Dr Charlotte Smith, Dr Emily Cadman

Abdominal pain is such a common problem in paediatric A&E and there are so many possible diagnoses, ranging from the minor to the life-threatening. Right iliac fossa pain in particular can cause clinicians a headache, especially in teenage girls (not forgetting trans or non-binary young people). In this article we’ll explore some of the possible diagnoses, how they present, and how they should best be managed.

Case 1

Carrie, who is a 15-year-old girl, comes to A&E with abdominal pain. Carrie tells you that she had pain in the lower part of her tummy yesterday afternoon for about an hour, rating it a 5/10 but it got better on its own, so she didn’t think too much about it. However, about 3 hours ago the pain came back in the lower right side of her tummy, getting worse and worse with time, now it’s a 10/10 on the pain score – she’s vomited four times with the pain. Her last period was 21 days ago and her periods are regular, cycles are usually 27-28 days. You do a quick HEEADSSS assessment with her parents out of the room, and she tells you she is not sexually active.

Examination: Carrie looks very uncomfortable, holding the right side of her abdomen. She struggles to get on the bed.

A: airway patent, no concerns.

B: normal chest expansion, good air entry bilaterally, RR 22, Sats 99%.

C: Warm and well perfused with a capillary refill time of less than 2 seconds, normal heart sounds, HR 120, BP 130/82.

D: GCS 15/15, PEARL 3mm, temperature 36.8C, BM not taken.

E: No rashes, tender abdomen particularly in RIF with guarding and rebound tenderness and you’re not sure but you think you might be able to feel a small mass in the RIF.

Bloods: WCC 12, Hb 130, CRP 12

Urine dip: Ketones negative, Blood negative, Protein trace, Leucocytes 2+, Nitrites negative

USS: The on-call radiologist has a keen interest in women’s health and agrees to scan Carrie between trauma calls. The radiologist calls to tell you that she has seen an oedematous ovary on the right-hand side with ‘whirlpool sign’.

Diagnosis: Ovarian Torsion

Management: Call the gynaecology SpR and paediatric surgical SpR – this is an emergency. Make sure Carrie is nil by mouth and that she has IV access, decent painkillers and anti-emetics – she will need to go to theatre as soon as possible.

Link to POCUS 101 USS findings in ovarian torsion: Gynecology/Pelvic Ultrasound Made Easy: Step-By-Step Guide – POCUS 101

Case 2

12 year old Nisha comes into A&E with abdominal pain. She tells you that the pain has been there for a couple of days but has been getting worse and worse and is now pointing to the right lower part of her tummy, rating the pain a 7/10, sharp and worse when moving around. Nisha hasn’t eaten anything today and has vomited twice with one episode of diarrhoea yesterday evening. Her last period was 4 days ago and they are normally regular with cycles every 28-30 days.

Examination: Nisha looks like she is in pain and is lying still on the bed.

A: airway patent, no concerns.

B: normal chest expansion, good air entry bilaterally, RR 21, Sats 97%.

C: Warm and well perfused with a capillary refill time of less than 2 seconds, normal heart sounds, HR 123, BP 124/72.

D: GCS 15/15, PEARL 3mm, temperature 38.3C, BM not taken.

E: No rashes, tender abdomen particularly in the RIF with guarding and rebound tenderness especially over McBurney’s point.

Bloods: WCC 17, Hb 120, CRP 56

Urine dip: Ketones 1+, Blood negative, Protein negative, Leucocytes 1+, Nitrites negative

USS: The afternoon ultrasound list has just started and the radiologist agrees to squeeze Nisha in. The report comes back showing a thickened, non-compressible dilated appendix.

Diagnosis: Appendicitis

Management: Call the general surgical SpR, make sure Nisha is nil by mouth, has IV access and good painkillers with IV fluids. She will need to have an operation.

Link to POCUS 101 USS findings in appendicitis: Abdominal Ultrasound Made Easy: Step-By-Step Guide – POCUS 101

Case 3

Kelsey, who is a 15, comes to A&E with abdominal pain. Kelsey says that she was sat in Maths class this afternoon when she suddenly had 10/10 pain in the lower right side of her tummy. The pain was so bad that when she stood up she felt faint and her friend caught her before she hit the floor. She found it too painful to walk, so her parents had to carry her to the car from school and into A&E. Since being in the car and waiting to be seen in A&E, Kelsey tells you the pain is slowly getting better and she can now move more freely. Her last period was about 14 days ago and they are normally regular. In the HEEADSSS assessment Kelsey tells you she has a boyfriend but they haven’t had sex.

Examination: Kelsey looks more comfortable than when she came in, and is looking more and more comfortable with each review.

A: airway patent, no concerns.

B: normal chest expansion, good air entry bilaterally, RR 20, Sats 99%.

C: Warm and well perfused with a capillary refill time of less than 2 seconds, normal heart sounds, HR 102, BP 110/72.

D: GCS 15/15, PEARL 3mm, temperature 36.8C, BM 5.6.

E: No rashes, tender abdomen in the RIF with initial guarding which resolves on subsequent review.

Bloods: WCC 13, Hb 110, CRP 14

Urine dip: Ketones negative, Blood negative, Protein negative, Leucocytes negative, Nitrites negative. bHCG negative.

USS: The ultrasound report shows a small amount of free-fluid in the pelvis with an empty sac-like structure with internal echoes on the right ovary.

Diagnosis: Ovarian cyst rupture

Management: Discussion with gynaecology leads you both to decide on conservative management as the pain is improving and no other cysts were seen on the ultrasound.

Link to POCUS 101 USS findings in ovarian cysts:  Gynecology/Pelvic Ultrasound Made Easy: Step-By-Step Guide – POCUS 101

Case 4

Alex is 14, and identifies as non-binary. The medical record states ‘gender: female’ but the triage nurse has written clearly at the top of the notes, ‘Alex prefers they/them pronouns’. They are in A&E with abdominal pain. Alex says that they had a cough, runny nose and sore throat for the last few days, along with a fever. For the last two days Alex has developed pain in the lower right side of their tummy, worse when moving around, and rated it a 6/10 on the pain scale. Alex hasn’t eaten very much for the last two days and feels like they might throw up but haven’t yet. Alex is uncomfortable when you ask about periods, but says they had a bleed 10 days ago. Alex doesn’t have a partner and is not sexually active.

Examination: Alex looks comfortable at rest but in pain when moving.

A: airway patent, no concerns.

B: normal chest expansion, good air entry bilaterally, RR 20, Sats 99%.

C: Warm and well perfused with a capillary refill time of less than 2 seconds, normal heart sounds, HR 108, BP 112/70.

D: GCS 15/15, PEARL 3mm, temperature 38C, BM 5.4.

E: No rashes, a quite tender abdomen in the RIF but no guarding or rebound tenderness.

Bloods: WCC 15, Hb 130, CRP 33

Urine dip: Ketones negative, Blood negative, Protein negative, Leucocytes 1+, Nitrites negative

USS: The report shows enlarged clustered lymph nodes in the right lower quadrant of the abdomen.

Diagnosis: Mesenteric adenitis

Management: Supportive management including simple painkillers and rest.

Link to POCUS 101 USS findings in mesenteric adenitis: Abdominal Ultrasound Made Easy: Step-By-Step Guide – POCUS 101

Case 5

History: Olivia, who is 15, comes to A&E with abdominal pain. She tells you that the pain is in the lower right side of her tummy, it started as a dull ache earlier on today but has gotten worse and worse. Olivia says that she feels faint and like she might throw up. Olivia goes to the toilet and as she’s going back to her bed she pulls you aside to tell she has had some bleeding from her vagina which she finds strange, as her period isn’t due and she can’t remember when her last period was. With her parents out of the room, she tells you that she has had sex with her boyfriend at a party, and she isn’t taking contraception.

Examination and observations: Olivia looks pale and in discomfort.

A: airway patent, no concerns.

B: normal chest expansion, good air entry bilaterally, RR 20, Sats 99%.

C: Slightly cool peripherally with a slightly prolonged capillary refill time of 3-4 seconds, normal heart sounds, HR 125, BP 86/52.

D: GCS 15/15, PEARL 3mm, temperature 36.8C, BM 5.6.

E: No rashes, tender abdomen in the RIF with guarding and rebound tenderness.

Bloods: WCC 16, Hb 90, CRP 25

Urine dip: Ketones negative, Blood 3+, Protein negative, Leucocytes negative, Nitrites negative, bHCG positive.

USS: You fell that Olivia is too unstable to wait for a formal USS from the radiologist but luckily one of your colleagues is trained in POCUS and tells you that there is free fluid in the pelvis with a heterogenous structure in the right adnexa.

Diagnosis: Ruptured ectopic pregnancy

Management: This is an emergency! Urgent referral to the gynaecology SpR is needed. She also needs IV access, resuscitation with blood products as needed and IV fluids, she needs to be nil by mouth with good painkillers and anti-emetics. Olivia will need urgent surgery.

Note: Olivia is pregnant at 15 years old – remember there are also important safeguarding aspects to think about here, which are not in the scope of this article.

Link to POCUS 101 USS findings in an ectopic pregnancy: Obstetric/OB Ultrasound Made Easy: Step-By-Step Guide – POCUS 101

Key learning points:

• Right iliac fossa pain is a common presentation to the paediatric emergency department
• Careful history taking is important
• Don’t forget a pregnancy test in those who have started their period
• Think about how you would approach trans and non-binary young people with abdominal pain – use the pronouns and language they prefer

Dr Charlotte Smith, Paediatric Emergency Medicine Junior Clinical Fellow; Dr Emily Cadman, Paediatric Emergency Medicine Consultant; Imperial College Healthcare NHS Trust