Case 22

16-YEAR-OLD WITH ABDOMINAL PAIN - MANDY

Author: Sherilyn Smith, M.D., University of Washington School of Medicine
Learning Objectives
Know the ethical responsibilities in caring for adolescent patients. 1.
Be able to conduct a focused acute-care visit for an adolescent patient. 2.
Be able to obtain a comprehensive pain history for abdominal pain. 3.
Be able to obtain a sexual history in an adolescent patient using the
HEEADDSSS screening tool.
4.
Review the physical examination findings suggestive of an acute abdomen. 5.
Construct a differential diagnosis for acute abdominal pain in an adolescent. 6.
Review the presentation of and risk factors for pelvic inflammatory disease. 7.
Summary of clinical scenario: Accompanied by her mother, 16-year-old Mandy
presents to the clinic with three days of abdominal pain. She reports vomiting and
feeling achey and chilled. She last had unprotected sex two weeks ago. Physical
exam reveals hypoactive bowel sounds, diffuse abdominal pain with increased
tenderness in the right upper quadrant, intermittent guarding during the
examination, mild to moderate rebound to palpation, and no increased pain with
palpation at McBurneys point. Pelvic exam reveals purulent cervical discharge and
moderate cervical motion tenderness. Gram stain of the cervical discharge shows
intracellular gram negative diplococci. Mandy is diagnosed with pelvic
inflammatory disease (PID).
Key Findings from
History
Acute abdominal pain
Vomiting, no diarrhea
No ill contacts
History of urinary tract infection
Sexually active
Occasional alcohol use
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Key Findings from
Physical Exam
Fever
Diffuse abdominal tenderness with
rebound and guarding
Negative McBurneys sign
Cervical motion tenderness
Right upper quadrant pain
No costovertebral angle tenderness
No jaundice
Normal lung exam
Differential Diagnosis
Appendicitis
Acute gastroenteritis
Pelvic inflammatory disease
Urinary tract infection
Ectopic pregnancy
Pancreatitis
Hepatitis
Pneumonia
Key Findings from
Testing
Cervical discharge gram stain,
culture, and wet mount positive for
intracellular gram negative diplococci
(N. gonorrhea)
Final Diagnosis Pelvic inflammatory disease
Case highlights: This case explores the approach and evaluation of acute
abdominal pain. Students work through a problem-focused interview, review
specific questions appropriate for adolescent patients, and construct a differential
diagnosis for acute abdominal pain. The students review the presentation of
common causes of acute abdominal pain and review in depth the etiology,
diagnosis, and management of pelvic inflammatory disease. Additionally, students
hear modeling of specific techniques used to discuss confidential issues with
teenagers. Multimedia features include an image of a cervix with purulent
discharge and two audiosone of the attending informing an adolescents mother
that part of the interview will be confidential and one of telling the patient she has
pelvic inflammatory disease.
Key Teaching Points
Knowledge
Pelvic inflammatory disease (PID):
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Epidemiology
Sexually active girls 1519 years are highest-risk group due to biological
and behavioral factors:
Fewer protective antibodies in vagina than in older women
Cells in cervical ectropion (transitional zone) particularly susceptible to
infection
More common in sexually active women:
Risk factors include intercourse during menses, infrequent or no
condom use, multiple sexual partners
Microbiology
Most common organisms (> 50% of cases) are Neisseria gonorrhea and
Chlamydia trachomatis.
Pathophysiology
Lower-tract infection alters normal vaginal flora and allows bacteria (such as
Escherichia coli, Bacteroides species, other anaerobes, Mycoplasma hominis
or Ureaplasma urealyticum) access to uterus and fallopian tubes.
Complications
Fitz-HughCurtis syndrome
Tubo-ovarian or other intra-abdominal abscess
Risk of infertility
Appendicitis:
Epidemiology
Most common condition requiring emergency surgery in the pediatric
population
60,000 to 80,000 cases a year in the U.S.
Most often occurs in older children
Rare in children < 2 years
Prevalence in children with acute abdominal pain 1-4%
Due to a third of pediatric patients presenting with atypical symptoms, there
is both an over-diagnosis of appendicitis (false-negative appendectomy rate
5-25%) and a high incidence of perforation (23-73%) in the pediatric
population.
Studies
Many clinicians use adjunctive laboratory and radiographic studies to
increase accuracy of diagnosis, including:
Complete blood count with differential
Sensitivity 19-88%, specificity 53-100%
C reactive protein
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Sensitivity 48-75%, specificity 57-82%
Skills
History:
Key elements for any pain history: A useful mnemonic to help remember
questions to ask about pain is PQRSTAAA:
P=Position (be exact)
Q=Quality (dull, sharp, burning)
R=Radiation (be exact)
S=Severity (scale from 1 to 10, if patient can do this)
T=Timing (when it happens)
A=Alleviating factors
A=Aggravating factors
A=Associated symptoms
Modified history for adolescent
Set up expectations for interview at beginning of visit.
In general, start with the least emotionally charged topics and progress to
increasingly personal subjects.
HEEADDSSS is a useful mnemonic for a screening tool that is important to
use with adolescents:
H=Home (includes parental and sibling relationships)
E=Education (school problems, career planning)
E=Eating (diet history, eating habits, self image)
A=Activities (how the patient spends her/his time, peer group interactions)
D=Drug use/abuse (Questions and counseling about alcohol, tobacco, and other
illicit drugs)
D=Depression (ask specific questions about depression, triggers)
S=Suicide (have suicidal thoughts occurred, what actions have been taken)
S=Sex (establish why you are asking this type of question)
S=Safety (ask how safe the patient feels at school and at home; may identify
potentially abusive or dangerous environments)
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Physical exam:
Pelvic exam
Perform in any sexually active adolescent girl with abdominal pain.
Small amount of vaginal discharge is normal; a significant amount indicates
infection.
Cervical motion tenderness or adnexal mass or uterine tenderness is
important in making a diagnosis of PID.
A chancre is usually found with syphilis (not usually associated with vaginal
discharge unless co-infection is present)
Rectal exam
With any abdominal complaint (e.g., atypical diarrhea, constipation, pain,
bleeding), think about doing a digital rectal examination.
It is also part of an in-depth neurological examination.
Inspect for fissures, inflammation or lack of tone.
Asking child to bear down as you insert examining finger into the rectum
relaxes the external sphincter and makes the process less uncomfortable.
Differential diagnosis
More likely diagnoses
Pelvic inflammatory disease (PID): May be diffuse abdominal pain, but
more typically in lower abdomen. Right upper quadrant pain, perhaps
referring to the right shoulder, can occur with perihepatitis that complicates
PID in 5% of cases (Fitz-HughCurtis syndrome). Highest rates are in
sexually active women 1519 years of age, but should be considered in a
young woman with acute abdominal pain, even without a history of sexual
activity. Sometimes associated with fever and vomiting. Cervical motion
tenderness pathognomonic for PID.
1.
Pancreatitis: Constant, severe abdominal pain (either right upper quadrant
or more localized to the epigastric region) common in pancreatitis. Band-like
pain radiating to the back is highly suggestive. Almost always accompanied
by nausea and vomiting and low-grade fever. (Vomiting without diarrhea
suggests extra-intestinal pathology.)
2.
Hepatitis: Usually presents with fever, malaise, diffuse abdominal pain,
nausea, vomitingno diarrhea. Associated with jaundice and change in
urine color. Hepatomegaly is usually seen. Onset of symptoms depends on
etiology (Hepatitis A, B, C, or alcohol-induced).
3.
Urinary tract infection (UTI): In older children, usually present with
dysuria, frequency, and urgency. Fever and/or back pain (costovertebral
angle tenderness) suggest pyelonephritis. More common in sexually active
women. Prior history of UTI may suggest structural abnormality.
4.
Ectopic pregnancy: Strongly consider in a sexually active female patient
with abdominal pain. Classically presents with lower abdominal pain,
5.
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bleeding, and abnormal menses. Requires emergent evaluation and
treatment. Physical exam may be completely normal in an early, unruptured
ectopic pregnancy.
Appendicitis: Must always consider with acute abdominal pain. Fever is
often seen, but is non-specific. Classic pattern (60% of the time) is
periumbilical pain followed by generalized, severe right lower quadrant
tenderness (sensitivity of 87% to 99% in adults). Right lower quadrant
tenderness at McBurneys point is expected. Vomiting is common; diarrhea
is not.
6.
Cholecystitis: Most often causes right upper quadrant pain (either constant
or colicky), sometimes radiating to the shoulder. Murphys signsevere pain
and interruption of breath on palpation of the right upper quadrantmay be
seen. Eating fatty foods may worsen the pain. Decreased appetite, nausea
and vomiting can accompany attacks. Cholecystitis is less common in
children than in adults but does occur.
7.
Less likely diagnoses
Acute gastroenteritis: While vomiting is a common presenting complaint, by
three days into the illness, typically diarrhea is the most pronounced symptom.
Ovarian torsion: Stabbing abdominal pain is a common symptom, typically in
lower abdomen or pelvic region. Also nausea and vomiting. Can happen in any
age group, but more common in post-menarchal women.
Pneumonia: Irritation of the pleural by a lower lobe infection is an important
cause of abdominal pain in young children. One would expect also to find cough,
difficulty breathing, and chest pain.
Incarcerated hernia:
Most present before 1 year of age
Incarcerated hernias occur slightly more often in girls, and an ovary may be
in the hernia instead of intestine.
Tender mass in groin or labia majora
Irritability (in an infant) is a common symptom.
Vomiting and abdominal distention may be seen if there is accompanying
intestinal obstruction.
In boys, need to consider the following:
Testicular torsion:
Most often occurs in early adolescence
Acute onset of severe hemi-scrotal pain, nausea, and vomiting
Enlarged, tender testis, scrotal edema, and absence of cremasteric muscle
reflex
Irreversible changes in testis may occur within four hours.
Requires prompt surgical exploration and detorsion to save affected testis.
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Studies
Pregnancy test: For consideration of pregnancy, complications of pregnancy and
ectopic pregnancy
Culture, andwet mount of cervical discharge: Identifies infecting organism(s)
Nucleic Acid Amplification Test (NAAT) : Tests for presence of bacteria (e.g.,
chlamydia, gonorrhea) or viruses in urine or cervical discharge
Urinalysis: Evaluates likelihood of urinary tract infection
Complete blood count (CBC): Helps gauge severity of inflammation (but
non-specific)
Erythrocyte sedimentation rate (ESR): Helps gauge severity of inflammation
(but non-specific)
Aspartate aminotransferase (AST), alanine aminotransferase (ALT), and
bilirubin: Evaluates likelihood of hepatitis
Abdominal ultrasound
Management
Pelvic inflammatory disease (PID): PID is a clinical diagnosis and treatment is
based on history and examination findings
Treatment:
Treatment with antibiotics often empiric unless rapid diagnostic tests are
available.
Partners must also be tested and treated to minimize risk of recurrence.
Hospitalization: Patients with mild/moderate PID may be managed as an
outpatient. Reasons for hospitalization include:
Pregnancy
Previous noncompliance
High fever
Intractable vomiting
Inability to exclude a surgical emergency
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