11 yo girl with abdominal pain

1. 11 yo girl with abdominal pain

2. The history: • 11 yo Persian girl presents with mother with 3 months of intermittant lower abdominal pain • PMHx: normal gestation and birth no hospitalizations. • FMHx: no IBD

3. The pain: • Intermittent stabbing lower abdominal pain - no aggravating factors - no relieving factors - occasional nausea with pain - food intake, BMs unchanged - no weight loss - occasional dysuria

4. “Tell me what happens.” ‘When I go to school in the morning my stomach hurts, and then it goes away. When I come after school it comes back and hurts for a while.’

5. Examination: • T 36.5 HR 95 RR20 Sat 100% GCS15 Shy but smiling and engaging young girl. H&N - no adenopathy Chest clear, equal bilateral air entry Heart sounds normal, no murmur Abdomen flat, thin, soft, normal BS, no masses, lower abdomen tender on palpation, no point tenderness Extremities normal, normal gait and movement Nice mother with a younger well behaved brother.

6. Any work up so far? • Family doc has ordered an ultrasound for later this month.

7. Why did you come today? ‘The pain is progressively worsening.”

8. What do you think about this?What would you do?

9. What do you think about this?What would you do? • We got a urinalysis. • Had her drink a liter of water. • ...and were able to get an ultrasound on a Sunday at 1600... ...that showed this

14. The radiologist’s interpretation was that this was a urachal cyst or diverticulum with a distended bladder.

15. ....so we talked to the pediatrician who agreed she needed the services of a peds urologist and didn’t think they had anything special to offer... She was able to void without difficulty and had no pain. They have a family doc. Given return advice and a copy of the u/s interpretation to give to the FD to initiate the referral.

16. Neat! A urachal cyst, when did you last see one of those? Something to go read about.

17. 48 hours later..... • She presents with her mother to another ER with recurrent pain AND a fever - 38.6 • She also has a white count of 15,000 • An EDUS looks just like the one 2 days ago.... • The pediatric urologist is called and says...”Hey, just do a CT....I need a CT to decide what to do.”

18. It looks like this:

42. The radiologist’s interpretation was that this was a distended, fluid filled uterus. !

43. Urachal anomalies: • Completely patent: persistent wet, draining umbilicus....occ’ll UTIs

44. Urachal anomalies: • Completely patent: persistent wet, draining umbilicus....occ’ll UTIs • Persistent tissue, no connnection to bladder: umbilical polyp.

45. Urachal anomalies: • Completely patent: persistent wet, draining umbilicus....occ’ll UTIs • Persistent tissue, no connnection to bladder: umbilical polyp. • Persistent tissue at bladder only: bladder diverticulum can cause ureteral obstruction at site of insertion.

46. Urachal anomalies: • Completely patent: persistent wet, draining umbilicus....occ’ll UTIs • Persistent tissue, no connnection to bladder: umbilical polyp. • Persistent tissue at bladder only: bladder diverticulum can cause ureteral obstruction at site of insertion. • Patent midduct: results in cyst. Abd mass in older children, may infect - pain, swelling, erythema infraumbilical

47. Primary amenorrhea • Definition: No menses by 15. Normal growth and secondary characteristics. • Etiologies - Chromosomal 50% Hypothalamic hypogonadism 20% Agenesis 15% Pituitary 5% Transverse vaginal septum or imperforate hymen 5%

48. So....where could we have done things differently? • Question the U/S interpretation? Lack of umbilical discharge or lack of umbilical polyp doesn’t rule out a urachal cyst or bladder diverticulum.

49. So....where could we have done things differently? Was our exam complete enough? Did she have sufficient secondary sexual characteristics that we should have pursued the possibility of occult menses? Would the examination of the perineum have disclosed a bulging hymen or unusual findings?

50. ...And so she went off to see the Gynaecologist at BCCH.....