A 4-year-old girl presents to the emergency department (ED) with a 12-hour history of progressively worsening episodic left lower quadrant (LLQ) abdominal pain and nonbilious emesis. There was no history of fever, diarrhea, hematochezia, constipation, or dysuria. The child was previously healthy, did not take any medications, and had no history of prior surgery.
On initial presentation, the girl appeared mildly uncomfortable with a temperature of 98.6⁰F; heart rate of 102 beats/minute; respiratory rate of 18 breaths/minute; and pulse oximetry of 98% in room air. Her abdomen was soft with mild distention, and she had significant tenderness to palpation and voluntary guarding in the left lower quadrant. No masses or organomegaly were appreciated, and normal active bowel sounds were present. The remainder of her exam was unremarkable.
Labs and imaging
A complete blood count, basic metabolic panel, and clean catch urinalysis all were within normal limits, and fecal occult blood was negative. Abdominal radiograph revealed a lower midline, abdominal-pelvic soft tissue mass, with internal calcifications that looked like teeth (Figure 1). Bowel gas was present throughout, without obvious obstruction. Computed tomography (CT) of the abdomen and pelvis with contrast subsequently revealed a 7.0 x 6.2 x 5.4-cm unilocular, complex cystic mass within the left adnexa with internal calcifications (Figure 2).
Common things being common, the differential diagnosis in the ED included constipation, gastroenteritis, viral illness, and urinary tract infection. Due to the patient’s examination findings suggestive of an acute abdomen, intestinal obstruction (to include volvulus and intussusception) was also highly considered. After review of the patient’s plain film, the differential diagnosis was expanded to include ovarian neoplasm and torsion.
Table 1 shows the differential diagnosis for acute LLQ pain in the prepubescent pediatric age group. However, it’s important to remember that abdominal pain in young children is often poorly localized. The differential diagnosis of acute abdominal pain is guided by other key findings on review of systems (ROS) to include the presence or absence of fever, and changes in bowel or bladder habits. In the absence of diarrhea, gastroenteritis should always be a diagnosis of exclusion.
Although many cases of acute abdominal pain are benign, others require rapid diagnosis and treatment to minimize morbidity.1 Signs and symptoms that suggest an acute surgical abdomen include bilious vomiting, absent bowel sounds, occult blood in stool, voluntary guarding or rigidity, and rebound tenderness (Table 2).2
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