Persistent Abdominal Pain

[Anonymous]

From Hawaii.edu

A nearly 8 year old female came to the ED with a
chief complaint of stomach aches for one week. These
pains would come and go and were best characterized
as crampy in nature with no particular location. She
also complained of back aches since her ballet
stretching exercises yesterday. There was no history of
fever, nausea, vomiting, diarrhea, or respiratory
symptoms. Her bowel movements were regular and
soft.
Exam: VS T36.8, P98, R24, BP 114/88. She was
alert, cooperative, and somewhat anxious. HEENT
exam was unremarkable. Neck supple without
adenopathy. Heart regular without murmurs. Lungs
clear. Abdomen was soft, flat, and non-tender. There
was no rebound. Bowel sounds were active. No
masses or hepatosplenomegaly were appreciated. A
rectal exam revealed no stool in the rectum and no
masses. She was observed to have more pain when
standing or when sitting up. There was no CVA
tenderness. Left flank pain and epigastric pain were
elicited on straight leg raising.
An abdominal series was obtained.

View radiographs.


This radiograph was initially read as showing
non-specific findings. Other laboratory results: CBC
WBC 2.9, 32 segs, 64 lymphs, 4 monos, Hgb 12.4, Hct
36.5, platelets adequate. Amylase 123, SGOT 24.
Her pain persisted, and review of her radiographs
revealed subtle compression fractures of the vertebral
bodies. Follow-up radiographs were obtained.

View follow-up radiographs.


This follow-up radiograph showed progressive
demineralization and multiple compression fractures of
the thoracic and lumbar vertebral bodies. This is not
obvious initially if your attention is directed at the
abdominal soft tissue. Upon close inspection, you can
appreciate multiple vertebral compression fractures of
her thoracic and lumbar vertebrae. Note that the
vertebral bodies appear to be flatter than normal. It is
remarkable that her clinical symptoms pointed to the
abdomen rather than her spine. Some hepatomegaly is
also noted on one of the views. These vertebral
fractures were felt to be most consistent with acute
leukemia. Bone marrow studies confirmed the
diagnosis of acute lymphocytic leukemia.
A lateral view of her lumbar spine makes these
fractures easier to appreciate. The vertebral bodies are
obviously flatter than they should be on this view.

View Lateral Lumbar Spine.


Teaching Points:
Abdominal radiographs are generally non-diagnostic
for the vast majority of cases. However, when they
reveal significant findings, they are often difficult to
appreciate. Abnormalities of the bony structures
include vertebral fractures, pelvic fractures, rib
fractures, congenital dislocated hips, other hip injuries,
etc. If one is not paying careful attention to the bony
structures, these findings can be easily overlooked,
although they may appear obvious once the
abnormalities are identified. Soft tissue findings include
fecaliths, intussusception, pneumoperitoneum, subtle
obstructions, volvulus, mass effects, etc.
Abdominal pain is a non-specific presentation for
many serious diagnoses, but abdominal pain is most
often the result of a benign cause. It is often
useful to observe the patient ambulating since this can
provide significant clues to the patient's severity.
Patients who cannot walk upright easily should be taken
more seriously than those who can ambulate normally.
Coughing and jumping are useful peritoneal signs for
children since this tends to distract them away from the
abdomen. When the patient is walking, ask the child to
jump and challenge them to jump higher if possible.
Then ask them if jumping hurt their tummy. Ask the
child to cough and then ask them if the cough hurt their
tummy. Negative findings on jumping and coughing
make the likelihood of peritoneal irritation extremely
remote.
In this case, if the examiners had observed the
patient ambulating, they may have noted some difficulty
since she did complain of pain with standing. If the
examiners asked her to jump, it is likely that she would
have complained of pain in her back, though in this
instance, such a maneuver may have worsened her
compression fractures. Hopefully, the patient would be
able to appreciate this and refuse to jump. It is difficult
to conceive that this patient with so many vertebral
compression fractures could tolerate ballet practice the
previous day and that she presented with such
non-specific findings. Often children can be
extraordinarily stoic despite being in substantial pain.
This can be deceiving for the examiners. A good
practice is to palpate all parts of the abdomen and all
parts of the back in patients with abdominal pain.