Transcription of What is causing this young girl's abdominal symptoms?
1 THE BABY BEAT November 28, 2012. D. Gary Benfield, What is causing this young girl's abdominal symptoms? Let's play pretend. Suppose you're a family doctor. An eight-year-old girl is your next patient. She is with her mother who made the appointment this morning. They give you a four-day history of intermittent vomiting and abdominal pain . Let's pause for a moment to remind ourselves of something important: An eight-year-old girl is built differently than an eight-year-old boy. She has two ovaries, two fallopian tubes, a uterus and a vagina. A young boy doesn't. So, when she presents with a history of vomiting and abdominal pain , she has a different list of possible causes than a boy does. Now, back to our story. Four days ago, she was seen in the emergency room.
2 Diagnosed as having a virus, she was given a rectal suppository and sent home. The next day, her parents took her back to the emergency room because of continued vomiting and abdominal pain . A routine analysis of her urine was "suspicious." So she was started on an antibiotic for a suspected urinary tract infection. The next day, her mother took her to an urgent care center. The doctor suspected constipation and prescribed treatment with enemas. The enemas THE BABY BEAT November 28, 2012. What is causing this young girl's abdominal symptoms? produced a good amount of stool, but didn't help her abdominal pain and vomiting. The girl describes the pain as cramping and says it comes and goes. When she vomits, it's clear-colored, not green or streaked with blood.
3 Her vital signs and physical exam are normal except for a slight temperature elevation and tenderness over her lower abdomen when you press on her belly. She seems to have something more significant going on than a virus or constipation. You order some tests and think about the possibilities. Her white count is elevated, but her urinalysis is normal. A call to the emergency room reveals that the urine culture obtained three days ago was negative. It's unlikely that she has a urinary tract infection. Appendicitis typically starts with the acute onset of vomiting and abdominal pain . A slight temperature elevation and the increased white count are consistent with this diagnosis. Did she have appendicitis that perforated and formed an abscess?
4 Bowel obstruction could start in this way, but she has had a bowel movement within the past 24 hours. Her abdomen is not distended, and she doesn't look sick enough for complete bowel obstruction. You admit her to the hospital and arrange for an ultrasound of her abdomen and pelvis. The ultrasound makes the diagnosis. A pelvic mass is seen 2. THE BABY BEAT November 28, 2012. What is causing this young girl's abdominal symptoms? pushing on the right side of her urinary bladder. Torsion or twisting of the right ovary seems most likely. You consult a pediatric surgeon who takes her to the operating room. The surgeon discovers a large, swollen, hemorrhagic ovary and twisted fallopian tube, which he removes. The girl's post-op course goes smoothly, and she is discharged in good condition.
5 Torsion or twisting of the ovary is uncommon in young girls, but it can occur at any age, even in newborns. Most cases are associated with ovarian cysts or other tumors. But they can also occur in normal ovaries, which was true in this case. The child typically presents to a doctor with abdominal pain , with or without vomiting. Because the right ovary is most commonly involved, preoperatively the diagnosis of acute appendicitis is often suspected. But at surgery, the surgeon is sometimes surprised. No one knows why a normal ovary will twist in this way. But torsion or twisting of the ovary should always be kept in mind when considering the diagnosis of appendicitis in a female. Early diagnosis and surgery may save the ovary. Unfortunately, in most reported cases, surgery came too late.
6 The involved ovary had to be removed. 3. THE BABY BEAT November 28, 2012. What is causing this young girl's abdominal symptoms? A further thought: Suppose we double our patient's age from 8 to 16, and she presents with abdominal pain and intermittent vomiting. Now the list of possibilities grows even longer. More than 50 years ago, before starting medical school, I observed the surgery for just such a case. As a matter of fact, it was the very first operation I had ever witnessed. The pre-operative diagnosis was acute appendicitis. But when the crusty old surgeon opened the teenager's abdomen, her appendix was completely normal. After widening his incision, he discovered a tubal pregnancy instead. In hindsight, the girl and her parents were close friends of the surgeon and his family.
7 As a result, the surgeon had deviated from his usual routine, failing to do a pregnancy test, failing to do a pelvic exam, and failing to ask his patient if she was sexually active. He just assumed his patient had appendicitis. However, the girl still needed the operation since acute appendicitis and a tubal pregnancy are both life-threatening events. 2012 Gary Benfield 4.
