Acute abdominal pain in children: Case

This adolescent girl has acute right lower quadrant pain that must be assumed to have a time-critical cause until proven otherwise, and the leading diagnoses are appendicitis and ovarian torsion, with ectopic pregnancy held as a must-not-miss given her missed period. The sudden onset overnight, the severity, the pallor and clamminess, and the exquisite right iliac fossa tenderness all argue for an urgent workup rather than observation alone, and a pregnancy test is the first bedside step. ^[1]

Clinical findings

The findings that demand urgency are the sudden severe onset, the pallor and clamminess, the tachycardia, and the exquisite localised tenderness with voluntary guarding in the right iliac fossa. Sudden, severe, constant unilateral lower abdominal pain with nausea and vomiting is the hallmark of ovarian torsion, in which the ovary twists on its vascular pedicle and becomes ischaemic within hours. The absence of fever and the normal temperature do not exclude a surgical cause. ^[1]

The candidate must build the differential around the surgical threats. Appendicitis remains the most common surgical cause in this age group and can present with sudden right iliac fossa pain, though the migration from a periumbilical ache is its signature and is absent here. Ectopic pregnancy must be excluded with a pregnancy test in any adolescent girl with acute abdominal pain, and a ruptured ovarian cyst and pelvic inflammatory disease are added. The candidate should state plainly that ovarian torsion and ectopic pregnancy cannot be excluded clinically and demand investigation without delay. ^[1]