Tricky Case of Pediatric Abdominal Pain..

12yo F with no significant PMH presenting with LLQ abdominal pain that began this morning. She states it is intermittent, radiates to her back, lasts an hour and worsens when she lays down. Denies fever, nausea, vomiting, dysuria, hematuria, vaginal bleeding/discharge/itching, bloody stool, or diarrhea. Last BM was 3 days ago. Menses started December 2017; occur monthly, and last 7 days. LMP was about two weeks ago. Upreg negative. Denies prior history of sexual intercourse.

ROS:

Constitutional: No weakness or fever, +chills.

Eyes/ENT: No throat pain, rhinorrhea, or otalgia.

Resp: No SOB.

Cardio: No CP.

GI: +LLQ abdominal pain. No nausea, vomiting, diarrhea, or constipation. No hematemesis. No melena or hematochezia.

GU: No dysuria, frequency, hematuria, or vaginal bleeding/discharge.

Skin: No itching or rash.

 

Vitals: T: 99.5F  BP: 118/72 HR: 125  RR: 18  SpO2: 98%

 PE

Constitutional: NAD, well appearing.

Pulm: CTAB, no wheezes/crackles/rhonchi.

CV: Tachycardic, normal S1 and S2, no m/r/g.

GI: +TTP on LLQ, BS +, soft, nondistended, no guarding/rebound.

Back: No CVA TTP bilaterally.

Neuro: A&Ox3, moving all extremities.

Questions:

1.     What US exams would you perform for this patient, and what are you concerned about/looking for? Which probe(s) and mode would you use?

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2.     Can you identify the structures in the above images?

3.     What abnormal findings, if any, can you visualize and what would be your management?

4.     What are the sequelae of this pathology if not treated?

 

Answers:

1.    FAST exam and transabdominal pelvic exam to evaluate for any free fluid, presence of normal anatomy, flow to ovaries to r/o and look for possible ovarian torsion, TOA, etc. Use the curvilinear probe in both B mode during FAST exam and color flow when looking at ovaries.

2.    A- ovarian cyst, B- bladder, C- left ovary

3.    Large left ovarian cyst. You should be concerned for an ovarian torsion with a cyst that is this size and attempt to evaluate for flow to the left ovary. Management would include prompt OBGYN consult and prepping patient for surgery.

4.    If ovarian torsion goes untreated, this can result in necrosis to the ovary secondary to loss of blood flow.