Abdominal Pain in an Adolescent Girl

AUTHORS:
Nicole D. Garcia Lacasse, MD, MPH¹ • Joseph Cao, MD² • Victoria Wurster Ovalle, MD³

AFFILIATIONS:
¹Department of Pediatrics, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio
²Department of Radiology, UT Southwestern Medical Center, Dallas, Texas
³Division of Emergency Medicine, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio

CITATION:
Garcia Lacasse, ND, Cao J, Wurster Ovalle V. Abdominal pain in an adolescent girl. Consultant. 2022;62(11):e4. doi:10.25270/con.2021.12.00003

Received July 9, 2021. Accepted August 10, 2021. Published online December 16, 2021

DISCLOSURES:
The authors report no relevant financial relationships.

CORRESPONDENCE:
Nicole D. Garcia Lacasse, MD, MPH, Cincinnati Children’s Hospital Medical Center, 3333 Burnet Avenue, Cincinnati, OH 45229 (garcia.ndv@gmail.com)

A previously healthy 14-year-old girl with no significant medical history presented to our pediatric emergency department (ED) with worsening right upper quadrant abdominal pain in the setting of generalized abdominal pain, which had been present for 1 month.

She described the pain as sharp and intermittent, without radiation. She reported some bloating and noted that her school uniform no longer fit well. She denied any associations with time of day, food, or activity but reported that the pain was exacerbated when she laid on her back. She denied nausea, vomiting, diarrhea, dysuria, urinary frequency, or vaginal symptoms.

She had been previously treated for constipation in the remote past but is now passing stool regularly, with one soft, nonbloody stool daily. Menstruation started at age 9 years and is irregular, with last menses noted approximately 1 month prior to presentation. She denied any sexual activity.

She had been evaluated at an outside hospital for similar symptoms 2 weeks prior to presentation at our ED. At that time, she had had negative pregnancy test results and negative urinalysis results.

Physical examination. Upon initial examination in the ED, she was well-appearing and in no acute distress. Her vital signs were notable for a slightly elevated blood pressure of 125/76 mm Hg. Her temperature, pulse, and oxygen saturation were within normal limits. Examination findings were significant for a full, distended abdomen without rebound tenderness or voluntary guarding. Bowel sounds were normal. The remainder of her physical examination was normal.

A urine pregnancy test conducted at our visit returned negative results. Results of initial abdominal radiography is unrevealing.

As the patient’s abdomen felt gravid despite negative urine pregnancy test results, the abdominal radiograph was reexamined and suggested decreased bowel gas in the lower abdomen. A bedside ultrasonography scan was conducted for further evaluation, which showed a large area of fluid of mixed echogenicity in the lower abdomen.

In consultation with a radiologist, the decreased bowel gas seen on a plain film radiograph (Figure 1) and bedside ultrasonography findings raised sufficient suspicion to warrant dedicated sonographic evaluation of the pelvis (Figure 2.)

Answer and discussion on next page.