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Pediatric Abdominal Pain
The Journal of Emergency Medicine, Vol. 36, No. 1, pp. 72–75, 2009 Copyright © 2009 Elsevier Inc. Printed in the USA. All rights reserved 0736-4679/09 $–see front matter
Case Presentations of the Harvard Affiliated Emergency Medicine Residencies
PEDIATRIC ABDOMINAL PAIN Emily L. Brown,
MD,*
David F. M. Brown,
MD,*†
and Eric S. Nadel,
MD*†‡
*Division of Emergency Medicine, Harvard Medical School, Boston, Massachusetts, †Department of Emergency Medicine, Massachusetts General Hospital, Boston, Massachusetts, and ‡Department of Emergency Medicine, Brigham and Women’s Hospital, Boston, Massachusetts Reprint Address: Eric S. Nadel, MD, Department of Emergency Medicine, Brigham and Women’s Hospital, 75 Francis Street, Boston, MA 02115
such as perforated viscous or diabetic ketoacidosis, likely would have been progressively worse, and not episodic. Likewise, certain infectious etiologies likely would be progressive as well, such as appendicitis or pyelonephritis, although it was possible that a ruptured and walledoff appendicitis might present in this way. Disease processes that often present with intermittent abdominal symptoms include an incarcerated hernia that intermittently reduced, a kidney stone, or ovarian torsion. Another interesting aspect of the history was the difficulty urinating and the increased abdominal girth, suggesting a possible obstruction or mass effect. Dr. Eric Nadel: Can you describe the physical examination? This will be important to further narrow the differential. Dr. E. Brown: Upon the patient’s presentation to the ED, the temperature was 38.2°C, blood pressure 110/70 mm Hg, pulse 108 beats/min, and respiratory rate 16 breaths/min. The patient appeared mildly uncomfortable due to abdominal pain but was otherwise alert and appropriate, answering questions and talking with her parents. Examination of the head and neck was normal. The eye examination was normal. The mucous membranes were mildly dry but otherwise the oropharynx was clear. The neck was supple without lymphadenopathy or meningismus. The cardiac examination demonstrated a regular rate and rhythm without murmurs, rubs, or gallops, and the lungs were clear bilaterally. The abdomen was distended, greatest in the right lower quadrant, and was tender to palpation in bilateral lower quadrants, but without rebound or peritoneal signs. There was a footballshaped fixed mass in the right lower quadrant and midlower abdomen spanning approx 10 cm. Bowel sounds were present. Right-sided costovertebral angle (CVA)
Dr. Emily Brown: Today’s case is that of a 10-year-old premenarchal girl, accompanied by her parents, who presented to the Emergency Department (ED) with a chief complaint of intermittent abdominal pain for the past 7 days. The pain was primarily located in the lower abdomen. There was no increase in the pain after ingestion of food. The patient also complained of nausea and non-bilious and non-bloody vomiting, approximately twice per day. The patient’s parents reported that the symptoms developed suddenly 7 days ago, persisted for 2 days, then spontaneously remitted. She was asymptomatic for the following 2 days and was able to resume normal summertime activities. However, 2 days before presentation, the abdominal pain recurred and has persisted since that time. Although the patient denied dysuria, she reported difficulty urinating over the past week. She stated “I feel like I really have to push to get it out.” The patient described bloating and said that her pants had not been fitting well over the past week. The patient denied fevers, chills, sick contacts, or recent travel. She denied melena, diarrhea, or constipation. The last bowel movement was the day before presentation and was normal. The past medical history was unremarkable and immunizations were up to date. The patient was not taking any medications and had no known drug allergies. She lives with her parents and younger brother in the suburbs of Boston and is active in summer sports. Dr. David Peak: The differential diagnosis of abdominal pain in a female can be broad. How did you use the initial history to narrow your differential? Dr. E. Brown: The most important factor in narrowing the differential was the intermittent nature of her symptoms. Several life-threatening disease processes, 72
Abdominal Pain
tenderness was present. The extremities were well perfused and there were no rashes or lesions. The neurological examination was normal. Dr. Kriti Bhatia: Based on the initial presentation, what were your thoughts regarding differential diagnosis and further diagnostic evaluation? Dr. E. Brown: Urinalysis and urine pregnancy test were negative. Complete blood count and chemistries also were normal. The physical examination findings and the results of this initial testing allowed us to narrow the differential to a few disease processes: ovarian torsion, incarcerated hernia, malignancy, and endometriosis. Furthermore, the finding of CVA tenderness on the right suggested compression of the right ureter with possible hydronephrosis. Of these conditions, we felt that ovarian torsion was the most emergent diagnosis to make, both due to the morbidity associated with torsion (infertility, necrosis, infection) and due to the time-sensitive nature of the disease. Dr. Jeffrey Siegelman: What do you mean by “timesensitive nature of the disease?” Dr. E. Brown: In both human and animal studies, there are data to suggest that time to diagnosis and definitive treatment impacts ovarian salvage. Traditionally, it was thought that salvage was unlikely after 8 h of symptoms. This teaching was supported by a 2001 review of 51 pediatric patients (16 years and younger), which concluded that most ovarian torsion was caused by ovarian pathologic features and that salvage was unlikely after 8 h of abdominal pain. In this study, the mean duration of symptoms was 44 h, with the majority (76%) of the children presenting 1 to 2 days after the onset of symptoms; no ovaries were salvaged in this series, and all 51 patients underwent salpingo-oophorectomy (1). Adolescent women were included in the largest case series of women (aged 14-82 years) with ovarian torsion (2). In this 2001 adult case series, 9% of ovaries were salvaged; the authors concluded that the diagnosis is difficult and salvage of the ovary rare. Animal studies have also supported this belief; in a study of 140 rats, a shorter time to reperfusion (4 –24 h) demonstrated ⬎ 70% ovarian viability, whereas delayed reperfusion (36 h) uniformly resulted in adnexal necrosis (3). However, more recent data suggest that the window for ovarian viability may be longer than we originally thought. A 2005 review of 22 pediatric cases of ovarian torsion demonstrated a 27% salvage rate, despite a mean time of symptoms before care of 76 h (4). Interestingly, there was not a significant association between duration of symptoms and ovarian necrosis, although a trend was observed between time from initial presentation to operation and likelihood of salvage. In practice, these data encourage the emergency physician (EP) to be
73
vigilant about ovarian torsion, to treat it expeditiously, and not to give up hope even if the patient has been symptomatic for several days. Dr. David Brown: At this point you are most worried about ovarian torsion, and would like to diagnose it as quickly as possible even though the patient’s symptoms had been present for approximately 1 week. In light of this, what is the imaging modality of choice? Dr. E. Brown: The choice is between ultrasound and computed tomography (CT); we chose to perform an ultrasound for a number of reasons. First, ultrasound is the preferred imaging modality to look at pelvic pathology. In a recent review of the management of adnexal masses by the Agency for Healthcare Research and Quality, ultrasound with Doppler had similar pooled sensitivity and specificity of 0.86 and 0.91, respectively, when compared to magnetic resonance imaging (MRI) (0.91 and 0.88, respectively) and CT scan (0.90 and 0.75, respectively), while conferring less expense to the health care system, and less radiation to the patient (5). Dr. Nadel: What were the results of her ultrasound examination? Dr. E. Brown: The ultrasound demonstrated a large echogenic mass consistent with ovarian torsion. It contained multiple small cysts and had the following approximate dimensions: 4.7 ⫻ 6.4 ⫻ 9.4 cm (Figure 1). Doppler was performed and no flow was appreciated (Figure 2). Of note, the ultrasonographer was unable to see a normal ovary on either side, but surmised that the torsed ovary was on the right side. Dr. Aaron Skolnik: Can you please describe the ultrasonographic features of ovarian torsion?
Figure 1. Ultrasound: sagittal view through a partially full bladder demonstrating a large, echogenic mass with the following dimensions: Superior–Inferior 4.7 ⴛ Transverse 6.4 ⴛ Anterior–Posterior 9.4 cm. The mass contains multiple small cysts and deviates the uterus inferiorly. A normal ovary is not visualized on either side.
74
Figure 2. Ultrasound: transverse view of the mass, with Doppler. Note the lack of Doppler flow through the mass.
Dr. E. Brown: The classic sign of ovarian torsion is ovarian enlargement with several peripheral immature follicles and no flow on Doppler. However, although lack of flow on Doppler in torsion can have prognostic value for the viability of the ovary, it is neither sensitive nor specific for torsion. For example, there can be intermittent flow in true torsion and there may be decreased flow in other types of adnexal masses. Dr. Zoe Howard: Is there a role for bedside ultrasonography by the emergency physician in diagnosis of ovarian torsion? Dr. E. Brown: Traditionally, the diagnostic imaging study is an ultrasound performed by a radiologist. As EPs become more proficient with bedside ultrasound, an EP-directed ultrasound may be enough to get the patient to the operating room (OR) in an expedient fashion, especially if hemodynamically unstable (6). Current standard of care remains ultrasonography performed by a radiologist.
E. L. Brown et al.
Dr. Nadel: Can you please discuss ovarian pathology and ovarian torsion in the pediatric population? E. Brown: Premenarchal ovarian torsion is relatively rare in the pediatric population, because a large percentage of torsion occurs in the setting of ovarian cysts, which are rare in this population. However, children may present with ovarian torsion secondary to neoplasm or secondary to the presence of an elongated utero-ovarian ligament with a normal ovary, allowing more movement of the ovary within the pelvis (7). In a retrospective chart review of 87 women of ages ranging from 14 to 82 years (mean ⫽ 32 years) with torsion, the most common symptoms were nausea and vomiting (70%) and sharp abdominal pain (70%), the majority of which was of sudden onset (59%). Of note, peritoneal signs (3%) and fever (2%) were rare, late signs, and could signify necrosis of the ovary. On examination, the presence of an adnexal mass was present in approximately half of the patients (2). As discussed above, although imaging with ultrasound and, less commonly, CT or MRI can be helpful, ovarian torsion is ultimately a surgical diagnosis; therefore, clinical suspicion is paramount. Moreover, management options are restricted to operative modalities (detorsion and salvage vs. salpingo-oophorectomy), which further emphasizes the importance of pre-operative clinical suspicion to obtain both definitive diagnosis and therapy for the patient. Dr. Helen Ouyang: What was the outcome of the case? Dr. E. Brown: Gynecology was consulted and the patient went to the OR within an hour for laparoscopy. In the OR, laparoscopy revealed a 6.0 ⫻ 5.4 ⫻ 3.0 cm necrotic ovary on the right and ovarian torsion of the left ovary as well. The left ovary was salvaged and the omentum tacked onto the abdominal wall to prevent retorsion. Interestingly, the operative report described a shared blood supply between the omentum and the left ovary, suggesting a more chronic picture. Looking back at the ultrasound report, the 4.7 ⫻ 6.4 ⫻ 9.4 cm (Anterior–Posterior) mass likely represented both torsed ovaries together. The patient did well post-operatively and was discharged on post-operative day 2. She has followed-up in clinic and remains asymptomatic 8 months after the operation. Due to the questionable viability of the remaining ovary, she is scheduled for evaluation by a pediatric endocrinologist to evaluate whether hormone replacement therapy is necessary.
REFERENCES 1. Kokoska ER, Keller MS, Weber TR. Acute ovarian torsion in children. Am J Surg 2000;180:462–5.
Abdominal Pain 2. Houry D, Abbott JT. Ovarian torsion: a fifteen-year review. Ann Emerg Med 2001;38:156 –9. 3. Taskin O, Birincioglu M, Aydin A, et al. The effects of twisted ischaemic adnexa managed by detorsion on ovarian viability and histology: an ischaemia-reperfusion rodent model. Hum Reprod 1998;13:2823–7. 4. Anders JF, Powell ED. Urgency of evaluation and outcome of acute ovarian torsion in pediatric patients. Arch Pediatr Adolesc Med 2005;159:532–5.
75 5. Myers ER, Bastian LA, Havrilesky LJ, et al. Management of adnexal mass. Evid Rep Technol Assess (Full Rep) 2006;(130): 1–145. 6. Johnson S, Fox J, Koenig K. Diagnosis of ovarian torsion in a hemodynamically unstable pediatric patient by bedside ultrasound in the ED. Am J Emerg Med 2006;24:496 –7. 7. Varras M, Tsikini A, Polyzos D, Samara C, Hadjopoulos G, Akrivis C. Uterine adnexal torsion: pathologic and gray-scale ultrasonographic findings. Clin Exp Obstet Gynecol 2004;31:34 – 8.
Case Presentations of the Harvard Affiliated Emergency Medicine Residencies
PEDIATRIC ABDOMINAL PAIN Emily L. Brown,
MD,*
David F. M. Brown,
MD,*†
and Eric S. Nadel,
MD*†‡
*Division of Emergency Medicine, Harvard Medical School, Boston, Massachusetts, †Department of Emergency Medicine, Massachusetts General Hospital, Boston, Massachusetts, and ‡Department of Emergency Medicine, Brigham and Women’s Hospital, Boston, Massachusetts Reprint Address: Eric S. Nadel, MD, Department of Emergency Medicine, Brigham and Women’s Hospital, 75 Francis Street, Boston, MA 02115
such as perforated viscous or diabetic ketoacidosis, likely would have been progressively worse, and not episodic. Likewise, certain infectious etiologies likely would be progressive as well, such as appendicitis or pyelonephritis, although it was possible that a ruptured and walledoff appendicitis might present in this way. Disease processes that often present with intermittent abdominal symptoms include an incarcerated hernia that intermittently reduced, a kidney stone, or ovarian torsion. Another interesting aspect of the history was the difficulty urinating and the increased abdominal girth, suggesting a possible obstruction or mass effect. Dr. Eric Nadel: Can you describe the physical examination? This will be important to further narrow the differential. Dr. E. Brown: Upon the patient’s presentation to the ED, the temperature was 38.2°C, blood pressure 110/70 mm Hg, pulse 108 beats/min, and respiratory rate 16 breaths/min. The patient appeared mildly uncomfortable due to abdominal pain but was otherwise alert and appropriate, answering questions and talking with her parents. Examination of the head and neck was normal. The eye examination was normal. The mucous membranes were mildly dry but otherwise the oropharynx was clear. The neck was supple without lymphadenopathy or meningismus. The cardiac examination demonstrated a regular rate and rhythm without murmurs, rubs, or gallops, and the lungs were clear bilaterally. The abdomen was distended, greatest in the right lower quadrant, and was tender to palpation in bilateral lower quadrants, but without rebound or peritoneal signs. There was a footballshaped fixed mass in the right lower quadrant and midlower abdomen spanning approx 10 cm. Bowel sounds were present. Right-sided costovertebral angle (CVA)
Dr. Emily Brown: Today’s case is that of a 10-year-old premenarchal girl, accompanied by her parents, who presented to the Emergency Department (ED) with a chief complaint of intermittent abdominal pain for the past 7 days. The pain was primarily located in the lower abdomen. There was no increase in the pain after ingestion of food. The patient also complained of nausea and non-bilious and non-bloody vomiting, approximately twice per day. The patient’s parents reported that the symptoms developed suddenly 7 days ago, persisted for 2 days, then spontaneously remitted. She was asymptomatic for the following 2 days and was able to resume normal summertime activities. However, 2 days before presentation, the abdominal pain recurred and has persisted since that time. Although the patient denied dysuria, she reported difficulty urinating over the past week. She stated “I feel like I really have to push to get it out.” The patient described bloating and said that her pants had not been fitting well over the past week. The patient denied fevers, chills, sick contacts, or recent travel. She denied melena, diarrhea, or constipation. The last bowel movement was the day before presentation and was normal. The past medical history was unremarkable and immunizations were up to date. The patient was not taking any medications and had no known drug allergies. She lives with her parents and younger brother in the suburbs of Boston and is active in summer sports. Dr. David Peak: The differential diagnosis of abdominal pain in a female can be broad. How did you use the initial history to narrow your differential? Dr. E. Brown: The most important factor in narrowing the differential was the intermittent nature of her symptoms. Several life-threatening disease processes, 72
Abdominal Pain
tenderness was present. The extremities were well perfused and there were no rashes or lesions. The neurological examination was normal. Dr. Kriti Bhatia: Based on the initial presentation, what were your thoughts regarding differential diagnosis and further diagnostic evaluation? Dr. E. Brown: Urinalysis and urine pregnancy test were negative. Complete blood count and chemistries also were normal. The physical examination findings and the results of this initial testing allowed us to narrow the differential to a few disease processes: ovarian torsion, incarcerated hernia, malignancy, and endometriosis. Furthermore, the finding of CVA tenderness on the right suggested compression of the right ureter with possible hydronephrosis. Of these conditions, we felt that ovarian torsion was the most emergent diagnosis to make, both due to the morbidity associated with torsion (infertility, necrosis, infection) and due to the time-sensitive nature of the disease. Dr. Jeffrey Siegelman: What do you mean by “timesensitive nature of the disease?” Dr. E. Brown: In both human and animal studies, there are data to suggest that time to diagnosis and definitive treatment impacts ovarian salvage. Traditionally, it was thought that salvage was unlikely after 8 h of symptoms. This teaching was supported by a 2001 review of 51 pediatric patients (16 years and younger), which concluded that most ovarian torsion was caused by ovarian pathologic features and that salvage was unlikely after 8 h of abdominal pain. In this study, the mean duration of symptoms was 44 h, with the majority (76%) of the children presenting 1 to 2 days after the onset of symptoms; no ovaries were salvaged in this series, and all 51 patients underwent salpingo-oophorectomy (1). Adolescent women were included in the largest case series of women (aged 14-82 years) with ovarian torsion (2). In this 2001 adult case series, 9% of ovaries were salvaged; the authors concluded that the diagnosis is difficult and salvage of the ovary rare. Animal studies have also supported this belief; in a study of 140 rats, a shorter time to reperfusion (4 –24 h) demonstrated ⬎ 70% ovarian viability, whereas delayed reperfusion (36 h) uniformly resulted in adnexal necrosis (3). However, more recent data suggest that the window for ovarian viability may be longer than we originally thought. A 2005 review of 22 pediatric cases of ovarian torsion demonstrated a 27% salvage rate, despite a mean time of symptoms before care of 76 h (4). Interestingly, there was not a significant association between duration of symptoms and ovarian necrosis, although a trend was observed between time from initial presentation to operation and likelihood of salvage. In practice, these data encourage the emergency physician (EP) to be
73
vigilant about ovarian torsion, to treat it expeditiously, and not to give up hope even if the patient has been symptomatic for several days. Dr. David Brown: At this point you are most worried about ovarian torsion, and would like to diagnose it as quickly as possible even though the patient’s symptoms had been present for approximately 1 week. In light of this, what is the imaging modality of choice? Dr. E. Brown: The choice is between ultrasound and computed tomography (CT); we chose to perform an ultrasound for a number of reasons. First, ultrasound is the preferred imaging modality to look at pelvic pathology. In a recent review of the management of adnexal masses by the Agency for Healthcare Research and Quality, ultrasound with Doppler had similar pooled sensitivity and specificity of 0.86 and 0.91, respectively, when compared to magnetic resonance imaging (MRI) (0.91 and 0.88, respectively) and CT scan (0.90 and 0.75, respectively), while conferring less expense to the health care system, and less radiation to the patient (5). Dr. Nadel: What were the results of her ultrasound examination? Dr. E. Brown: The ultrasound demonstrated a large echogenic mass consistent with ovarian torsion. It contained multiple small cysts and had the following approximate dimensions: 4.7 ⫻ 6.4 ⫻ 9.4 cm (Figure 1). Doppler was performed and no flow was appreciated (Figure 2). Of note, the ultrasonographer was unable to see a normal ovary on either side, but surmised that the torsed ovary was on the right side. Dr. Aaron Skolnik: Can you please describe the ultrasonographic features of ovarian torsion?
Figure 1. Ultrasound: sagittal view through a partially full bladder demonstrating a large, echogenic mass with the following dimensions: Superior–Inferior 4.7 ⴛ Transverse 6.4 ⴛ Anterior–Posterior 9.4 cm. The mass contains multiple small cysts and deviates the uterus inferiorly. A normal ovary is not visualized on either side.
74
Figure 2. Ultrasound: transverse view of the mass, with Doppler. Note the lack of Doppler flow through the mass.
Dr. E. Brown: The classic sign of ovarian torsion is ovarian enlargement with several peripheral immature follicles and no flow on Doppler. However, although lack of flow on Doppler in torsion can have prognostic value for the viability of the ovary, it is neither sensitive nor specific for torsion. For example, there can be intermittent flow in true torsion and there may be decreased flow in other types of adnexal masses. Dr. Zoe Howard: Is there a role for bedside ultrasonography by the emergency physician in diagnosis of ovarian torsion? Dr. E. Brown: Traditionally, the diagnostic imaging study is an ultrasound performed by a radiologist. As EPs become more proficient with bedside ultrasound, an EP-directed ultrasound may be enough to get the patient to the operating room (OR) in an expedient fashion, especially if hemodynamically unstable (6). Current standard of care remains ultrasonography performed by a radiologist.
E. L. Brown et al.
Dr. Nadel: Can you please discuss ovarian pathology and ovarian torsion in the pediatric population? E. Brown: Premenarchal ovarian torsion is relatively rare in the pediatric population, because a large percentage of torsion occurs in the setting of ovarian cysts, which are rare in this population. However, children may present with ovarian torsion secondary to neoplasm or secondary to the presence of an elongated utero-ovarian ligament with a normal ovary, allowing more movement of the ovary within the pelvis (7). In a retrospective chart review of 87 women of ages ranging from 14 to 82 years (mean ⫽ 32 years) with torsion, the most common symptoms were nausea and vomiting (70%) and sharp abdominal pain (70%), the majority of which was of sudden onset (59%). Of note, peritoneal signs (3%) and fever (2%) were rare, late signs, and could signify necrosis of the ovary. On examination, the presence of an adnexal mass was present in approximately half of the patients (2). As discussed above, although imaging with ultrasound and, less commonly, CT or MRI can be helpful, ovarian torsion is ultimately a surgical diagnosis; therefore, clinical suspicion is paramount. Moreover, management options are restricted to operative modalities (detorsion and salvage vs. salpingo-oophorectomy), which further emphasizes the importance of pre-operative clinical suspicion to obtain both definitive diagnosis and therapy for the patient. Dr. Helen Ouyang: What was the outcome of the case? Dr. E. Brown: Gynecology was consulted and the patient went to the OR within an hour for laparoscopy. In the OR, laparoscopy revealed a 6.0 ⫻ 5.4 ⫻ 3.0 cm necrotic ovary on the right and ovarian torsion of the left ovary as well. The left ovary was salvaged and the omentum tacked onto the abdominal wall to prevent retorsion. Interestingly, the operative report described a shared blood supply between the omentum and the left ovary, suggesting a more chronic picture. Looking back at the ultrasound report, the 4.7 ⫻ 6.4 ⫻ 9.4 cm (Anterior–Posterior) mass likely represented both torsed ovaries together. The patient did well post-operatively and was discharged on post-operative day 2. She has followed-up in clinic and remains asymptomatic 8 months after the operation. Due to the questionable viability of the remaining ovary, she is scheduled for evaluation by a pediatric endocrinologist to evaluate whether hormone replacement therapy is necessary.
REFERENCES 1. Kokoska ER, Keller MS, Weber TR. Acute ovarian torsion in children. Am J Surg 2000;180:462–5.
Abdominal Pain 2. Houry D, Abbott JT. Ovarian torsion: a fifteen-year review. Ann Emerg Med 2001;38:156 –9. 3. Taskin O, Birincioglu M, Aydin A, et al. The effects of twisted ischaemic adnexa managed by detorsion on ovarian viability and histology: an ischaemia-reperfusion rodent model. Hum Reprod 1998;13:2823–7. 4. Anders JF, Powell ED. Urgency of evaluation and outcome of acute ovarian torsion in pediatric patients. Arch Pediatr Adolesc Med 2005;159:532–5.
75 5. Myers ER, Bastian LA, Havrilesky LJ, et al. Management of adnexal mass. Evid Rep Technol Assess (Full Rep) 2006;(130): 1–145. 6. Johnson S, Fox J, Koenig K. Diagnosis of ovarian torsion in a hemodynamically unstable pediatric patient by bedside ultrasound in the ED. Am J Emerg Med 2006;24:496 –7. 7. Varras M, Tsikini A, Polyzos D, Samara C, Hadjopoulos G, Akrivis C. Uterine adnexal torsion: pathologic and gray-scale ultrasonographic findings. Clin Exp Obstet Gynecol 2004;31:34 – 8.