Module 604 PaediatricsCase study:

Adolescent with abdominal pain

Mazin Eragat

Aims

• Review case presentation

• Clinical work through

• Discuss what we do know

• What else is there to know?

• Emergency differentials

• Questions

Overview of child & parent / carer

• 15 yo (F), attended with mother (‘Mary’)• Pc/ Abdominal pain and nausea• HPc/

– 14/7 Hx of abdo pain & N&V (*haematemesis)– Rapid onset, colicky/deep?, alleviated by rest, starts during /

after school, 6/10 severity (currently 1/10)– Recent UTI treated with 3 day course 200 mg BD Trimethoprim

(completed course)– No longer has urinary Sx of; increased frequency or dysuria

• PMHx/ None, Dx/ None, NKDA• SHx/ Lives at home with Mum & Dad, also has 4 sisters

– No alcohol intake, no smoking intake

• GHx - ?Previous incisions or abdominal surgeries (none)

Key points from history

• Vomiting – volume, hungry, forceful (projectile) or effortless (regurgitation); keeping down solids / liquids?

• Contains? – coffee grounds, bile-stained, fresh blood, ect

• Painful abdomen – constipation, diarrhoea, bloating, normal bowel motions? Blood (fresh / old)

• Urinary symptoms – have they resolved?• FHx of anything?

Overview of assessment and examination

• Observations: Pulse 95, BP 103/63, RR 14, Sats 98%, GCS 15, T 36.2 – not worried (tachy?)

• OE/ HEENT normal, *LN, A&O, pain low at rest, PEARL, low BMI, CRT <2s centrally, pale and cold peripheries

• CVS / Resp – all normal• GI/ Soft abdomen, mild

flinching on palpation (left adnexae and central), no uterus palpated and *organomegaly, BS heard

Abdominal pain DDx?

•

*peritonitis*rebound tenderness *involuntary guarding *abdo wall rigidity*uterus palpated

Assessing a teenager

Tanner Staging Female

• Thelarche– I. None– II. Breast bud– III. Further enlargement of areola and

breasts with no separation of contours– IV. 2. mound of areola and papilla– V. Areola recessed to general contour

of breast – adult

• Pubarche– I. None– II. Downy hair along labia only– III. Darker/coarse hair extends over

pubis– IV. Adult type covers smaller area, no

thigh involvement– V. Adult hair in quantity and type.

Extends over thighs

• Thelarche: breast development• Pubarche: pubic and axillary hair

development• Menarche: onset of menses, usually

following peak height velocity and/or 2 yr following breast budding

Anything else?

• Sisters: one of them got pregnant at 16 and went 'off the rails' and she is concerned she will end up the same

• Took a pregnancy test last week as was asked to by boyfriend of 5 months duration (also 15 years old?), because she missed period of two weeks duration

• Her test was positive, yet both daughter and mother did not believe it could be true as daughter states ‘I have never done anything’, mother thinks the UTI was to blame..

• Questions: Intermenstrual bleeding, postcoitalbleeding.. When asked described a ‘smelly discharge’

Interventions

• Investigations/ PDT – positive

• Urine Dipstix – NAD

• Separate discussion with mother/ Her thoughts, concerns, expectations..

• Why did she come to A&E?..

Ideally

• Pelvic U/S: visualize intrauterine preg to r/o ectopic; if preg., intrauterine not seen, &

– bHCG > discrim. zone → concern for ectopic;

– if bHCG < discrim. zone → follow bHCG;

• Placental position to r/o placenta praevia and likely severe abruption

• Ectopic pregnancy is life-threatening diagnosis, ∴ must rule out if Pt pregnant

B-hCG

+ve in serum 9 d post-conception+ve in urine 28 d after first day LMPPlasma levels double every 1-2 d, peak 8-10 wk, fall to plateau until delivery

Levels less than expected by dates suggest:• Ectopic pregnancy• Abortion• Inaccurate datesLevels higher than expected suggest:• Multiple gestation• Molar pregnancy• Trisomy 21• Inaccurate dates

Outcomes & Plan

• Plan/ Discharge and discuss positive test result with mum and daughter, implications…

• Also engage social services & safeguarding so they are aware of this case, also let her know about GP planning so they can do a staging scan and determine things about the pregnancy, like how far along it is (Mother: asked whether it is too late to abort it (if it should come to that)..)

• GP referral – appointment for follow up on smelly discharge – STI?

Considerations

• Safeguarding

• Contraception use

• Obs & gynae emergencies

• Schooling

• Bullying

Contraceptive methods

• Condoms

• Long-acting reversible contraception (LARC)

• Combined hormonal contraception

• Progestogen-only pill

• ‘Morning after pill’

Acute abdo in pregnancy DDx

RUPTURED ECTOPIC PREGNANCY

• Suspect this in women with syncope and abdominal pain or gynecological symptoms

• 1* cause maternal mortality 1st trimester• Do a pregnancy test• Immediate major surgery• Take patient to OT before anaesthesia, as the loss of

sympathetic tone after the onset of anaesthesia can cause catastrophic hypotension in a hypovolaemic patient (In extreme cases, it may be necessary to operate in the ED)

• 1-30,000 1-3,000 with PID…• It is important to note that rare cases of ruptured ectopic

pregnancies with negative pregnancy tests have been reported

Diagnostic tests

• Urine pregnancy test = +ve• High resolution transvaginal ultrasound (TVUS) – no

intrauterine pregnancy detected, ectopic visualised occasionally

• Transabdominal ultrasound – no intrauterine pregnancy detected

• Serial serum hCG - <53% increase in level over 48 hours or plateau of level

• Serum progesterone – rules out if 1) <15.9nmol/L, or 2) >63.6 nmol/L

• Diagnostic laparoscopy• Dilation and curettage (D&C)

Fig. 1. Possible anatomic sites in ectopic pregnancies.

Reflection / consideration of alternative actions etc

• Medical:

• Psychosocial aspects?– Breaking bad news.. To a child

• Mothers view

• Termination / Continuation of pregnancy?

• How to take history from daughter without mother

• Importance of collateral history?

Guidance

• The 'Changing childbirth' report (Department of Health 1993) and 'Maternity matters' (Department of Health 2007) explicitly confirmed that women should be the focus of maternity care, with an emphasis on providing choice, easy access and continuity of care.

• Care during pregnancy should enable a woman to make informed decisions, based on her needs, having discussed matters fully with the healthcare professionals involved.

References

• Burns, E., Korn, K. and Whyte, J. (2011) Oxford American Handbook of Clinical Examination and Practical Skills. New York: Oxford University Press. Practice, 4

• Simon, C., et al (2014) Oxford Handbook of General Practice 5th edition. UK: Oxford University Press

• Young, A., Vojvodic, M. (2014) Toronto Notes for Medical Students, 30th Edition. Toronto: Canada

• Public Health England (2013) Teenage Pregnancy Resources. Available at: http://www.apho.org.uk/resource/view.aspx?RID=116351 (Accessed: 7 May 2015).

• Seeber, B., Barnhart, K. (2006) Suspected Ectopic Pregnancy. Obstet Gynecol2006;107:399-413 (Accessed: 10 May 2015)

• https://www.nice.org.uk/guidance/cg154/ifp/chapter/Treatment-for-ectopic-pregnancy

• http://www.nice.org.uk/guidance/cg62/chapter/Aim• http://www.ahcmedia.com/articles/20867-vaginal-bleeding-in-pregnancy-part-i