Day: September 19, 2005

Acute Abdominal Pain Through the Ages. What Causes It?

Patient Presentation
A 13-year-old male came to the clinic with a 6 hour history of lower abdominal pain. He complained that his left testicle hurt especially when he coughed.
The abdominal pain began with the left testicle and moved to the lower abdomen. He described it as like being kicked. It slightly improved before he came to the clinic.
The past medical history and family history are negative.
The review of systems shows no trauma, emesis, or fever. He has had normal urination and stooling.
The pertinent physical exam reveals a male in moderate distress from pain with slight tachycardia. His right testicle is normal but his left testicle shows severe edema and discoloration (i.e. red/blue). He has no left-sided cremasteric reflex, and elevation of the testicle does not improve the pain. The entire testicle is exquisitely tender.
His abdominal examination is normal.
The diagnosis of presumed tesicular torsion was made. The urologist was called and an emergency ultrasound was performed which showed no arterial or venous blood flow.
He was taken to the operating room where the torsion was confirmed. After detorsion, there was minimal improvement in the color of the testicle. It was decided to take him to the recovery room and carefully monitor him.
Unfortunately, he continued to have pain and another ultrasound again showed no blood flow. At re-operation there was obvious necrosis and an orchiectomy was performed.

Discussion
Testicular torsion is a surgical emergency. It occurs in 1:4000 boys and men under age 25 years. Peak incidence is in the preadolescent age group. Acute onset of pain with emesis is common. Scrotal edema, redness and loss of the cremasteric reflex, in a high-lying, horizontal testes are often seen on physical examination.
As edema increases it is often more difficult to differentiate from other causes of acute scrotal pain. Time is of the essence as irrevesible changes can occur within 4-6 hours. After 24 hours infarction is the general rule.

Learning Point
Acute abdominal pain has a large differential but its characteristics makes one suspect an urgent need for diagnosis and management. History should include onset, location and nature of pain and the progression. A child with sudden onset of severe, well-localized pain that is worsening makes a healthcare provider quite worried.
Areas to emphasize on the physical examination include the general appearance including hydration, chest (looking for pulmonary or musculoskeletal pathology), and the abdomen and genitourinary examinations.

The differential diagnosis of acute abdominal pain by ages includes:

  • Infants
    • Anatomic abnormalities of gastrointestinal tract
    • Colic
    • Necrotizing enterocolitis
    • Pyloric stenosis
    • Volvulus/malrotation
  • Toddler/Preschooler
    • Hernia
    • Intussusception
    • Plumbism
  • School Ager
    • Appendicitis
    • Diabetes mellitis
    • Hemolytic-uremic syndrome
    • Henoch-Schonlein purpura
    • Mesenteric lymphadenitis
    • Psychogenic abdominal pain
  • Pre-teen/Teenager
    • Abdominal epilepsy
    • Crohn’s disease
    • Diabetes mellitis
    • Mononucleosis
    • Ovarian cyst
    • Ovarian/testicular torsion
    • Pelvic inflammatory disease
    • Psychogenic abdominal pain
    • Pregnancy
    • Ulcerative colitis
  • Any Age
    • Anatomic abnormalities of gastrointestinal tract
    • Child abuse
    • Constipation
    • Cystic fibrosis
    • Foreign body/bezoar
    • Gallstones/gallbladder disease
    • Gastritis/peptic ulcer disease
    • Gastroenteritis
    • Hepatitis
    • Hirschsprung’s Disease
    • Mumps
    • Obstruction – gastrointestinal, nephrogenic, gall bladder, etc.
    • Pancreatitis
    • Pinworms
    • Perforation/peritonitis
    • Pneumonia
    • Sickle cell anemia
    • Trauma
    • Tumor
    • Urinary tract infection
    • Urolithiasis

Questions for Further Discussion
1. Should the contralateral testes be explored and an orchipexy performed in a child with testicular torsion?
2. How common is prenatal testicular torsion?
3. What evaluation should be performed for acute abdominal pain?

Related Cases

To Learn More
To view pediatric review articles on this topic from the past year check PubMed.

Information prescriptions for patients can be found at Pediatric Common Questions, Quick Answers for this topic: Acute Abdominal Pain.

To view current news articles on this topic check Google News.

Rudolph CD, et.al. Rudolph’s Pediatrics. 21st edit. McGraw-Hill, New York, NY. 2003:1740.

Woodhead JC. Pediatric Clerkship Guide. Mosby. St. Louis MO, 2003:121-130.

Author
Donna M. D’Alessandro, MD
Associate Professor of Pediatrics, Children’s Hospital of Iowa

Date
September 19, 2005