Index of Suspicion

Case 1 Presentation

A 12-year-old girl has had abdominal pain for 3 hours. The pain developed suddenly and is severe, sharp, constant, and located in the epigastrium and lower quadrants, with no radiation. She has had five episodes of bilious, nonbloody emesis. The pain worsens with movement and vomiting, and she has found no way to relieve it. Her last bowel movement was yesterday and was normal. She has had no fever, diarrhea, bloody stools, or back pain. Past medical history reveals intermittent constipation.

On physical examination, her temperature is 96.3°F (35.7°C), heart rate is 106 beats/min, respiratory rate is 14 breaths/min, and blood pressure is 103/60 mm Hg. Her abdomen is soft and slightly distended, with hypoactive bowel sounds and both right and left lower quadrant tenderness. Slight voluntary guarding is noted. The rest of the physical findings are normal.

Her WBC is 9.6×10³/mcL (9.6×10⁹/L), Hgb is 11.4 g/dL (114 g/L), Hct is 33.3% (0.333), and platelet count is 406×10³/mcL (406×10⁹/L). Values for electrolytes, BUN, creatinine, liver enzymes, amylase, and lipase are within normal limits; a pregnancy test is negative.

Abdominal/pelvic CT scan with intravenous contrast reveals a moderate amount of free fluid around the cecum; the appendix is not visible. Pelvic and abdominal ultrasonography is read as normal, but the appendix is not visible.

Following intravenous hydration, she experiences persistent bilious vomiting and abdominal pain and undergoes a diagnostic laparoscopy, which is converted to an exploratory laparotomy when no colon is located on the right side of her abdomen. The cause of her pain and vomiting is revealed at surgery.

Case 2 Presentation

A 14-year-old girl is seen in the ED because of 2 days of lower abdominal and back pain. The pain is a constant, dull, bandlike ache of 9/10 in intensity. She denies fever, …