A teenager suffered from two years of vomiting and abdominal pain | Medical Mystery
The patient said she had on and off belly pain for the last two years, but now the pain above her belly button had intensified to what she described as “stabbing.”
A worried mother brought her 14-year-old daughter to the emergency department after the girl suffered a full night of vomiting and abdominal pain.
The patient said she had on and off belly pain for the last two years, but now the pain above her belly button had intensified to what she described as “stabbing.”
She had not had any fevers over the days leading up to her trip to the ER and she reported regular bowel movements. When asked about the belly pain over the last two years, the patient said it fluctuated on a daily basis, but she noticed it got worse after eating acidic or fatty foods.
At the hospital, her vital signs were stable and she did not have a fever. When we pressed on her belly, she had significant pain. She felt very nauseous and was not able to eat or drink, so she was started on IV fluids. There are many things that could cause her symptoms, but some are more serious than others, so we needed some fast answers.
Appendicitis occurs when a small organ (the appendix) attached to the large intestine becomes inflamed and infected. We needed to consider appendicitis quickly because if an infected appendix ruptures, the infection can spread rapidly.
Appendicitis can present with severe abdominal pain, vomiting, and fevers, however typically the pain goes to the lower right side of the abdomen, not as high as our patient’s pain. Still, an ultrasound was performed and ultimately ruled out appendicitis.
We also needed to consider an ectopic pregnancy, which is when a fertilized egg implants somewhere outside the uterus, typically in the fallopian tubes but can also occur in the abdomen. It would be unusual to have upper belly pain with an ectopic pregnancy, but we needed to rule it out to avoid a surgical emergency. But, her pregnancy test was negative.
Sometimes a urinary tract infection, kidney stones, or kidney infection can cause belly (or back) pain as well as vomiting. This patient’s urine sample came back with evidence that she was dehydrated, but it was negative for signs of an infection or stones. So these were unlikely to be the cause of her symptoms.
A small bowel obstruction can also cause belly pain and vomiting, and if left untreated, can result in a bowel perforation (a hole in the bowel) which can be deadly. The patient was still passing gas and had a bowel movement the day prior, so this was unlikely. An abdominal X-ray confirmed this was not the problem.
A few more blood tests needed to be sent before we reached our conclusion.
Solution
The solution came when one of those blood tests returned.
Her lipase was 24,000 U/L, far higher than the normal level of 0-160 U/L. Lipase is an enzyme produced by the pancreas to help breakdown fats and digest food in our intestines. The high lipase, along with her severe pain, confirmed her diagnosis of acute pancreatitis.
The pancreas is an important organ located behind the stomach that aids in the digestion of food and regulation of blood sugar. When it is inflamed, it causes pain above the belly button and back and can cause vomiting. A CT scan of her abdomen confirmed findings of acute pancreatitis and also evaluated for complications which can arise from pancreatitis including an abscess or cyst. Luckily for our patient, she did not have any of these complications.
The CT showed something else though — our patient had gallstones, which probably caused her pancreatitis. Gallstones arise in the gallbladder and are calcified balls of bile which can get stuck in our bile ducts and cause pain when the gallbladder squeezes to release bile to digest fatty foods.
This explained our patient’s two years of fluctuating belly pain when eating certain foods. Gallstones are more common in adults, but they are important to think about in kids, too. The surgery team was consulted and ultimately decided to remove our patient’s gallbladder once her episode of pancreatitis improved so that this hopefully would not happen again.
Take home points for parents:
If your child has multiple episodes of vomiting in a row and is not able to eat or drink, you should call your doctor’s office. Younger children are more susceptible to becoming dehydrated and they may need IV fluids. Signs that indicate your child is dehydrated include:
If they are peeing less often than usual (more than every 4-6 hours for babies, or 6-8 hours for older kids).
If they are crying without making tears.
If their lips or tongue appears dry or cracked.
Your doctor may recommend bringing your child to the ER if they are showing these signs.
There are many causes of vomiting in children, and only some of them are serious. But if you are worried, do not hesitate to call your doctor’s office.
Lindsay Becker is a second-year pediatrics resident and Hayley Goldner is a pediatrician in the adolescent medicine department at Nemours Children’s Hospital, Delaware.