Lower Quadrant Pain and Emesis in a Young Boy

March 14, 2014

The 9-year-old was admitted after 1 day of symptoms; he had no fever, diarrhea, constipation, dysuria, or rash. More details here. What's your diagnosis?

A 9-year-old Hispanic boy was admitted to the county hospital after 1 day of crampy abdominal pain, emesis, and anorexia. His pain started in the left lower quadrant and then migrated to the right lower quadrant. There was a mild cough but no fever, diarrhea, constipation, dysuria, or rash. His past medical history included an open appendectomy for acute appendicitis with perforation 5½ years earlier that was complicated by prolonged ileus and a wound infection. He was discharged 11 days after the operation with no further complications. Childhood immunizations were up to date and the patient denied any allergies. There were no identified sick contacts and no report of recent travel.

On physical examination, the patient was afebrile and all other vital signs were within normal limits. His abdomen was flat with a small transverse incision scar over McBurney point, and bowel sounds were normal. He exhibited tenderness to palpation with guarding in the right lower quadrant but no rebound tenderness.        

His WBC count was 20.6 x 103/µL (20.6 x 109/L) with a predominance of neutrophils and bands. Other blood cell counts, electrolytes, and urine analysis results were within normal limits. Liver function tests were: amylase, 62 U/L; lipase, 196 U/L; AST, 26 U/L; ALT, 37 U/L; T bili, 0.6 mg/dL; D bili, 0.1 mg/dL; alk phos 305 U/L.

The differential diagnosis at this point included Crohn disease, Meckel diverticulum, stump appendicitis, retained appendicolith, mesenteric adenitis, bowel obstruction from adhesions, intussusception, incarcerated hernia.

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