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Gastroenterology 17. Approach to a Child with Abdominal Complaints Sources: Eddleston et al, Oxford handbook of tropical medicine, 2008; The Harriet Lane handbook, 19th ed., 2012. Abdominal Pain Questions for HPI • Duration • Quality (sharp, dull, constant, intermittent) • Associated symptoms (fever, vomiting, diarrhea, constipation, etc) • Ability to feed • Activity level • Sick contacts • HIV status • Relieving factors • Aggravating factors • Medications/herbs given 17. Approach to a Child with Abdominal Complaints 55 Differential Diagnosis This list is not exhaustive but additional conditions to consider while working in developing countries of sub-­ Saharan Africa: • Infectious diseasesºº Gastroenteritisºº Wormsºº Amoebic colitisºº Typhoidºº Malariaºº Choleraºº Porphyriaºº Pneumoniaºº UTI/pyelonephritisºº Abdominoperitoneal TBºº Yersiniaºº HIV related—CMV, HSV, candidiasis, etcºº Henoch-­Schönlein purpuraºº Appendicitisºº Hepatitisºº Liver abscess (particularly amoebic)ºº Liver flukesºº Hydatid liver diseaseºº Schistosomiasis • Gastrointestinalºº Gastritisºº Peptic ulcer diseaseºº Intestinal obstructionºº Pyloric stenosisºº Intussusceptionºº Incarcerated herniaºº IBDºº Pancreatitisºº Cholecystitisºº AIDS cholangiopathy 56 Gastroenterology • Genitourinaryºº Testicular torsionºº Ovarian torsionºº Intra-­abdominal testis • Hematology/oncologyºº Sickle cell crisisºº Wilms tumorºº Leukemia/lymphoma • Otherºº Toxic ingestion, overdoseºº Foreign body Vomiting Questions for HPI • Frequency, quantity • Quality (color, bilious, bloody) • Associated symptoms (fever, abdominal pain, diarrhea, cough, etc) • Is it projectile? • Weight loss • Ability to feed, UOP • Activity level • Sick contacts • HIV status • Relieving factors • Aggravating factors • Medications/herbs given Differential Diagnosis This list is not exhaustive but additional conditions to consider while working in developing countries of Sub-­ Saharan Africa: • NBNB (nonbloody, nonbilious): malaria, ascariasis (roundworm ; with high fever can migrate to stomach → emesis), re- 17. Approach to a Child with Abdominal Complaints 57 flux, gastroenteritis, milk protein allergy, other infection (UTI, PNA), NEC, pyloric stenosis, CNS lesion, appendicitis • Bilious: bowel obstruction (typhoid and TB can be common causes), intussusception, malrotation, incarcerated inguinal hernia , appendicitis • Bloody: typhoid (GI hemorrhage is a complication), gastritis, Mallory-­Weiss tear Abdominal Mass/Swelling Questions for HPI • Duration • Quality • Associated symptoms (fever, abdominal pain, vomiting, diarrhea , hematuria, jaundice, history of joint swelling, etc) • Ability to feed, UOP • Activity level • Sick contacts • HIV status • Medications/herbs given • Traditional healer remedies tried Differential Diagnosis This list is not exhaustive but additional conditions to consider while working in developing countries of sub-­ Saharan Africa: • Infectious diseasesºº Malaria (splenomegaly)ºº Abscessºº Schistosomiasis (hepatomegaly) • Hematology/oncologyºº Sickle cell (splenomegaly)ºº Tumor (Wilms, neuroblastoma, lymphoma, germ cell tumor) • Gastroenterologyºº Pyloric stenosis (“olive”)ºº Intussusception 58 Gastroenterology Diarrhea Questions for HPI • Duration • Frequency, quantity • Quality (color, bloody) • Associated symptoms (fever, abdominal pain, emesis, etc) • Recent antibiotic use • Weight loss • Ability to feed, UOP • Activity level • Sick contacts • HIV status • Relieving factors • Aggravating factors • Medications/herbs given Differential Diagnosis This list is not exhaustive but additional conditions to consider while working in developing countries of sub-­ Saharan Africa: • Acute, nonbloody:ºº Malariaºº Sepsisºº Rotavirusºº Astrovirusºº Enteric adenovirusºº Norovirusºº E. coli (enterotoxigenic-­ETEC, enteropathogenic-­EPEC, enteroaggregative-­EAEC)ºº Choleraºº Clostridia spp.ºº Enterotoxin-­ producing strains of Staph. aureusºº Giardiasisºº Cryptosporidiosisºº Cyclospora cayetenesis 17. Approach to a Child with Abdominal Complaints 59ºº Strongyloidiasisºº Food poisoningºº Antibiotic use • Acute, bloody:ºº Shigellaºº E. coli (enterohemorrhagic)ºº Campylobacterºº Salmonellaºº Clostridium difficileºº Yersiniaºº Balantidium coli enterocolitisºº Amoebic dysenteryºº Schistosomiasisºº IBDºº Ischemic colitis • Chronic (lasts >2 weeks):ºº Lactose intoleranceºº Cow’s milk protein intoleranceºº Persistent infection (strongyloidiasis, cryptosporidiosis, microsporidiosis , enteropathogenic E. coli, giardiasis, intestinal flukes, chronic intestinal schistosomiasis)ºº Malnutritionºº Zinc deficiencyºº HIV enteropathyºº Ileocecal TBºº Burkitt lymphomaºº Chronic calcific pancreatitisºº Acute and chronic liver diseaseºº IBDºº Celiac disease 60 Gastroenterology 18. Diarrheal Diseases Sources: WHO, Pocket book of hospital care for children, 2013; Eddleston et al, Oxford handbook of tropical medicine, 2008; Bugando Medical Centre, Paediatrics management guidelines, 2011. Causes Viruses Bacteria Parasites/Worms Fungal Rotavirus E. coli† Entamoeba histolytica† Candida Adenovirus C. difficile† Giardia lamblia Norwalk virus Salmonella† Cryptosporidium HIV Shigella spp.† Strongyloides Astrovirus S. aureus Trichuris trichiura† Yersinia enterocolitis† Cyclospora Vibrio cholerae Malaria (esp. P. falciparum) Campylobacter† Schistosoma spp.† Other: Food poisoning, antibiotics, IBD, celiac disease † May present with bloody stools. Risk Factors: • Poor hygiene • Lack of immunizations • Failing to exclusively breastfeed for first 4–6 months • Contaminated drinking water • Malnutrition • Immunosuppression • Improperly stored food Clinical Manifestations • Diarrhea +/-­blood/mucus • Abdominal pain • Signs of dehydration (restlessness, irritability, lethargy, sunken eyes, slow skin pinch, thirsty, drinks eagerly or poorly) • Signs of severe malnutrition 18. Diarrheal Diseases 61 • Abdominal distension • +/-­abdominal mass • Fatigue • Anorexia • Vomiting Definitions WHO Acute (Watery) Diarrhea • More than 3 loose stools/day • No blood in stools WHO Dysentery • Acute diarrhea (>3 loose stools/day) plus blood mixed with stool WHO Persistent Diarrhea • Diarrhea lasting ≥ 14 days WHO Some Dehydration ≥2 of these signs: • Restlessness • Irritability • Sunken eyes • Drinks eagerly/thirsty • Skin pinch...

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