Volume 1, Case 3
Loren G. Yamamoto, MD, MPH
Kapiolani Medical Center For Women And Children
University of Hawai‘i John A. Burns School of Medicine
A 6 year old male presents to the ED with a chief complaint of fever and stomach pain since last night. It is now 11:00 a.m. The temperature was not measured at home but he felt warm. He was given an unspecified dose of acetaminophen at 4:00 a.m. There was no history of nausea, vomiting, or diarrhea. His last bowel movement was three days ago. He pointed to his epigastrium as the location of most of his pain.
Exam: VS T38 (tympanic), P136, R24, BP 113/61. He was noted to be small for age (19.3 kg), alert, active, in no distress. He did not appear to be uncomfortable at all. HEENT exam was unremarkable. Neck supple without adenopathy. Heart regular without murmurs. Lungs clear. Abdominal exam was positive for mild tenderness in the epigastrium. Bowel sounds were active. No tenderness in the right lower quadrant. No rebound tenderness. No hepatosplenomegaly or masses were appreciated. Testes were normal. A rectal exam revealed normal sphincter tone, no masses, and no right lower quadrant tenderness. The stool tested negative for occult blood. An abdominal series was ordered. An AP view of the chest was also ordered as part of the abdominal series.
View abdominal series: Flat (Supine) view
View abdominal series: Upright view
View AP chest:
The radiographs were interpreted as showing non-specific findings. Because the cause of the
abdominal pain was suspected to be constipation, the patient was given an enema. Following this, he passed a large amount of stool and felt much better. His abdominal exam continued to be benign. He was discharged from the ED. Overnight, the patient continued to experience fever at home and some abdominal pain though the degree of abdominal pain was improved. A review of his radiographs the following morning revealed an alternative diagnosis for his symptoms.
Review his abdominal series again above.
If you are still unable to identify the radiographic diagnosis, review the focused enlarged view of the lesion.
This view provides a focused view of the lesion. Note the triangular density superimposed on the heart. The flat (supine) view shows this best (see below). It is located at the very top of the flat (supine view).
This represents a pulmonary infiltrate in the medial aspect of the left lower lobe. The top of it is cut off in the flat (supine) view of the abdomen. It is almost impossible to appreciate this density on the upright view because most of it is cut off. The chest radiograph was taken using a different degree of penetration to view the lungs better. Because of this, it is even more difficult to appreciate the infiltrate behind the heart. Upon close inspection, you should be able to appreciate the triangular density superimposed on the heart on the chest radiograph view. A lateral view of the chest was not taken in this case since the chest view was part of an abdominal series that was ordered.
The patient was placed on antibiotics and his fever promptly improved by the next day. His abdominal pain and his other symptoms gradually improved.
Discussion and Teaching Points:
Pneumonia is a known cause of abdominal pain. This diagnosis is often not considered because the abdominal pain is the chief complaint. The pain can be very severe at times. This can easily mislead a clinician to limit the area of investigation to the abdomen. This pitfall should be avoided. Causes of abdominal pain that are not related to the abdomen include pneumonia, pneumothorax, pneumomediastinum, pericarditis, zoster, vertebral conditions (eg., osteomyelitis, discitis), diabetic ketoacidosis, etc. Adult conditions that are less likely but still possible in children include myocardial ischemia and aortic dissection.
Pulmonary conditions should be considered in patients with respiratory symptoms, tachypnea, or a borderline oxygen saturation. Documentation of these findings should be routine in patients with abdominal pain. The history should include the presence of and the severity of respiratory symptoms. The vital signs should include a respiratory rate and a pulse oximetry reading. The examination should include notes describing the presence or absence of any observed tachypnea, the degree of coughing observed, the characteristics of the cough (eg., moist, productive, bronchospastic, dry, etc.), and the standard pulmonary auscultation and percussion findings. If any of these findings suggest the possibility of pneumonia, PA and lateral chest radiographs should be ordered, or alternatively, treatment prescribed for a clinical diagnosis of a respiratory infection.
Although the likelihood of aortic dissection is low (especially in children), this condition is associated with a substantial likelihood of death which may be preventable if the diagnosis is suspected early. While aortic contrast studies by CT or aortography are not routine, one suggestion has been to document the presence and character of peripheral pulses in all patients presenting with abdominal pain.
Although the appendix is often the focus of clinical examination in patients with abdominal pain, there are other serious causes of abdominal pain that should be considered as well, such as intussusception, volvulus, pancreatitis, ovarian torsion, testicular torsion, acute cholecystitis, etc.
The radiographic findings in intussusception may range from normal to various indirect signs of intussusception (refer to Case 2 which describes the radiographic findings in intussusception). A volvulus is usually associated with a true bowel obstruction, but the presentation clinically and radiographically can occasionally be subtle.
Ovarian torsion may be a difficult diagnosis to make. Even the use of color flow doppler ultrasound used to assess blood flow to the ovaries is not able to totally rule out this diagnosis since, early in its presentation, some blood flow may still be preserved.
Testicular torsion is usually suspected on clinical grounds, but occasionally the testes are not examined in some patients because their pants and underwear (or diapers) are not removed. Younger patients may fail to point to their testes as the location of the pain. Some may complain of non-specific abdominal pain because of failure to appreciate the source of the pain, or because of modesty.
In summary, the causes of abdominal pain are extensive. In the acute care setting, it is most important to rule out diagnoses that must be made early to result in the best possible outcome for the patient. Some of these diagnoses have been mentioned, but there are others.