Case 22: 16yo - Female abdominal pain

Question 1

Healthy 17 year old female with two days of abdominal pain and nausea. She has been camping with her family and is now unable to go hiking because of her pain.

Pain at first was intermittent but is now more constant.
Samantha describes her pain as sharp and crampy pains in her right lower quadrant. Some radiation down into the inguinal area
She has vomited once (came after the pain)
No diarrhea. Normal stool this morning.
Pain is not associated with eating and she still has an appetite.
No dysuria or vaginal discharge

Family has been camping in Maine. They have been drinking water from the stream. Other family members feel well.
PMH: Healthy and no recent illnesses
She takes OCP’s for “heavy periods” but denies sexual activity. LMP 2 weeks ago.
Denies drugs, alcohol, tobacco.
No significant family history.

Exam = Writhing on exam table, unable to get comfortable. Guarding and tenderness in RLQ and suprapubic area

Diffdx?
Mgmt?

Answer 1

Diffdx (2w)

• Cyst (hemorrhagic/cystic)
• Mittleschmerz
• Ovarian torsion (SIMILAR to kidney stone)
• Ureteral stone
• Appendicitis
• Giardia [but usually more watery/frothy diarrhea]
• SBO
• dehydration/constipation
• terminal ileitis (Crohn’s)

WOULD BE LATER IN MENSTRUAL CYCLE

• ectopic pregnancy (+/- rupture)
• endometriosis (at time of menses)
• dysmenorrhea

MGMT

• CBC (infection), BMP (electrolytes d/t vomiting - low K, Cl, H)
• UA
• b-hCG
• Pelvic US with doppler

Only if REALLY necessary

Question 2

Pelvic US findings of an ovarian torsion

tx?

Answer 2

large ovary with an edematous wall, a large fluid-filled cyst, free fluid, and no blood flow demonstrable by doppler.

Question 3

Female Patient is prepubescent and you are concerned that she has ovarian torsion. Why would you consider abdominal versus transvaginal ultrasound?

Answer 3

During the prepubescent years, the ovaries will migrate into the pelvis. It can be either (more likely best to do transvaginal if pt can psychologically manage it).

Question 4

patho of ovarian torsion

Answer 4

1) venous drainage blocked ==> due to OR causing ovarian cysts (cortical cysts line up)
2) arterial drainage blocked == ischemia == PAIN

Question 5

ovarian v. testicular torsion - which has better prognosis?

Answer 5

testicular torsion == higher “save” rate.

Question 6

Kid comes in with URI, then abdominal pain. 2d later, get a rash on their butt

Answer 6

==> Henoch Scholein purpura

• responsive to NSAIDs (for arthralgia); Steroids (for abd pain)

Question 7

define: testicular torsion
- presentation:
- dx:
- tx:

Answer 7

== EMERGENCY

• presentation: early adolescence; ACUTE onset of severe local hemi-scrotal pain, N and V; enlarged tender testis, scrotal edema, NO I/L cremasteric reflex
• dx: clinical suspision; color Doppler US; irreversible changes within 4h
• tx: SAVE THE TESTIS - surgical exploration, detorsion

Question 8

most common condition requiring emergency surgery in the pediatric population

Answer 8

acute appendicitis

Question 9

appendicitis in children

• epidemiology:
• presentation:
• dx:
• tx:

Answer 9

• epidemiology: 60-80K cases/year (1-4% of kids with acute abd pain); >2yo
• presentation: kids have ATYPICAL PRESENTATION - sometimes looks like constipation, vague periumbilical abdominal pain
• dx: CBC, CRP

Question 10

PID

• cause:
• epidemiology:
• presentation:
• dx:
• tx:
• complication:

Answer 10

• cause: Neisseria gonorrhea, Chlamydia trachomatis ==> altered normal vaginal flora –> infection of uterus and fallopian tubes by E.coli, bacteroides, mycoplasma, ureaplasma
• epidemiology: sexually active females 15-19yo == fewer protective Abs in vagina; immature cervical ectropion (very susceptible to STDs); behavioral (intercourse during menses
• presentation: (1) cervical motion tenderness (2) abd pain (3) cervical discharge
• dx: Culture for bacteria; NAAT on urine/cervical discharge
• tx: doxycycline + azithromycin
• complication: infertility, sepsis, tubo-ovarian abscess, intra-abd abscess

Question 11

characteristics of pain (memonic)

Answer 11

PQRST AAA

P=Position (be exact)
Q=Quality (dull, sharp, burning, crampy)
R=Radiation (be exact - to back, to flank, to groin, etc)
S=Severity (scale from 1 to 10, if the patient can do this)
T=Timing/Duration (when it happens)

A = Age (Causes of abd pain vary by age)
A=Alleviating / Aggravating factors
A=Associated symptoms

Question 12

in what cases with an adolescent do you HAVE to do a rectal exam

Answer 12

==> abd complaint (atypical diarrhea, constipation, pain, bleeding)
==>in-depth neurological examination

• inspection for fissures, inflammation, hypotonia
• child to bear down as palpate anus ==> relax external sphincter

Question 13

what does vomiting without diarrhea suggest?

Answer 13

extra-intestinal pathology

e.g. pregnancy (ectopic/intrauterine)

Question 14

what is the cause of RUQ pain in PID/

Answer 14

perihepatitis -fitz-hugh-curtis syndrome == N. gonorrhea / C. trachomatis

Infectious material may spill from the uterus and track along the paracolic gutter and cause inflammation of the hepatic capsule and diaphragm. This results in RUQ pain and referred scapular pain

sudden onset, may refer to R shoulder

Question 15

diffdx Fever, abd pain +/- vomiting, based on age :

- all peds

Answer 15

ALL PEDS

• intussusception (+ Fhx of polyposis)
• pancreatitis [genetic, anatomic (annular), gallbladder dz, infection, ETOH use, injury, meds] == low-grade fever; diffuse/epigastric/RUQ abd pain + radiate to back; CONSTANT, severe, N/V
• hepatitis [ETOH +/- infectious] == fever, malaise, diffuse/RUQ abd pain, N and V without diarrhea;JAUNDICE, dark urine, hepatomegaly
• mass/obstruction
• lymphoid hyperplasia
• AV malformation
• C. diff (with exposure)
• DKA
• constipation
• HSP

Question 16

diffdx Fever, abd pain +/- vomiting, based on age :

- baby <12mo

Answer 16

BABY

• pyloric stenosis
• Hirschsprungs
• malrotation –> volvulus
• incarcerated hernia (most <1yo) (F>m) = of bowel / ovary == pain, irritability, +/- vomting and abd distension (if intestinal obstruction); tender mass in groin / labia majora

Question 17

diffdx Fever, abd pain +/- vomiting, based on age :

- toddler (1-3yo)

Answer 17

TODDLER

• post-viral gastroparesis (+ kids, diabetics)
• Meckel’s == + pain if you have inutussusception on it.
• Porphyria

Question 18

diffdx Fever, abd pain +/- vomiting, based on age : )

- school age (4-11yo)

Answer 18

SCHOOL AGE

• UTI/pyelo; cystitis == dysuria, freq, urgency; poorly localized abd pain +/- fever, back pain; if recurrent –> underlying structural abnormalities
• ovarian torsion
• appendicitis == periumbilical pain THEN generalized RLQ abd pain (» McBurneys); vomiting, constipation (less, diarrhea)
• mesenteric adenitis (not palpable) == RLQ pain, fever, V/D
• acute gastroenteritis == vomiting THEn diarrhea; hx sick contacts
• Willms tumor
• Group A Strep throat (vague abd pain)
• pneumonia ==irritation of pleura d/t LL infection + cough, SOB, rhinorrhea, chest pain

Question 19

diffdx Fever, abd pain +/- vomiting, based on age :

- teen / pubertal (>12yo)

Answer 19

TEEN

• pregnancy
• PID/tubo-ovarian abscess == fever; diffuse abd pain; cervical motion tenderness, purulent cervical discharge
• torsion (testicular / ovarian) == stabbing lower /RUQ abd pain, N/V
• ectopic pregnancy == EMERGENCY; [NO FEVER] lower abd pain, vaginal bleeding, abn menstrual dx +/- mild enlargement of uterus, diffuse abd tenderness, adnexal/cervical motion tenderness
• IBD
• endometriosis
• Mittleschmerz
• hemorrhagic ovarian cyst / ruptured
• imperforate hymen
• cholecystitis (obese teens) == intermittent colicky RUQ pain (Murphy’s), steady, +/- shoulder pain (pain esp. after fatty foods); +anorexia, N/V

Question 20

indications to hospitalize patient with PID

Answer 20

• pregnancy with PID
• prior noncompliance with meds
• high fever
• intractable vomting
• inability to exclude surgical emergency

Question 21

reporting laws for STIs

Answer 21

diseases to report

• chlamydia
• gonorrhea
• syphilis
• chancroid

Question 22

when to treat the partner of a STI + patient

Answer 22

== encourage pt to inform partner to get treated
- gonorrhea, chlamydia

NOT bacterial vaginosis

Question 23

indications for pelvic exam

Answer 23

Persistent vaginal discharge

Dysuria or urinary tract symptoms in a sexually active female

Dysmenorrhea unresponsive to nonsteroidal anti-inflammatory drugs

Amenorrhea

Abnormal vaginal bleeding

Lower abdominal pain

Contraceptive counseling for an intrauterine device or diaphragm

To perform a Pap test (see note below)

If there is suspected/reported rape or sexual abuse (in cases of suspected sexual abuse, an expert in child abuse should be consulted)

Pregnancy

Question 24

labs to order if suspect PID

Answer 24

• pregnancy test
• a gram stain
• culture and wet mount of the cervical discharge
• a urine nucleic acid amplification test (NAAT) for chlamydia and gonorrhea -abdominal ultrasound

CBC with differential
ESR –> severity of inflammation
UA with microscopy –> UTI
lipase –> pancreatitis

Question 25

those at risk for Hep B

Answer 25

• IV drug users
• Individuals with multiple heterosexual partners
• Men who have sex with men
• People who reported surgery 6 weeks to 6 months before the onset of symptoms
• Workers with occupational exposure to blood or body fluids
• Staff of institutions and nonresidential child care programs for children with developmental disabilities
• Patients undergoing hemodialysis
• Sexual or household contacts of people with acute or chronic infection

Question 26

A 16-year-old obese Caucasian female with a history of irregular menses presents to the ED with severe abdominal pain and altered mental status. She uses intravenous drugs weekly. She has regular unprotected sexual intercourse with multiple male sexual partners. She has experienced fevers, nausea, vomiting, and right shoulder pain and reports no vaginal bleeding. She has not regularly seen a physician for years. Only bedside studies are performed. Vitals are T 38.0 C, BP 90/60 mmHg, P 120 bpm, R 20 bpm. Qualitative B-hCG is positive, and hemoglobin is 7 g/dL. On exam, she is in apparent distress and has difficulty answering questions. Auscultation of the chest is clear. The abdomen is somewhat rigid with tenderness in the right lower quadrant as well as guarding and rebound tenderness. On pelvic exam, there is cervical motion tenderness but no bleeding or masses noted. What is the most likely diagnosis?

 Single Choice Answer:
Please select one answer.  
A		Pelvic inflammatory disease	
B		Ruptured ectopic pregnancy	
C		Fitz-Hugh-Curtis syndrome	
D		Appendicitis	
E		Hepatitis

Answer 26

B == ruptured right-sided ectopic pregnancy, as indicated by the positive pregnancy test and hemodynamic instability. Hemorrhage into the peritoneum may irritate the peritoneum and cause referred pain to the right shoulder. Cervical motion tenderness may also be found. Patients may experience nausea, vomiting, and fever.

sever abd pain
altered mental statud
IVDU
unprotected sexual intercourse + multiple male partners

fever, n/v, R shoulder pain
hypotension
positive pregnancy test

–> hepatitis, PID with Fitz-hugh-curtis

Fitz-Hugh-Curtis syndrome is a possible complication of pelvic inflammatory disease, a possibility given the patient’s sexual history. The abdominal pain would be felt in the right upper quadrant and may be referred to the right shoulder if the peritoneum becomes irritated. Although Fitz-Hugh-Curtis syndrome may occur during pregnancy, Fitz-Hugh-Curtis syndrome would not account for the low hemoglobin, peritonitis, or vital signs suggesting fluid loss/bleeding.

Pelvic inflammatory disease (PID) is a possibility, as indicated by the patient’s sexual history and cervical motion tenderness. Symptoms of PID include lower abdominal or pelvic pain, vaginal discharge, fever, fatigue, nausea, vomiting, diarrhea, dysuria, and dyspareunia, among other symptoms. Although PID may occur during pregnancy, it would not account for the low hemoglobin, peritonitis, or vital signs suggesting fluid loss/bleeding.

Question 27

A 16-year-old female presents with acute onset of diffuse abdominal pain with periodic sharpness in the right upper quadrant that radiates to her back. She has had some episodes of vomiting and has a fever. She is sexually active and has used alcohol in the past. Which of the following is most likely to present with right upper quadrant pain?

 Single Choice Answer:
Please select one answer.  
A		Pancreatitis	
B		Urinary tract infection	
C		Ectopic pregnancy	
D		Appendicitis	
E		Ovarian torsion

Answer 27

A

diffuse abd pain
RUQ pain radiating to back
vomiting, fever
sexual active
ETOH

pancreatitis commonly causes continuous abdominal pain that can localize to the right and left upper quadrants (“band-like pain”) as well as radiating to the back. Nausea and vomiting are nearly always present. Lipase is the most sensitive and specific lab test to diagnose pancreatitis.

Question 28

A 16-year old female presents to the ED with abdominal pain. Upon questioning, the patient notes that the pain is pretty consistently in the RLQ without radiation. She denies dysuria, hematuria, or blood in the stool. She has a history of multiple sexual partners and inconsistent condom use. She does not use any other contraceptive measures. She believes her last menstrual period was 3 weeks ago, but she is unsure. She has no history of abdominal or pelvic surgeries. Her temperature is 100.8 F, heart rate is 85 bpm, respiratory rate is 12 bpm, and blood pressure is 110/70 mmHg. Her abdominal exam is notable for involuntary guarding, tenderness to palpation in the RLQ without rebound tenderness, and no CVA tenderness. Her pelvic exam is notable for cervical motion tenderness with some discharge. What is the best NEXT step in management?

 Single Choice Answer:
Please select one answer.  
A		Abdominal CT	
B		Pregnancy test	
C		Pelvic ultrasound	
D		Cervical cultures	
E		Empiric antibiotics

Answer 28

B

RLQ consistently
no urination problems, no hematochezia, no CVA tenderness
multiple sexual partners
fever
involuntary guarding
ttp in RLQ without rebound
cervical motion tenderness + discharge

== likely PID

A pregnancy test is the best first step in management. Pregnancy is one of the indications for inpatient management of PID, so this is very important information when determining whether to admit the patient from the ED or to provide outpatient treatment. While cervical cultures and empiric antibiotics are obviously a must when you suspect PID, pregnancy test is the first step, and the best answer.

Question 29

Luanne is a 15-year-old female who presents with three hours of abdominal pain and two episodes of non-bilious, non-bloody vomiting. She rates her pain at 8/10 and describes it as constant, located mainly in the middle of her belly but somewhat present throughout her abdomen. It is worse with coughing and moving. She has never had pain like this before, and has had no appetite since the pain started. She is sexually active with her boyfriend of three months, always uses condoms, and has not been tested for STIs. She is due to start her period next week. Vitals: 37.9 C, HR 100 bpm, BP 120/85 mmHg, RR 14 bpm. On exam, she exhibits involuntary guarding, mild rebound tenderness, and tenderness to palpation between her right anterior superior iliac spine and umbilicus. On pelvic exam, she reports tenderness when attempting to palpate her right adnexa, but no masses are appreciated and there is no cervical motion tenderness. Her WBC and CRP are within normal limits. Based on the information above, what is the most likely diagnosis?

 Single Choice Answer:
Please select one answer.  
A		Ovarian torsion	
B		Pelvic inflammatory disease	
C		Ectopic pregnancy	
D		Appendicitis	
E		Cholecystitis

Answer 29

D. Appendicitis is the most common condition in children requiring immediate surgical intervention, but often presents differently than in adults (especially in infants). Aspects of their atypical presentation include lack of migration of pain to the RLQ, negative Rovsing’s sign, and involuntary guarding and fever without perforation. In school-age children who can articulate the pain, they often describe pain with movement or coughing (cat’s eye sign). Also, rebound tenderness was found to be neither sensitive nor specific in the pediatric population, while in the adult population it is one of the most accurate PE findings (86%). Luanne is of the older pediatric population, and so will present with a more typical appendicitis. Her sudden onset of intense pain at the umbilicus with vomiting, anorexia, and tenderness at McBurney’s point are all classic findings. The more atypical signs include diffuse pain centered below the umbilicus, and rebound tenderness that might point to a perforation (more likely, it is part of the atypical pediatric presentation given her normal WBC study). Another atypical aspect of her exam is her adnexal pain during the pelvic exam, which could be due to the degree of inflammation and the positioning of her appendix. The key take-away point is to have a high index of suspicion for appendicitis for pediatric patients with abdominal pain given their atypical presentation.

abd pain = 3h ago (8/10) 
nonbilious, nonbloody vomiting
umbilical --> diffuse
worse with coughing, moving
anorexia
involuntary guarding, rebound, ttp in R ASIS, R adnexa
no cervical motion tenderness == NOT PID
no palpable mass == not cyst

sexually active, + contraception
? STIs
3rd week of menstrual cycle == NOT ECTOPIC (8th week), could be cyst

afebrile, tachycardic. normotensive

ovarian torsion or appendicitis

Ovarian torsion is more common in the post-menopausal population, though it can present in any age group. It is described as intermittent stabbing pain in the lower abdominal or pelvis. Torsion is often secondary to an ovarian mass, such as a neoplasm or corpus luteal cyst, which is occasionally appreciated on exam. Nausea and vomiting are very common findings as well. Ultrasound is essential to initial workup. Given that Luanne has periumbilical pain, tenderness at McBurney’s point, and no palpable masses on pelvic exam, ovarian torsion is a less likely diagnosis.

Question 30

A 16-year-old homeless female presents with low-grade fever and abdominal pain. The patient reports recent unprotected sex. Abdominal examination reveals tenderness to palpation in the lower abdominal region, but no masses are appreciated. Pelvic examination reveals whitish cervical discharge and cervical motion tenderness. The discharge is sent for culture, and a pregnancy test is negative. What is the next best step in management?

 Single Choice Answer:
Please select one answer.  
A		Pelvic ultrasound	
B		Begin oral antibiotics antibiotics and treat her partner	
C		Arrange for hospitalization	
D		Abdominal CT	
E		Surgical consult

Answer 30

C

homeless
low-grade fever
abd pain
unprotected sex
ttp to palpation in lower abdomen
no masses
cervical discharege, cervical motion tenderness
\+ pregnancy test

PID+ pregnant

This patient has signs and symptoms of PID. Cervical discharge should be tested for gonorrhea and chlamydia and sent for culture. As she is a homeless patient, she is at high risk for failure to complete her antibiotic course. Given the deleterious sequelae of incompletely treated PID, she should be hospitalized in order to ensure a full course of treatment.