Hot Seat #48 Denouement: 5 yo M abd pain transfer

Posted on: December 15, 2014, by :

by Rosemary Thomas-Mohtat, Children’s National
with Moh Saidinejad, Children’s National

The Case
5 yr old male transferred from OSH for abd pain found to be mostly left sided, worse on left flank/LLQ.  This case addresses the challenges of different imaging modalities for abdominal pain.

Here’s How You Answered Our Questions

 

Denouement
Infectious etiology was high on differential with abd pain/emesis/fever/backpain. Also with + left hydronephrosis, consider UPJ obstruction (as etiology of flank pain), but neg UA for pyelonephritis.

Rose ultrasound

On US: tech had concern for mass in abd, but radiology review thought maybe stool. Given unclear US findings, free fluid, LNs, fever, abd exam- Abd CT with po/iv contrast was ordered to further delineate abd pathology. Did also consider UPJ obstruction from mass effect as etio of pelviectasis.

Rose CTAbd CT: noted large heterogenous mass most consistent with left retroperitoneal/perinephric hematoma (possibly involving left renal vein).  Also with left hydronephrosis.

Admitted to PICU. Seen by surgery. Managed conservatively- serial H/H. Had an MRI the following day, showing left perinephric lobulated nonenhancing lesion compatible with a hematoma.

Diagnostic considerations included bleeding into a pre-existing arteriovenous malformation or lymphatic malformation. Pt was discharged after pain controlled in 48hrs. Returned to IR outpt 10 days later for drainage and sclerotherapy of possible lymphatic malformation. Outpt doing well. Plan to follow up in 3months with repeat US to see if fluid recollected.

Teaching Points from Thursday Conference
1. When constellation of symptoms are unusual, they warrant further investigation.
2. Back pain and borderline anemia are things to be attentive to.

Rosemary Thomas-Mohtat MD

Pediatric Emergency Medicine Attending at Children's National Health System
Rosemary has lived an adventurous life both geographically and professionally. She grew up an army brat in India living in 5 cities in her ten years there, then schooling in the many boroughs of NYC.Her professional journey has involved residency and a year of private practice in Pittsburgh, followed by a fellowship in Pediatric Nephrology at Montefiore and a year of bench genetics research at Columbia University, all the while working in a Peds ER in the Bronx. It was there that she found her true calling! She graduated PEM Fellowship at Children's National Medical Center, and then completed a one year Point of Care Ultrasound (POCUS) Fellowship. In her spare time, she loves running around Bethesda and the world with her family, including 2 sweet kiddos.
Rosemary Thomas-Mohtat MD

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