Film:

The Diagnosis view provides a focused view of the lesion. Note the triangular density superimposed on the heart. The flat (supine) view shows this best. It is located at the very top of the film. This represents a pulmonary infiltrate in the medial aspect of the left lower lobe. The top of it is cut off in the flat (supine) view of the abdomen. It is almost impossible to appreciate this density on the upright view because most of it is cut off. The chest radiograph was taken using a different degree of penetration to view the lungs better. Because of this, it is even more difficult to appreciate the infiltrate behind the heart. Upon close inspection, you should be able to appreciate the triangular density superimposed on the heart on the chest radiograph view. A lateral view of the chest was not taken in this case since the chest view was part of an abdominal series that was ordered.

The patient was placed on antibiotics and his fever promptly improved by the next day. His abdominal pain and his other symptoms gradually improved.

Discussion and Teaching Points:

Pneumonia is a known cause of abdominal pain. This diagnosis is often not considered because the abdominal pain is the chief complaint. The pain can be very severe at times. This can easily mislead a clinician to limit the area of investigation to the abdomen. This pitfall should be avoided. Causes of abdominal pain that are not related to the abdomen include pneumonia, pneumothorax, pneumomediastinum, pericarditis, zoster, vertebral conditions (eg., osteomyelitis, discitis), diabetic ketoacidosis, etc. Adult conditions that are less likely but still possible in children include myocardial ischemia and aortic dissection.

Pulmonary conditions should be considered in patients with respiratory symptoms, tachypnea, or a borderline oxygen saturation. Documentation of these findings should be routine in patients with abdominal pain. The history should include the presence of and the severity of respiratory symptoms. The vital signs should include a respiratory rate and a pulse oximetry reading. The examination should include notes describing the presence or absence of any observed tachypnea, the degree of coughing observed, the characteristics of the cough (eg., moist, productive, bronchospastic, dry, etc.), and the standard pulmonary auscultation and percussion findings. If any of these findings suggest the possibility of pneumonia, PA and lateral chest radiographs should be ordered, or alternatively, treatment prescribed for a clinical diagnosis of a respiratory infection.

Although the likelihood of aortic dissection is low (especially in children), this condition is associated with a substantial likelihood of death which may be preventable if the diagnosis is suspected early. While aortic contrast studies by CT or aortography are not routine, one suggestion has been to document the presence and character of peripheral pulses in all patients presenting with abdominal pain.

Although the appendix is often the focus of clinical examination in patients with abdominal pain, there are other serious causes of abdominal pain that should be considered as well, such as intussusception, volvulus, pancreatitis, ovarian torsion, testicular torsion, acute cholecystitis, etc.

The radiographic findings in intussusception may range from normal to various indirect signs of intussusception (refer to Case 2 which describes the radiographic findings in intussusception). A volvulus is usually associated with a true bowel obstruction, but the presentation clinically and radiographically can occasionally be subtle.

Ovarian torsion may be a difficult diagnosis to make. Even the use of color flow doppler ultrasound used to assess blood flow to the ovaries is not able to totally rule out this diagnosis since, early in its presentation, some blood flow may still be preserved.

Testicular torsion is usually suspected on clinical grounds, but occasionally the testes are not examined in some patients because their pants and underwear (or diapers) are not removed. Younger patients may fail to point to their testes as the location of the pain. Some may complain of non-specific abdominal pain because of failure to appreciate the source of the pain, or because of modesty.

In summary, the causes of abdominal pain are extensive. In the acute care setting, it is most important to rule out diagnoses that must be made early to result in the best possible outcome for the patient. Some of these diagnoses have been mentioned, but there are others.

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Loren Yamamoto, MD, MPH 
Associate Professor of Pediatrics
University of Hawaii John A. Burns School of Medicine
loreny@hawaii.edu