Insidious, no specific signs/symptoms so often delayed diagnosis. Pain in region of lower back or hip, fever. Often 10+ days later that becomes more obvious.

Usually caused by haematogenous spread, but may be due to local suppuration.

Blood tests are not very helpful!  WCC/CRP/ESR non-specifically high.  CK is rarely raised!  Blood cultures often positive.

MRI is investigation of choice as ultrasound is only 60% sensitive.

Rx IV antibiotics for min 5/7 then complete 3-6/52 oral.  Large abscesses will require surgical drainage (open or ultrasound guided).  No reported sequelae but can be complicated by iliac thrombophlebitis followed by pulmonary emboli (akin to Lemierre’s disease).

Classic history in less than 60% of cases! Retrocaecal in 15% so hip pain (psoas irritation), flank or right upper quadrant pain/symptoms. A deep appendix tip can give rectal pain especially on defaecation, plus diarrhoea, dysuria!

Under 6 with 48+hr symptoms are likely to have appendicitis.

Periumbilical pain due to T10 innervation, then localises to RIF as serosa involved. But can be suprapubic if appendix lies medially, or flank pain if lateral.

Vomiting at start unusual except retrocaecal, tends to start later.

Fever low grade or absent.

Under 5 can just present with diffuse pain and peritonitis as omentum under developed, so fails to contain. Higher risk of delayed diagnosis, perforation.

To check for psoas irritation, hyperextend hip (lie on side). For obturator, flex hip and internally rotate.

Speed bump sign good positive predictive sign!

Investigations

WCC/CRP poor sens/spec especially in first 24hrs.

USS – hyperechoic mesenteric fat, fluid collection, local dilated loop suspicious if appendix cannot be seen. 90-95% sens/spec.

Post adenoidectomy

Trickling blood behind uvula or hanging clot are reasons for re-exploration.

Post tonsillectomy

Secondary haemorrhage typically at 5-7 days.  Beware constant swallowing! White slough normal. Yellow (with pain) might mean infection so Corsodyl or peroxide gargles, 3-6x daily, possibly antibiotics.

History of bleeding but clear fossae – assess general condition and exclude bleeding disorder (family history), safety net.

If small clot, observe to see if enlarging. Every 15 mins or more if still spitting/swallowing. IV access and fast. Sit up.

Active bleeding needs anaesthetist for airway management, crossmatch too. Tonsil tray – adrenaline solution soaked swab applied to bleeding spot with Magill’s forceps until reaches theatre. Ice packs for back of neck. Post exploration NG tube to keep stomach empty.

Tranexamic acid, DDAVP? Eg vWD

Pylorus is the name of the outflow tract of the stomach, the muscle in the wall controls how quickly the stomach empties.

For some reason, this muscle can become hypertrophied in the first month or two of life, to the point that the baby begins to vomit with feeds, become dehydrated and lose weight. Remains hungry of course, which may not be the case with some of the differentials.

The vomit is non-bilious of course, as the obstruction is above the bile duct.

4 male:1 female. Less common in black/Asian groups. Maternal history is more significant than paternal! NB Associated with TOF, other abnormalities. Associated with erythromycin use in infancy, particularly in first 14 days of life.

1st week to 5 months, but usually after 3 weeks. Only 6% present within 14 days of life – increasing proportion over time? (Even before US available) More likely to have family history?

Preterm babies make up only 3% of cases, and symptoms/signs tend to be less dramatic. Unclear whether USS criteria (below) are valid for preterms. [Arch Peds Adol Med 1996]

Diagnosis

Peristalsis may be visible through abdominal wall. Olive shaped mass (2 cm diameter) felt RUQ just lateral to midline, under liver (sit on left side), after vomit.

When well established vomiting, hypochloraemic, hypokalaemic alkalosis characteristic (but not 100% specific).

On ultrasound scan, muscle thickness more than 3mm, transverse pyloric diameter more than 14mm (length similarly) – ie 3.14 (Pi, the mathematical constant)! [radiopaedia]

Differential diagnosis = reflux, sepsis, cow’s milk intolerance, other surgical condition eg malrotation, raised intracranial pressure, Congenital Adrenal Hyperplasia, biochemical imbalance eg renal tubular acidosis, inborn error of metabolism etc.

Treatment

Surgical pyloromyotomy (Ramstedt’s)- usually laparascopic. Quite a minor procedure, since the muscle is incised and then left to heal without any need to enter bowel itself or repair anything.