Fever, vomiting, diarrhea, and severe abdominal pain-leave well enough alone?

DR. OCHOTORENA is a staff pediatrician at Pediatric and Adolescent Health, and DR. SHAW is medical director of, and a staff pediatrician at, North Country Children's Clinic, both in Watertown, N.Y.

You're just about to close your office for this October day when a 17-year-old female-she's an established patient-walks in, accompanied by her mother. The girl complains that she had diarrhea for the entire past month. She describes her stools as "mucusy" but without blood and occurring six or seven times a day. Over the past 24 hours, she began vomiting and developed severe, cramping abdominal pain; tenesmus; and fever. Her mother has been giving her loperamide.

The medical history is significant for major depression, for which the patient takes escitalopram (Lexapro), 10 mg once a day by mouth, and quetiapine (Seroquel) 100 mg once a day by mouth-both prescribed by a psychiatrist. Because neither drug is approved for use in children, her therapy is closely monitored by the psychiatrist. In addition, she receives counseling weekly.

Listening to your patient, you begin to think of the many causes of severe abdominal pain with fever, vomiting, and prolonged diarrhea in an adolescent. Could she have inflammatory bowel disease? Appendicitis? Infectious colitis or pyelonephritis? Your hope is that the physical exam will help you to decide the direction in which to take the evaluation.

On examination, the girl is alert and complaining of diffuse abdominal pain and bilateral flank pain. Weight is 86 kg. She is febrile (axillary temperature, 100.9° F). Blood pressure is 117/76 mm Hg; heart rate, 117/min; and respiratory rate, 22/min. Height is 165 cm; body mass index, 32 (>95th percentile for age). The mucous membranes are slightly dry; lungs are clear to auscultation; and no murmur is heard. The abdomen is obese and diffusely tender on deep palpation. There are neither guarding nor peritoneal signs; hyperactive bowel sounds can be heard. She has no hepatosplenomegaly or costovertebral angle tenderness. There are no rectal fissures, fistulas or tags. She does not permit a rectal examination because of the severe abdominal pain, so you plan to attempt one later.

Examination of both hips is fully normal-no pain on hyperextension or abduction of the hip. She walks without difficulty. The remainder of the physical exam is unremarkable.

Now where?

You're disappointed-the physical examination did not narrow the differential diagnosis much. You proceed to draw specimens for a complete blood count, erythrocyte sedimentation rate (ESR), blood chemistry panel, complete metabolic panel, urinalysis, and cultures of urine and blood. Luckily, the patient has an episode of diarrhea in your office; you save the specimen and send it out for guaiac analysis, culture, and tests for ova and parasites.

You decide to send your patient home while you await the test results. A few hours later, you have some information. The CBC reveals a leukocytosis of 22.1 X 10³/μL, with 86% neutrophils, 7% bands, 5% lymphocytes, and 2% monocytes. The platelet count is 316 X 10³/μL; hematocrit, 44.1%; and ESR, 11 mm/hr. Serum electrolytes, creatinine, blood urea nitrogen, aspartate aminotransferase, and alanine aminotransferase are all within normal ranges.

Stool-guaiac testing is negative. Urinalysis is remarkable for a positive leukocyte esterase test and 3 to 5 WBCs/high-powered field.

Leukocytosis with pyuria concerns you, so you call your patient back for immediate re-evaluation. She continues to vomit in the office and complains that the abdominal pain has become worse. You note that abdominal tenderness that was initially diffuse is now worse in the right lower quadrant of the abdomen.

Now you really have something to worry about-acute appendicitis-so you admit the girl and call for a surgical consult.

Continuing uncertainty

The surgeon does not think that the findings are consistent with appendicitis, however. He recommends that you continue intravenous hydration, and orders a computed tomography (CT) scan of the abdomen with oral contrast.