A 6 year old male presents to the ED with a chief  
complaint of fever and stomach pain since last night.  It
is now 11:00 a.m.  The temperature was not measured 
at home but he felt warm.  He was given an unspecified 
dose of acetaminophen at 4:00 a.m.  There was no  
history of nausea, vomiting, or diarrhea.  His last bowel 
movement was three days ago.  He pointed to his 
epigastrium as the location of most of his pain.
     Exam:  VS T38 (tympanic), P136, R24, BP 113/61.  
He was noted to be small for age (19.3 kg), alert, 
active, in no distress.  He did not appear to be 
uncomfortable at all.  HEENT exam was unremarkable.  
Neck supple without adenopathy.  Heart regular without 
murmurs.  Lungs clear.  Abdominal exam was positive 
for mild tenderness in the epigastrium.  Bowel sounds 
were active.  No tenderness in the right lower quadrant.  
No rebound tenderness.  No hepatosplenomegaly or  
masses were appreciated.  Testes were normal.  A  
rectal exam revealed normal sphincter tone, no 
masses, and no right lower quadrant tenderness.  The 
stool tested negative for occult blood.  An abdominal 
series was ordered.  An AP view of the chest was also 
ordered as part of the abdominal series.

View abdominal series:  Flat (Supine) view


View abdominal series:  Upright view


View AP chest:


     The radiographs were interpreted as showing 
non-specific findings.  Because the cause of the 
abdominal pain was suspected to be constipation, the 
patient was given an  enema.  Following this, he passed 
a large amount of  stool and felt much better.  His 
abdominal exam  continued to be benign.  He was 
discharged from the  ED.  Overnight, the patient 
continued to experience  fever at home and some 
abdominal pain though the  degree of abdominal pain 
was improved.  A review of his radiographs the 
following morning revealed an alternative diagnosis for 
his symptoms.

Review his abdominal series again above.

     If you are still unable to identify the radiographic 
diagnosis, review the focused enlarged view of the 
lesion.



     This view provides a focused view of the lesion.   
Note the triangular density superimposed on the heart. 
The flat (supine) view shows this best (see below).   
It is located at the very top of the flat (supine view).   

This represents a pulmonary infiltrate in the medial 
aspect of the left lower lobe.  The top of it is cut off in 
the flat (supine) view of the abdomen.  It is almost 
impossible to appreciate this density on the upright view 
because most of it is cut off.  The chest radiograph was 
taken using a different degree of penetration to view the 
lungs better.  Because of this, it is even more difficult to 
appreciate the infiltrate behind the heart.  Upon close 
inspection, you should be able to appreciate the 
triangular density superimposed on the heart on the 
chest radiograph view.  A lateral view of the chest was 
not taken in this case since the chest view was part of 
an abdominal series that was ordered.
     The patient was placed on antibiotics and his fever 
promptly improved by the next day.  His abdominal pain 
and his other symptoms gradually improved.         

Discussion and Teaching Points:
     Pneumonia is a known cause of abdominal pain.   
This diagnosis is often not considered because the  
abdominal pain is the chief complaint.  The pain can be 
very severe at times.  This can easily mislead a 
clinician to limit the area of investigation to the 
abdomen.  This pitfall should be avoided.  Causes of 
abdominal pain that are not related to the abdomen 
include pneumonia, pneumothorax, 
pneumomediastinum, pericarditis, zoster, vertebral 
conditions (eg., osteomyelitis, discitis), diabetic 
ketoacidosis, etc.  Adult conditions that are less likely 
but still possible in children include myocardial ischemia 
and aortic dissection.
     Pulmonary conditions should be considered in  
patients with respiratory symptoms, tachypnea, or a  
borderline oxygen saturation.  Documentation of these  
findings should be routine in patients with abdominal  
pain.  The history should include the presence of and 
the severity of respiratory symptoms.  The vital signs 
should include a respiratory rate and a pulse oximetry 
reading.  The examination should include notes 
describing the presence or absence of any observed 
tachypnea, the degree of coughing observed, the 
characteristics of the  cough (eg., moist, productive, 
bronchospastic, dry, etc.), and the standard pulmonary 
auscultation and percussion  findings.  If any of these 
findings suggest the possibility  of pneumonia, PA and 
lateral chest radiographs should  be ordered, or 
alternatively, treatment prescribed for a  clinical 
diagnosis of a respiratory infection.
     Although the likelihood of aortic dissection is low 
(especially in children), this condition is associated with 
a substantial likelihood of death which may be 
preventable if the diagnosis is suspected early.  While  
aortic contrast studies by CT or aortography are not  
routine, one suggestion has been to document the  
presence and character of peripheral pulses in all 
patients presenting with abdominal pain.
     Although the appendix is often the focus of clinical 
examination in patients with abdominal pain, there are  
other serious causes of abdominal pain that should be  
considered as well, such as intussusception, volvulus,  
pancreatitis, ovarian torsion, testicular torsion, acute  
cholecystitis, etc.
     The radiographic findings in intussusception may 
range from normal to various indirect signs of 
intussusception (refer to Case 2 which describes the 
radiographic findings in intussusception).  A volvulus 
is usually associated with a true bowel obstruction, but 
the presentation clinically and radiographically can 
occasionally be subtle.
     Ovarian torsion may be a difficult diagnosis to make.  
Even the use of color flow doppler ultrasound used to 
assess blood flow to the ovaries is not able to totally 
rule out this diagnosis since, early in its presentation, 
some blood flow may still be preserved.
     Testicular torsion is usually suspected on clinical 
grounds, but occasionally the testes are not examined 
in some patients because their pants and underwear (or 
diapers) are not removed.  Younger patients may fail to 
point to their testes as the location of the pain.  Some  
may complain of non-specific abdominal pain because 
of failure to appreciate the source of the pain, or 
because of modesty.
     In summary, the causes of abdominal pain are  
extensive.  In the acute care setting, it is most important 
to rule out diagnoses that must be made early to result 
in the best possible outcome for the patient.  Some of 
these diagnoses have been mentioned, but there are 
others.