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A particular case
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The child presented with unbearable abdominal pain
Xiao A is a 13-year-old boy, tall and thin, usually healthy, 1 day ago after eating more miscellaneous food, abdominal pain, self-complained of persistent knife-like pain in the abdomen, especially in the upper abdomen, abdominal distention, accompanied by vomiting stomach contents, two yellow watery stools, abdominal pain slightly relieved after vomiting and defecation, but still unbearable, call 120 to send to our hospital emergency.
体格检查：T 36.5℃ P 124次/分 R 26次/分 BP 135/69mmHg H 172cm W 45kg，
Emaciated, painful face, no rash all over the body, no yellow staining of the skin, abdominal distention, no gastrointestinal type, slightly tense abdominal muscles, obvious abdominal tenderness, epigastric predomination, no rebound tenderness at McT's point, negative Murphy's sign, no palpable mass in the groin area, no redness, no mass in the scrotum, and slightly weakened bowel sounds. Cardiopulmonary and neurological examination is unremarkable.
急诊查血常规无异常。 随机血糖：6.7mmol/L。
Peel back the cocoon to find the cause of abdominal pain
Clinically, a history of abdominal pain and analysis of the cause of abdominal pain are often taken in the order of P (trigger), Q (nature of pain), R (pain radiation), S (pain severity), and T (pain duration/treatment).
01P (Inducement):
Xiao A should be vigilant for gastric ulcer, pancreatitis, cholelithiasis/cholecystitis, acute gastric dilation, ischemic bowel disease, gastrointestinal obstruction, functional dyspepsia, etc. However, he was in good health in the past, did not have similar episodes of abdominal pain, and was less likely to have a gastric ulcer; In addition, there is no fever, no jaundice, Murphy's sign is negative, no radiating pain, cholelithiasis/cholecystitis is unlikely, and abdominal ultrasonography or CT can be used for differentiation; Pancreatitis can be differentiated by amylase and lipase examination; Acute gastric distension is common in long-term poor diet (frequent overeating) or long-term excessive emotional tension and depression, resulting in normal gastric tone reduction and impaired function. For ischemic bowel disease (e.g., superior mesenteric artery embolization) and gastrointestinal obstruction (e.g., intra-abdominal hernia, volvulus), CT can be used for co-diagnosis; Pain is severe, knife-like, and functional dyspepsia is unlikely.
02Q (Nature of Pain):
The abdominal pain of small A is persistent knife-like pain, and it is necessary to distinguish centrally-mediated abdominal pain syndrome, gastrointestinal obstruction, pancreatitis, cholelithiasis, urinary stones, and Henoch-Schonlein purpura, which is often chronic abdominal pain and recurrent attacks, and has nothing to do with eating, defecation, etc., and the pain site is diffuse, difficult to accurately locate, and inconsistent with the performance of small A, which can be ruled out; Gastrointestinal obstruction, pancreatitis, and cholelithiasis are analyzed above; No hematuria, no low back pain, no previous medical history, epigastric pain, urinary calculi are unlikely, and B-ultrasound can be used for differentiation; Onset with abdominal pain, no rash, and insufficient evidence for Henoch-Schonlein purpura, further examination and observation are required, and gastrointestinal endoscopy can be performed if necessary. Abdominal pain is slightly relieved after vomiting and defecation, upper gastrointestinal obstruction, irritable bowel syndrome and even colorectal cancer should be considered, but there is no similar attack in the past, and the abdominal pain is severe, irritable bowel syndrome can be ruled out, Xiao A is a teenager and has no relevant family history, the pain is severe, and colorectal cancer can be basically ruled out.
03R (Pain Radiation):
There is no radiation for small A abdominal pain, which does not support pancreatitis, cholelithiasis, angina, splenic infarction, etc.
04S (Pain Severity):
Xiao A has severe pain and is unbearable, and needs to be admitted to the hospital with 120, to distinguish ischemic bowel disease, gastrointestinal obstruction, acute appendicitis/Merkel diverticulitis, aortic dissection, inguinal incarcerated hernia, and testicular torsion. Children with aortic dissection are rare, Xiao A is in good health, has no history of congenital heart disease, hereditary connective tissue, no history of surgical trauma, no radiation for pain, and is less likely, and D-dimer, echocardiography or even CTA can be used for co-diagnosis if necessary; Inguincarcerated hernia with a history of herniated sac prolapse that is not supported by physical examination can be excluded; Testicular torsion is often sudden, severe testicular pain radiates to the lower abdomen, and the testicle is red and swollen, which is not supported by physical examination and can be ruled out.
05 T (Pain Time/Treatment):
The course of Xiao A's disease is only 1 day, and there is no similar episode in the past, which is undoubtedly acute abdominal pain, which does not support functional diseases, central-mediated abdominal pain syndrome, etc.
Further refinement of the inspection
After admission, there were no abnormalities in two items of blood pancreatitis, electrolytes, four items of cardiac enzymes, eight items of liver function, blood lactate, blood creatinine and urea nitrogen, blood lipids, and coagulation. Blood uric acid: 620.8umol/L.
Further CT showed that the superior mesenteric artery compressed the horizontal segment of the duodenum and narrowed, and the upper duodenum and gastric cavity were obstructed and dilated.
Fig.1 CT: dilation of duodenal and gastric obstruction (blue arrows)-author's image
Fig.2 CT arteriography: the angle between the superior mesenteric artery and the abdominal aorta is about 17° (blue arrow) - author's image
Q
Readers, seeing this, do you know what Xiao A's diagnosis is? How is it treated?
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Editor in charge: Moon
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