting for approximately 95% of cases. Features of this enzyme deficiency are related to androgen excess. It presents as masculinization of females and can range from ambiguous genitalia and pseudohermaphroditism in infants to oligomenorrhoea, hirsutism and acne in postpubertal females. In males it can cause enlarged external genitalia and precocious puberty.
Severe enzyme deficiency can be life threatening, presenting with vomiting, severe dehydration, electrolyte abnormalities (severe hyponatraemia from salt wasting and hyperkalaemia), metabolic acidosis and occasionally hypoglycaemia. The patient should be resuscitated and treated with hydrocortisone. The patient will require treatment with long-term steroids.
All of the other conditions mentioned are a cause of abdominal pain.
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Which of the following is most CORRECT with respect to intussusception?
Answer: C: Intussusception is the most common cause of intestinal obstruction in young children. The peak incidence occurs between 5–12 months of age and more common in males (3:2). In children under the age of 5 years the aetology is either idiopathic or secondary to an enlarged Peyer’s patch from viral infection. Over the age of 5 an underlying lesion is more likely to be the cause. These include Meckel’s diverticulum, haematoma from Henoch-Schönlein purpura or other bleeding diathesis, coeliac disease, cystic fibrosis, postsurgical scars, lymphoma and polyps.
The majority of intussusceptions are ileocolic (80–90%); however, colocolic and, rarely, ileoileal intussusceptions can occur. Intermittent crampy abdominal pain, a palpable abdominal mass and bloody ‘currant-jelly’ stool is the classical triad of signs and symptoms. At presentation all three are only found in 30% of patients while 75% of patients have two of these present. The child will experience episodes of severe abdominal pain that occurs at frequent intervals. It may last for 10–15 minutes each time, during which the child will be inconsolable and draw the legs up towards the chest. Lethargy is a significant finding and is out of proportion to the degree of dehydration. As the intussusception progresses the child will become more lethargic and weak.
Stools will be normal in the first few hours but will decrease as time progresses. Bloody stool may be passed within the first 12 hours but sometimes will not be present for 1–2 days. This, ‘currant-jelly’ stool (which is sloughed mucosa, mucus and blood) is present in up to 50% of cases. Vomiting can occur and is initially non-bilious; however, as the duration of obstruction continues the vomiting may become bilious.
On examination the child is well in between episodes early in the illness. As the illness progresses the child may become very lethargic with a low-grade temperature. On palpation of the abdomen a sausage-shaped mass can be felt in the right upper quadrant in 30% of cases. The long axis of the mass lies cephalocaudal. This mass represents the intussusceptus. Along with the mass there is a hollowness in the right lower quadrant because the caecum has moved from its usual position. The abdomen may be distended and on auscultation there is a paucity of bowel sounds in the right lower quadrant (Dance’s sign). If perforation has occurred, peritonitis may be evident.
X-ray is not sensitive or specific and is frequently normal. Absence of bowel gas in the right upper and lower quadrants may be detected or there can be the impression of a soft tissue mass in the right upper quadrant. Abdominal ultrasound is highly sensitive (98–100%) and specific (88%) – a doughnut sign is visualized and is due to several concentric rings of bowel loops. Contrast enemas can be both diagnostic and therapeutic; however, air enema is preferred because it is associated with few complications and lower radiation exposure.
A 2-year-old boy presents with rectal bleeding, mild crampy abdominal pain and mild anaemia. Abdominal X-rays are unremarkable and a barium enema looks normal.
What is the MOST likely diagnosis?
Answer: A: Meckel’s diverticulum is the most common congenital anomaly of the gastrointestinal tract and occurs in 2% of the population. Symptoms can occur at any age but the majority present around the age of 2 years. It is a 2–6 cm out-pouching of the ileum approximately 2ft proximal to the ileocaecal valve. Only 2% of affected patients become symptomatic (rule of twos for Meckel’s diverticulum). It is a remnant of the embryonic omphalomesenteric duct, contains bowel wall and 60% contain ectopic mucosa, most commonly gastric mucosa.
Symptoms include crampy abdominal pain and painless rectal bleeding, from bright red to melena, depending on the site and how rapid the bleeding is. The highly acidic gastric tissue in the diverticulum causes ulcerations that bleed. If the diverticulum contains pancreatic tissue, ulcerations and bleeding can result from the alkaline environment. Bleeding is usually self-limiting because the splanchnic vessels constrict secondary to hypovolaemia. Anaemia is usually transient. Meckel’s diverticulum can be a lead point for intussusception and can present as bowel obstruction or perforation.
Diagnosis is aided by a technetium 99m scan. If bleeding is present the sensitivity and specificity of this test is 75–85% and 95% respectfully. Abdominal X-rays are of no assistance and barium studies rarely fill the diverticulum. Treatment of Meckel’s diverticulum involves fluid resuscitation and blood transfusion if required. If the patient is unstable then urgent surgical intervention is necessary. Definitive treatment is surgical excision. Gastrointestinal bleeding is a less common presentation of haemophilia. It is more likely to manifest with easy bruising or haemarthrosis in mobile patients. Intracranial haemorrhage in neonates or following head trauma is another common presentation. The coagulation profile will be abnormal with a prolonged APTT (activated partial thromboplastin time) and a normal PT (prothrombin time).
An anal fissure is a tear or laceration of the anal margin, at the anal mucocutaneous junction. It is diagnosed on examination. In the paediatric population it is more frequent in age <1 year. It presents with bright red rectal bleeding, pain on defaecation and constipation.
Which ONE of the following statements relating to upper gastrointestinal tract foreign bodies is CORRECT?
Answer: C: A button battery that is stuck in the oesophagus requires urgent removal. An impaction time of as little as 2–2.5 hours can result in significant injury. Batteries >15 mm size are more likely to become lodged and cause significant complications.
Complications from button batteries arise from one of four mechanisms:
If the object has made it to the stomach it will likely continue to pass without complication. Most will pass within 48–72 hours. If they are still in the stomach after this time then removal is usually recommended. Button batteries look very similar to coins on X-ray; however, the battery displays a double ring shadow on X-ray (junction between the anode and the cathode). As the oesophagus is wider in the coronal plane, coins that get lodged are seen to lie in the coronal plane on plain AP X-ray. They tend to lie in the sagittal plane if they are in the trachea.
Complications of oesophogeal foreign bodies are similar to that of any object that has prolonged impaction time and include:
Foreign body ingestion occurs most frequently in the paediatric age group. It is most commonly seen between the ages of 3 months to 12 years old. It is important to note from a history-taking and risk assessment point of view that the grasping and pinching motion are seen at 6 and 7 months respectively. Other populations that may have foreign bodies in the alimentary canal include, intellectually impaired patients, psychiatric patients, prisoners, body packers, patients who have a history of oesophageal anatomical abnormalities such as strictures, webs or malignancy or those with a muscular dysfunction such as achalasia or scleroderma.
There are three main areas where the oesophagus narrows, it is around one of these regions that objects are most likely to become lodged. They are:
Children are more likely to have a foreign body stuck at the level of the cricopharyngeus muscle, adults more frequently at the level of the lower oesophageal sphincter.
A 6-year-old girl presents with a 4-day history of a large 6.5 cm left submandibular swelling. She has a fever of 39.2°C and is lethargic, airway is not compromised, pharynx is red and inflamed, tonsils are not enlarged, no conjunctivitis or rash. The swelling is red, hot, tender and fluctuant.
What is the MOST appropriate action?
Answer: D: Cervical lymphadenitis is the most likely diagnosis in this child. However, other differentials that should be considered include:
This patient should have analgesia and blood work to assist with exclusion of some of the above mentioned differential diagnosis including serology or cultures to identify any causative organism and sensitivities. The patient will require IV antibiotics and admission. An ultrasound scan would be helpful to confirm the presence of an abscess prior to incision and drainage.
The estimated weight of a 6-year-old is 20 kg. Therefore, the correct dose of paracetamol is (15 mg/ kg) 300 mg. PR paracetamol comes in 125 mg, 250 mg and 500 mg. So answer A is incorrect. The correct dose for ibuprofen is 200 mg (10 mg/kg) not 400 mg (20 mg/kg), so answer C is incorrect. Blood work helps to exclude differential diagnoses such as lymphoma and leukaemia. Cultures should be taken to identify any bacterial causative organism and its antibitotic sensitivities.
Unilateral cervical lymphadenitis is usually due to either Staphylococcus aureus or Streptococcus pyogenes. Anaerobes should be considered if there is evidence of periodontal disease. In this case the IV antibiotics of choice include flucloxacillin (12.5–50 mg/ kg) 6-hourly or cephazolin (10–50 mg/kg) 6-hourly, not 12-hourly. So, answer D is correct and answer B is incorrect. Clindamycin or lincomycin can be used if there is a penicillin allergy. Metronidazole should be added if anaerobic infection is suspected.
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