What Is the Cause of This Left Lower Quadrant Pain in an 11-Year-Old Girl?

AUTHORS:
Parag Bhattarai, MD¹ • Lindsey Carswell, DO² • Logan Bartsch, DO³

AFFILIATION:
¹Department of Pediatrics, Cape Fear Valley Medical Center, Fayetteville, North Carolina
²Department of Emergency Medicine, Cape Fear Valley Medical Center, Fayetteville, North Carolina
³Department of Family Medicine, Cape Fear Valley Medical Center, Fayetteville, North Carolina
 

CITATION:
Bhattarai P, Carswell L, Bartsch L. What is the cause of this left lower quadrant pain in an 11-year-old girl? Consultant. 2021;61(12):e15-e16. doi:10.25270/con.2021.04.00004

Received December 17, 2020. Accepted January 15, 2021. Published online April 13, 2021.

DISCLOSURES:
The authors report no relevant financial relationships.

CORRESPONDENCE:
Parag Bhattarai, MD, Cape Fear Valley Medical Center, 1638 Owen Dr, Fayetteville, NC 28304 (bhattaraiparag@gmail.com)

An 11-year-old girl was brought to our emergency department (ED) by her parents with pain in the left lower quadrant of her abdomen. The pain had started approximately 4 to 5 hours prior to presentation. She described the pain as intermittent cramping and stabbing and rated the pain as moderate to severe depending on timing, but it never fully remitted.

History. Onset of menarche was 2 weeks prior to presentation, and the patient had no current bleeding. There was associated nausea and vomiting without any other gastrointestinal or urinary symptoms. The patient denied sexual activity and vaginal insertions.

Her family history was notable for renal disorders and vesicoureteral reflux. However, no conditions were diagnosed in our patient.

Physical examination. Initial examination showed voluntary guarding and tenderness in the lower left quadrant without rebound, rigidity, mass, or distension. The physical examination was otherwise grossly benign.

Given her symptoms, diagnostic workup was initiated, including an abdominal radiography scan, urinalysis, urine pregnancy test, and transabdominal transvesical ultrasonography scan of the pelvis. The patient was given acetaminophen for the pain upon presentation.

Diagnostic testing. The abdominal radiographs were interpreted by radiology as normal but showed a slightly increased stool burden. Results of the urinalysis were negative for infection and blood, and results of the pregnancy test were negative.

The ultrasonography scan was performed at this time. While waiting for the official read, the patient was given an adult fleets enema. She had good remission of her pain with the enema and had a bowel movement. The sonogram ultimately showed good flow to the bilateral ovaries with unilateral left hydrosalpinx. Gynecology was consulted, and a repeat ultrasonography scan to ensure remission of the hydrosalpinx was planned.

Given the patient’s remission of her pain, stable vital signs, and painless re-examination, the decision was made to establish close follow-up with gynecology and discharge the patient with a diagnosis of constipation. Strict return precautions were given, including return of pain.

Two days later, the patient returned to the ED with a fever of 38.3 °C and worsening abdominal pain, described as “excruciating.” A repeat transabdominal transvesical ultrasonography scan of the pelvis was conducted, results of which showed a left adnexal dilated tubular structure and mild pelvic free fluid. The uterus and bilateral ovaries were normal appearing with physiologic ovarian follicles with no evidence of ovarian torsion (Figure 1).

Answer and discussion on next page.