PAEDIATRIC GASTROENTEROLOGY
DDx of paediatric abdo pain:
RED FLAGS for abdo pain: Diagnostic tests for abdo pain:
Ø PR bleeding Ø Anaemia ® IBD, coeliac, malignancy
Ø Disproportionate pain
Ø Raised ESR/CRP ® IBD
Ø Obstipation OR chronic
diarrhoea Ø Anti-TTG or anti-EMA ® Coeliac
Ø Dysphagia Ø Raised faecal calprotectin ® IBD
Ø Fever Ø BSL + ketones ® DKA
Ø UWL, poor feeding, FTT Ø +ve dipstick (nitirites, lecocytes) ®
Ø Nocturnal pain UTI
Ø Dysphagia Ø Urine/serum B-HCG – ectopic
Ø Peritonism signs – involuntary Ø AXR = SBO/LBO
guarding, rebound po
Ø Air enema = ISS
percussion tenderness
Medical causes Surgical Causes Non-organic
GI cause Urology/Gynae Other GI cause Non-GI cause • Functional cause –
• Constipation • UTI - urethritis, • HSP • Appendicitis • Testicular no underlying
(common) cystitis, pyelonephritis torsion pathology (very
• DKA • Bowel obstruction
common in children
• Infantile colic • Mittleschirmz • Malignancy • Incarcerated • Ovarian torsion
> 5yo)
• Coeliac (ovulation pain) (neuroblastoma, hernia • Ectopic
• IBD • Dysmenorrhoea Wilm’s) • Malrotation /
(Period pain ) volvulus
• IBS
• PID • ISS
• Mesenteric adenitis
• STI • Hirschsprung
• Abdominal migraine
• Mesenteric
ischaemia
COMMON ABDO PAIN – Dx of Exclusion
RECURRENT abdo pain Abdominal migraine
Child presents w/ repeated non-organic/functional abdo pain episodes with NO Migraine lasting > 1hrs WITH central abdo pain
PP underlying cause
RF Stressful life events (?increased sensitivity & stimulation of visceral nerves in gut) Children > adults
Abdominal migraine, IBS, functional abdo pain Recurrent abdo pain, IBS, functional abdo pain
DDx ICH, classical migraine
Recurrent abdo pain Central abdo pain - anorexia, pallor
Sx Migraine Sx – N/V, photophobia, headache,
Ix None None
Careful education + reassurance Careful education + reassurance
Ø Distraction techniques for pain Ø Acute Mx = Panadol + NSAID, + triptans + keep in dark
Ø Encourage sleep, regular meals, balanced diet, regular PA room
Mx Ø AVOID NSAIDs Ø Long-term Mx = Pizotifen (serotonin agonist),
propranolol, CCB
Ø Refer to school counsellor or child psychologist
*Slow weaning of pizotifen – prevent withdrawal Sx –
depression, anxiety, poor sleep and tremor
CONSTIPATION IN CHILDREN
Ø VERY common issue -- most is idiopathic or functional constipation (NO underlying cause)
Typical Sx RF DDx – organic Comp. Mx
• < 3x stools/week • Low fibre diet GI CAUSES: • Pain Educate + reassure – may
• Hard stools (difficult to pass) – rabbit • Inadequate hydration • Hirschsprung’s • Reduced sensation take months to resolve
droppings • Inactivity • Cystic fibrosis (meconium • Anal fissures • Correct reversible
• Straining ileus) cause
• Habitually not opening • Haemorrhoids
• Abdo pain ® ISS, SBO/LBO bowels ® • Bowel obstruction • High fibre diet +
• Faecal soiling adequate hydration
• Vomiting ® SBO/LBO, Hirsch desensitization of • Cow’s milk intolerance (overflow diarrhoea)
rectum ® feacal • Laxatives (e.g. Movicol
• No meconium ® Hirsch, CF • Anal stenosis / atresia • Psychosocial – osmotic laxatives)
impaction
• Ribbon stools ® anal stenosis morbidity
• Psychosocial issues
• Abnormal anus ® anal stenosis, sexual abuse, (e.g. home difficulties, OTHER: For psychosocial, idiopathic
IBD stresses) • Hypothyroidism cause
• Abnormal buttock OR lower limb FNDs® • SC lesion • Bowel diary
Spina bifida, SC lesion, sacral agenesis
• Sexual abuse • Reward for visit toilet
• FTT ® Coeliac, hypothyroidism, safeguarding
• Retentive posturing
• Overflow soiling – ENCOPARESIS (due to
faecal impaction) – loose smelly stool
• May be lose sensation to control bowels
DDx of paediatric abdo pain:
RED FLAGS for abdo pain: Diagnostic tests for abdo pain:
Ø PR bleeding Ø Anaemia ® IBD, coeliac, malignancy
Ø Disproportionate pain
Ø Raised ESR/CRP ® IBD
Ø Obstipation OR chronic
diarrhoea Ø Anti-TTG or anti-EMA ® Coeliac
Ø Dysphagia Ø Raised faecal calprotectin ® IBD
Ø Fever Ø BSL + ketones ® DKA
Ø UWL, poor feeding, FTT Ø +ve dipstick (nitirites, lecocytes) ®
Ø Nocturnal pain UTI
Ø Dysphagia Ø Urine/serum B-HCG – ectopic
Ø Peritonism signs – involuntary Ø AXR = SBO/LBO
guarding, rebound po
Ø Air enema = ISS
percussion tenderness
Medical causes Surgical Causes Non-organic
GI cause Urology/Gynae Other GI cause Non-GI cause • Functional cause –
• Constipation • UTI - urethritis, • HSP • Appendicitis • Testicular no underlying
(common) cystitis, pyelonephritis torsion pathology (very
• DKA • Bowel obstruction
common in children
• Infantile colic • Mittleschirmz • Malignancy • Incarcerated • Ovarian torsion
> 5yo)
• Coeliac (ovulation pain) (neuroblastoma, hernia • Ectopic
• IBD • Dysmenorrhoea Wilm’s) • Malrotation /
(Period pain ) volvulus
• IBS
• PID • ISS
• Mesenteric adenitis
• STI • Hirschsprung
• Abdominal migraine
• Mesenteric
ischaemia
COMMON ABDO PAIN – Dx of Exclusion
RECURRENT abdo pain Abdominal migraine
Child presents w/ repeated non-organic/functional abdo pain episodes with NO Migraine lasting > 1hrs WITH central abdo pain
PP underlying cause
RF Stressful life events (?increased sensitivity & stimulation of visceral nerves in gut) Children > adults
Abdominal migraine, IBS, functional abdo pain Recurrent abdo pain, IBS, functional abdo pain
DDx ICH, classical migraine
Recurrent abdo pain Central abdo pain - anorexia, pallor
Sx Migraine Sx – N/V, photophobia, headache,
Ix None None
Careful education + reassurance Careful education + reassurance
Ø Distraction techniques for pain Ø Acute Mx = Panadol + NSAID, + triptans + keep in dark
Ø Encourage sleep, regular meals, balanced diet, regular PA room
Mx Ø AVOID NSAIDs Ø Long-term Mx = Pizotifen (serotonin agonist),
propranolol, CCB
Ø Refer to school counsellor or child psychologist
*Slow weaning of pizotifen – prevent withdrawal Sx –
depression, anxiety, poor sleep and tremor
CONSTIPATION IN CHILDREN
Ø VERY common issue -- most is idiopathic or functional constipation (NO underlying cause)
Typical Sx RF DDx – organic Comp. Mx
• < 3x stools/week • Low fibre diet GI CAUSES: • Pain Educate + reassure – may
• Hard stools (difficult to pass) – rabbit • Inadequate hydration • Hirschsprung’s • Reduced sensation take months to resolve
droppings • Inactivity • Cystic fibrosis (meconium • Anal fissures • Correct reversible
• Straining ileus) cause
• Habitually not opening • Haemorrhoids
• Abdo pain ® ISS, SBO/LBO bowels ® • Bowel obstruction • High fibre diet +
• Faecal soiling adequate hydration
• Vomiting ® SBO/LBO, Hirsch desensitization of • Cow’s milk intolerance (overflow diarrhoea)
rectum ® feacal • Laxatives (e.g. Movicol
• No meconium ® Hirsch, CF • Anal stenosis / atresia • Psychosocial – osmotic laxatives)
impaction
• Ribbon stools ® anal stenosis morbidity
• Psychosocial issues
• Abnormal anus ® anal stenosis, sexual abuse, (e.g. home difficulties, OTHER: For psychosocial, idiopathic
IBD stresses) • Hypothyroidism cause
• Abnormal buttock OR lower limb FNDs® • SC lesion • Bowel diary
Spina bifida, SC lesion, sacral agenesis
• Sexual abuse • Reward for visit toilet
• FTT ® Coeliac, hypothyroidism, safeguarding
• Retentive posturing
• Overflow soiling – ENCOPARESIS (due to
faecal impaction) – loose smelly stool
• May be lose sensation to control bowels
