Abdominal pain

Question 1

A 14 year old male attends an emergency department with severe lower abdominal pain. He describes mild pain since completing rugby training this evening but now presents having woken overnight with increased pain. On arrival to the ED he is now unable to walk due to pain in the lower abdomen.

Answer 1

Impression
With this non-specific presentation of RLQ abdominal pain, a wide-range of differentials should be considered in the approach to assessment and management.

DDx
- GI: appendicitis, trauma, volvulus, constipation, IBD, hernia, bowel obstruction (LBO/SBO), mesenteric adenitis
- Genitourinary: testicular torsion, appendiceal torsion
- Infective: gastro, UTI, pyelo

Question 2

Abdominal pain - History

Answer 2

History
- pain hx (SOCRATES), migratory, diffuse, etc. infective sx,
- trauma sustained at training,
- medications, PMHx, family history
- paeds hx, any surgeries as a newborn (undescended testes, etc)
- gynae history in girls of this age group

Question 3

Abdominal pain - Examination

Answer 3

Examination
- general appearance + vitals (any HD instability
- abdominal examination: signs of appendicitis
- external genitalia exam: swelling, tenderness, prehn’s sign, blue dot sign
- systems review
- hydration status assessment

Question 4

Abdominal pain - Investigations

Answer 4

Investigations
- bedside: urinalysis, Urine MCS
- bloods: FBC, CRP, ESR, UEC, LFT, lipase, VBG (ketones), cultures if septic
- imaging: abdo ultrasound, abdo x-ray, further imaging pending findings from assessment (CT, etc)

Question 5

Abdominal pain - Management

Answer 5

Management
Supportive
- analgesia
- antiemetics
- antipyretics if fever
- fluids and electrolytes as required
- parental and patient education, reassurance

Definitive
Pending underlying aetiology
- surgical review if uncertain

• Appendicitis: Gen Burg review, either for conservative of surgical management pending sx and if complicated or not - ABx (amp gent metro)
• Torsion: urgent uro consult and theatres for orchidopexy (of both affected and non-affected testis to prevent future events) given time-sensitive nature of presentation.