Non-traumatic abdominal pain is a common presenting complaint in emergency department (ED) patients, quoted in some contemporary literature as being the third most frequent reason for ED visits. We present the ED and hospital course of an unusual case of an 11 year old female with right lower quadrant abdominal pain. The admission assessment of this patient was “possible appendicitis versus gastroenteritis”; however, laparatomy revealed a right adnexal torsion. The need for emergency medicine physicians to always include gynecologic and other less common causes in the differential diagnosis and workup of abdominal pain in children is emphasized

Bowker, Debra

Ferguson, Glen

Heer, Jag

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Western Journal of Emergency Medicine

An Unusual Case of Abdominal Pain in a Female Child

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UC IrvineWestern Journal of Emergency Medicine: Integrating Emergency Care with Population HealthTitleAn Unusual Case of Abdominal Pain in a Female ChildPermalinkhttps://escholarship.org/uc/item/5kw7z6tdJournalWestern Journal of Emergency Medicine: Integrating Emergency Care with Population Health, 6(3)ISSN1936-900XAuthorsHeer, JagBowker, DebraFerguson, GlenPublication Date2005Copyright InformationCopyright 2005 by the author(s). All rights reserved unless otherwise indicated. Contact the author(s) for any necessary permissions. Learn more at https://escholarship.org/terms Peer reviewedeScholarship.org Powered by the California Digital LibraryUniversity of CaliforniaPage 52 The California Journal of Emergency Medicine VI:3, Jul-Sep, 2005An Unusual Case of AbdominalPain in a Female ChildJag Heer, MDDebra Bowker, MDGlen Ferguson, DOKern Medical Center, Bakersfield, CaliforniaCorrespondence:Jag Heer, MD, FAAEMAssistant Professor, UCLAAttending Faculty Kern Medical(661) 326-2160ABSTRACTNon-traumatic abdominal pain is a commonpresenting complaint in emergency department(ED) patients, quoted in some contemporaryliterature as being the third most frequent reasonfor ED visits. We present the ED and hospitalcourse of an unusual case of an 11 year old femalewith right lower quadrant abdominal pain. Theadmission assessment of this patient was“possible appendicitis versus gastroenteritis”;however, laparatomy revealed a right adnexaltorsion. The need for emergency medicinephysicians to always include gynecologic and otherless common causes in the differential diagnosisand workup of abdominal pain in children isemphasized.INTRODUCTIONRight lower quadrant abdominal pain is a commonpresenting complaint in the emergency department(ED). In older adolescent and adult women thiscomplaint provokes consideration of not onlyappendicitis and gastroenteritis, but also ofgynecologic and urologic disease processes orinfections. For pre-pubertal females, however,gynecologic disorders are less commonly consideredin the differential diagnosis. This is particularly true inthe case of idiopathic adnexal torsion in children. Thedifficulty in this diagnosis is twofold: most cliniciansencounter it rarely, and the presentation often doesnot provide a clear clinical picture differentiatingidiopathic adnexal torsion from other causes ofabdominal pain.It is acceptable surgical practice to follow nonspecificabdominal pain in children with observation and serialphysical exams. In spite of its often nonspecificpresentation, ovarian torsion is a true surgicalemergency, just as with testicular torsion. Anemergency medicine physician making the correctdiagnosis early may expedite the appropriate surgicalintervention for a female child’s torsed ovary andincrease the likelihood of salvaging ovarian tissue. Thiscase report presents some features and reviews thediagnostic studies that might point the clinician towardthis diagnosis.CASEAn eleven year old female presented to the ED,accompanied by her mother, with a chief complaintof abdominal pain beginning at approximately noonon the day of presentation. She had experienced afew episodes of vomiting after the onset of pain. Atthe time of her initial exam by the ED physician twelvehours later, the vomiting had resolved. However, thepatient remained anorexic, and reported that she hadnot eaten that day. She was not able to fully describethe character of her pain, but did say that the pain hadbeen constant and located in the right lower quadrantof her abdomen. She denied dysuria. Her motherstated that the patient had not had any fever ordiarrhea, and had a normal bowel movement themorning before presenting to the ED. The patient hadexperienced a very similar episode of abdominal painabout one month prior, for which she had not soughttreatment and which had resolved spontaneously. Hermedical history was otherwise unremarkable; she waspre-menarchal, denied any history of sexual activity,and had no prior surgeries in the abdomen.Upon initial physical examination in the ED hertemperature was 95.6 F, her pulse was 91 beats perminute, her respiratory rate was 22 breaths per minute,her blood pressure was 99/71 mmHg, and her pulseoximetry saturation was 98% on room air. She wasalert and appeared comfortable. Her abdomen wassoft, with mild tenderness focally in the right lowerPage  53The California Journal of Emergency Medicine VI:3, Jul-Sep, 2005quadrant. Minimal guarding was noted upon deeppalpation. There was no rebound tenderness, nocostovertebral angle tenderness, no guarding, and nosigns of peritoneal irritation. No abdominal distentionor bowel sounds were appreciated. The patient’srectal exam was unremarkable, with normal tone, notenderness, and guaiac negative. Urinalysis revealedslight ketonuria and trace proteinuria, but no signs ofinfection or nephrolithiasis. The white blood cell countwas 13,700 k/ml with a left shift of 88% neutrophils.She received intravenous fluids while awaitinglaboratory results, after which her abdomen wasreexamined and found to be unchanged. The generalsurgery service was called to evaluate the patient.She was admitted to the general surgery service witha presumptive diagnosis of possible early appendicitisversus gastroenteritis, with a plan to follow hercondition with serial physical exams and repeatlaboratory tests. On hospital day number two, thepatient’s condition was largely unchanged. Sheremained afebrile with a temperature of 98.7 F; nofurther emesis was noted, and her physical examunchanged. Her white blood cell count rose to 15,300with 82% neutrophils. On hospital day number three,the patient stated that her pain had improved from theprevious day. However, her white blood cell counthad risen to 18,800 with 82% neutrophils, and hertemperature had risen to 100.2 F. She was taken tothe operating room by general surgery that afternoonfor laparatomy for what was thought to be appendicitis.Upon inspecting the pelvis, right adnexal torsion wasdiscovered. The right ovary and fallopian tube werenoted to be purplish-black in color, hemorrhagic andnecrotic. The right ovary was enlarged to 7cm x 6cmx 3cm. After untwisting the right adnexa, there wasno return of normal color to the ovary or tube.Gynecology was consulted intraoperatively, and theyproceeded with complete right salpingo-oophorectomy. The appendix was mildly congestedbut otherwise normal, and appendectomy wasperformed by the general surgery team. The uterus,left ovary, and left fallopian tube were normal. Thepatient was discharged on hospital day number sevenafter an uneventful recovery. The surgical pathologyreport noted a markedly hyperemic right ovary andfallopian tube with extensive hemorrhage and necrosisconsistent with adnexal torsion. No tumors, cysts, orabnormalities were found within the ovary. Theappendix was reported as essentially normal with amildly hyperemic serosa. At follow-up one week laterin gynecology clinic, she was pain-free and doing well.DISCUSSIONThe preoperative diagnosis of adnexal torsion isespecially difficult because it may not receive primaryconsideration in a differential diagnosis of abdominalpain in the pediatric age group, and because of themany nonspecific findings. The classic presentationfor adnexal torsion is acute onset of severe persistentlower quadrant abdominal pain, often immediatelyfollowed by nausea and emesis in the absence of fever,gastrointestinal, urinary, or gynecologic symptoms.1Acute appendicitis is the most frequent misdiagnosisfor pediatric patients with adnexal torsion. Right-sidedtorsions occur much more often than left-sidedtorsions, contributing to the confusion withappendicitis.1Abdominal pain, whether acute or chronic, is the mostconsistent symptom. Patients may present withrecurrent episodes of pain over several months.2 Thisis suggestive of an adnexa that torses and thenspontaneously detorses, or incomplete torsions thatresolve.3 This patient’s mother told the ED physicianat initial evaluation that the child had a similar episodeof abdominal pain one month prior to presentation,which had resolved spontaneously. Investigation ofthe chart for this case report revealed another episodeof right lower quadrant abdominal pain approximatelyfour months prior to presentation which had beenevaluated by a different ED physician. At that visit,only mild tenderness to palpation of the right lowerquadrant was noted, with normal vital signs, a normalwhite blood cell count, and normal urinalysis. Thepatient was sent home and rechecked in the urgentcare the next day, at which time her abdominal painand tenderness had completely resolved.Other presenting findings of adnexal torsion mayinclude fever, vomiting, anorexia, constipation, andurinary symptoms. If nausea and vomiting are presentPage 54 The California Journal of Emergency Medicine VI:3, Jul-Sep, 2005in adnexal torsion, they are usually immediately afteronset of pain, whereas with appendicitis nausea andvomiting usually follow the initial discomfort by severalhours.4 Diarrhea is rarely part of this clinical picture.Bowel sounds are often hypoactive or absent. Pelvicorgans in children lie relatively higher because the pelvishas not fully developed; therefore the rectal exam maynot reveal tenderness or a mass with bimanualpalpation.5 Development of peritoneal signs and anacute abdomen are commonly reported, althoughthese were not present in our case. Laboratory values are not diagnostic in adnexaltorsion. White blood cell count can be normal orelevated. Leukocytosis is mild and occurs after at least24 hours, by which time the damage is generallyirreversible.5 Microhematuria may be present, perhapsmisleading the clinician to suspect urinary infection orurolithiasis.6Early diagnosis provides the only possibility of salvageof the affected ovary and tube. In the more acutepresentations in which the decision to operate for anacute surgical abdomen is an obvious and immediateone, there may be little to gain by pursuing anextensive radiologic evaluation.1 However, in thesymptomatic female patient without signs of acutedistress, who may otherwise be a candidate forobservation with serial physical exams and repeat labs,ultrasound and abdominal CT may be helpful. This isespecially relevant for female children with “possibleappendicitis” who are being admitted for observation.1IMAGING STUDIESUltrasonography is the preferred imaging study. It isnoninvasive and can delineate the presence or absenceof ovarian masses quickly, allowing prompt surgicalintervention.1 It usually confirms a pelvic mass but maynot establish the diagnosis. Although one case seriesnoted a low 37% rate of correct diagnosis bysonogram, an enlarged dishomogeneous ovary withsome pelvic ascites is expected. A sonographic imageof an enlarged ovary with small cystic structures inthe periphery is strongly suggestive of adnexal torsion.2A more specific sonographic finding in torsion is thedemonstration of multiple follicles (8 to 12 mm in size)in the cortical portions of a unilaterally enlarged ovary.This feature has been detected in as many as 74% ofovarian torsion in children and adolescents.3 Whenultrasonographic expertise is not available, CT is alsouseful for assessing children with lower abdominalpain.4 Although limited data is available regarding theutility of CT in adnexal torsion, patients have beenfound to have heterogeneous, retrovesical masses.SUMMARYThe low rate of ovarian salvage in pediatric adnexaltorsion is attributable to the combination of delay inpatient presentation and surgical delay, often resultingfrom the nonspecific clinical presentation. Expeditiousimaging and a high level of clinical suspicion shoulddecrease the surgical delay and improve the likelihoodof ovarian salvage.7REFERENCES1. Cunnion KM, Dolan MA, Sonnino RE. CaseRecords of the Medical College of Virginia: A 10-year-old girl presenting with an acute onset of abdominalpain. Pediatr Emerg Care 1996;12(1):52-5.2. Dolgin SE, Lublin M, Shlasko E. Maximizing ovariansalvage when treating idiopathic adnexal torsion. JPediatr Surg 2000;35(4):624-6.3. Shust NM, Hendricksen DK. Ovarian torsion: anunusual cause of abdominal pain in a young girl. Am JEmerg Med 1995;13(3):307-9.4. Kokoska ER, Keller MS, Weber TR. Acute ovariantorsion in children. Am J Surg 2000;180(6):462-5.5. Weir CD, Brown S. Torsion of the normal fallopiantube in a premenarcheal girl: a case report. J PediatrSurg 1990;25(6):685-6.6. Jaffe WI, Cooper CS, Johnson JO, Kirsch AJ.Ovarian torsion mimicking urological disease. J Urol1998:160(6 Pt 1):2160.7. Meyer, JS, Harmon CM, Harty MP Markowitz RI,Hubbard AM, Bellah RD. Ovarian torsion: clinical andimaging presentation in children. J Pediatr Surg1995;30(10):1433-6.

Acute ovarian torsion in children.

Case Records of the Medical College of Virginia: A 10-yearold girl presenting with an acute onset of abdominal pain. Pediatr Emerg Care

An Unusual Case of Abdominal Pain in a Female Child

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