11 yo girl with abdominal pain

11 yo girl with abdominal pain

The history: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

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

The pain: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

Intermittent stabbing lower abdominal pain - no aggravating factors

- no relieving factors- occasional nausea with pain- food intake, BMs unchanged- no weight loss

- occasional dysuria

“Tell me what happens.”“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.’

‘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.’

Examination:Examination: T 36.5 HR 95 RR20 Sat 100% GCS15

Shy but smiling and engaging young girl. H&N - no adenopathyChest clear, equal bilateral air entryHeart sounds normal, no murmurAbdomen 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.

T 36.5 HR 95 RR20 Sat 100% GCS15Shy but smiling and engaging young girl. H&N - no adenopathyChest clear, equal bilateral air entryHeart sounds normal, no murmurAbdomen 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.

Any work up so far?Any work up so far?

Family doc has ordered an ultrasound for later this month.

Family doc has ordered an ultrasound for later this month.

Why did you come today?Why did you come today?

‘The pain is progressively worsening.”

‘The pain is progressively worsening.”

What do you think about this?

What would you do?

What do you think about this?

What would you do?

What do you think about this?

What would you do?

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

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

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

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

....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.

....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.

Neat!Neat!

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

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

48 hours later.....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.”

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.”

It looks like this:It looks like this:

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

!

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

!

Urachal anomalies:Urachal anomalies:Completely patent: persistent wet,

draining umbilicus....occ’ll UTIsCompletely patent: persistent wet,

draining umbilicus....occ’ll UTIs

Urachal anomalies:Urachal anomalies:Completely patent: persistent wet,

draining umbilicus....occ’ll UTIsPersistent tissue, no connnection

to bladder: umbilical polyp.

Completely patent: persistent wet, draining umbilicus....occ’ll UTIs

Persistent tissue, no connnection to bladder: umbilical polyp.

Urachal anomalies:Urachal anomalies:Completely patent: persistent wet,

draining umbilicus....occ’ll UTIsPersistent tissue, no connnection

to bladder: umbilical polyp.Persistent tissue at bladder only:

bladder diverticulum can cause ureteral obstruction at site of insertion.

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.

Urachal anomalies:Urachal anomalies:Completely patent: persistent wet,

draining umbilicus....occ’ll UTIsPersistent 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

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

Primary amenorrheaPrimary amenorrheaDefinition: 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%

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%

So....where could we have done things differently?

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.

Question the U/S interpretation?Lack of umbilical discharge or

lack of umbilical polyp doesn’t rule out a urachal cyst or bladder diverticulum.

So....where could we have done things differently?

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?

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?

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

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

Take home points:Take home points:

1. In pre/peripubertal females with lower abdominal pain and no menses consider a imperforate hymen and inspect their perineum.

2. Presented with an unusual/unexpected ultrasonic diagnosis - consider doing a confirmatory test.

1. In pre/peripubertal females with lower abdominal pain and no menses consider a imperforate hymen and inspect their perineum.

2. Presented with an unusual/unexpected ultrasonic diagnosis - consider doing a confirmatory test.