Hot Seat #48 Denouement: 5 yo M abd pain transferPosted on: December 15, 2014, by : Rosemary Thomas-Mohtat MD
by Rosemary Thomas-Mohtat, Children’s National
with Moh Saidinejad, Children’s National
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.
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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.
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.
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.