Diseases information. Disorders. Treatment.

In addition, many women experience characteristic symptoms associated with the phases of the cycle. The most common of these is lower abdominal midline cramping pain, referred to as dysmenorrhea, which typically begins on the first day of bleeding and spontaneously resolves by the second or third day. Dysmenorrhea that is newly worse or longer lasting can be associated with the conditions that cause menorrhagia. Most women also experience premenstrual symptoms in the week before the onset of bleeding; among the most common are breast tenderness, bloating, food cravings, insomnia, and mood changes. Although negative mood symptoms such as irritability and mood lability are common, many women actually experience an increase in energy during this phase. Finally, a smaller proportion of women experience periovulatory symptoms. Cervical mucus, under the influence of the midcycle surge in estradiol, becomes thin and copious just before ovulation and becomes thick and viscid just after ovulation in response to progesterone secretion. Some women also have transient unilateral pelvic discomfort at midcycle, referred to as mittelschmerz and thought to be due to peritoneal irritation associated with ovulation.

Sometimes the history alone will be inconclusive regarding ovulation; in these cases, additional methods can be helpful. Recording of basal body temperature can be used to determine whether the expected postovulatory rise in basal temperature is present. Serum progesterone, measured in the midluteal phase, should be greater than 2 U/mL if ovulation has occurred. The level of luteinizing hormone rises just before ovulation, and this surge can be measured in the urine with an over-the-counter home testing kit. Finally, the endometrium undergoes predictable histologic changes in response to progesterone secretion, and these can be identified in a sample of the endometrium obtained by office biopsy or aspiration.
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Abnormal genital tract bleeding in the reproductive-age woman results from a wide variety of underlying conditions, and the task of the clinician is to identify the specific cause accurately and cost-efficiently. There is a high prevalence of mood disorder among women who present with menstrual complaints, and this possibility should be evaluated if clinical findings are not consistent with a diagnosis.
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Differential Diagnosis

The overall differential diagnosis of abnormal bleeding is shown in the box. Pregnancy should always be considered in the presence of abnormal bleeding. Although the history and pelvic examination will be decisive in most cases, the only definitive way to screen for pregnancy is to do a test of human chorionic gonadotropin. The urine tests available are sufficiently sensitive and specific to serve as an adequate screening test and should be done whenever there is any question of pregnancy status.
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Once pregnancy is excluded, abnormal bleeding can be divided into two broad categories: ovulatory and anovulatory bleeding. Of women who present with abnormal bleeding, roughly one third have anovulatory bleeding, one third have heavy ovulatory menstrual periods, and one third have bleeding from other causes associated with ovulatory cycles (eg, intermenstrual bleeding). The terminology used to describe the various abnormal bleeding patterns is shown in the box. The term “dysfunctional uterine bleeding” should only be used to refer to anovulatory abnormal bleeding.
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In most cases the assessment of ovulation can be done by history. The normal range of values for characteristics of menstrual cycle bleeding is shown in Table 13. Ovulatory cycles are characterized by a predictable (±5 days) inter-menstrual interval and a consistent amount and duration of flow. The intermenstrual interval should be measured from the first day of regular bleeding (leaving out premenstrual spotting) to the first day of the next period. An important problem in the assessment of bleeding patterns is that the retrospective recall of the timing of bleeding is often inaccurate. The menstrual calendar, on which the woman is asked to record all bleeding episodes prospectively, is invaluable in assessing chronic menstrual cycle disturbances.
GERD

Abdominal Pain From Abdominal Scars

Adhesive small bowel obstruction occurs in 2-15% of children following a laparotomy. Seventy five percent of such patients present with adhesive obstruction between 2 weeks and 3 months after their operation. Eighty percent will occur within 2 years of operation. The disorder is treated with nasogastric decompression.

Postoperative intussusception occurs most commonly after major abdominal operations. Usually it is seen around age 26 months, but any age child may be affected. Postoperative intussusception presents with emesis, increased nasogastric drainage, abdominal distention, and irritability. Severe colicky pain and bloody stools are unusual. Ninety percent of the patients present within 2 weeks following surgery. Postoperative intussusception is managed with repeat laparotomy.
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Meckel Diverticulum

Meckel diverticulum are present in 2% of the population. It presents as a tender left lower quadrant mass, associated with blood in the stool. Occasionally, technetium nuclear scans are positive for Meckel’s in the symptomatic patient.

Vague abdominal pain with hemoccult positive stools suggests a Meckel Diverticulum. Bleeding is seen in 35-40% of childhood cases. RLQ pain, suggestive of appendicitis, is the usual complaint of children with bleeding.

Meckel diverticulum may cause intestinal obstruction or diverticulitis, which cannot be distinguished from appendicitis.

Pancreatitis
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Pancreatitis is a rare cause of abdominal pain in children. Trauma is the most frequent cause of this disorder in children.

Symptoms include mid-epigastric abdominal pain, nausea and vomiting, jaundice, and acholic stools.

Signs include epigastric tenderness, abdominal distention, decreased bowel sounds, and an epigastric mass may be detected.

An elevated serum amylase or serum lipase level is diagnostic.
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Abdominal x-ray may show an epigastric sentinel loop or pancreatic calcifications. US is very sensitive and shows an enlarged, hypoechoic pancreas. A pseudocyst or an enlarged pancreatic duct may also be seen.
Abdominal Pain

Gonadal Pain in Males

In males with lower abdominal pain, the scrotum and its contents must be examined. Testicular torsion is a surgical emergency and must be treated within 6 hours of the onset of the pain to save the testicle.
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Testicular torsion may present as lower abdominal pain, which may be associated with recent trauma or cold The gonad is tender and elevated in the scrotum, with a transverse orientation. Although testicular torsion may occur at any age, it usually occurs in adolescent males at puberty or shortly afterwards. It may occur in neonates. If the scrotum is empty, then torsion of a testicle located in the groin or in the abdomen should be ruled out. Torsion of undescended testicles occurs more frequent than in normally descended ones.

Torsion of an appendix testis may cause testicular pain, which occasionally be visualized as a “blue dot” beneath the scrotal surface on the testicle, associated with point tenderness. This disorder requires only analgesics and bedrest.
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Laboratory Studies.

Ultrasound can sometimes help to localize an intraabdominal torsion. Doppler US may distinguish torsion (testes without blood flow) from epididymitis (where blood flow is normal or increased).

Gonadal Pain in Females

The leading causes of gonadal pain in females are ovarian cysts and torsion of uterine adnexal structures. Ovarian tumors are often associated with precocious puberty or virilization.

Ovarian cysts are responsible for 25% of childhood ovarian tumors. They are most common in adolescents. Bleeding into the cyst or cystic rupture causes pain, which usually subsides within 12-24 hours.

An ultrasound, performed after a cyst ruptures, may show pelvic fluid and the cyst.
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Surgery is required if bleeding is uncontrolled. Growing cysts >5 cm should be considered for surgical enucleation.

Torsion of Uterine Adnexal Structures

Torsion is associated with unilateral, sudden, severe pain with nausea and vomiting. However, the patient may have subacute or chronic symptoms, with intermittent pain for days. The pain is usually diffuse and periumbilical in younger patients, but in older children and adolescents, the pain may radiate initially to the anterior thigh or ipsilateral groin. Torsion is more commonly right-sided.

Fever and leucocytosis are usually present. Physical exam may reveal muscle rigidity and fixation of the mass on pelvic examination.
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Ultrasound will identify the mass accurately.

Surgical exploration may sometimes salvage the ovary. Malignant neoplasms may cause torsion in 35% of cases.

Ectopic pregnancy must be considered in any postmenarchal, sexually active adolescent with abdominal pain. It is uncommon and usually seen in late adolescence. Ectopic pregnancy occurs in 0.5-3% of all pregnancies.

Signs of ectopic pregnancy include abdominal pain in any location, vaginal bleeding, and/or amenorrhea. Nausea and vomiting, other symptoms of pregnancy, and lightheadedness may also be present.
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Abdominal, adnexal, and/or cervical tenderness are often found on pelvic examination, but occasionally abdominal tenderness is absent. The cervix may be soft (Godell’s sign) and bluish in color (Chadwick’s sign). The examination may reveal adnexal fullness and uterine enlargement. Some patients present with blood loss and hypotension or unexplained anemia. Ten percent will be in shock.

Evaluation includes a pregnancy test and ultrasound.

Treatment consists of removal of the ectopic pregnancy by laparoscopy or exploratory laparotomy.

Cholecystitis in children occurs most commonly in the adolescent female, but it may affect infants who are only a few weeks of age. Cholecystitis is suggested by RUQ pain, back pain, or epigastric pain, radiating to the right subscapular area, bilious vomiting, fever, RUQ tenderness, and a RUQ mass. Jaundice is present in 25-55%, usually in association with hemolytic disease.

Hydrops of the gallbladder is characterized by massive gallbladder distention in the absence of stones, infection, or congenital malformations. It usually is preceded by another systemic disease (viral syndrome), and it is often associated with dehydration (bile thickening) or lymphadenopathy (partial obstruction). The usual treatment is a cholecystectomy.

Acalculous cholecystitis accounts for about 10-30% of gallbladder disease in children. It may occur with severe illnesses, such as burns, sepsis, or trauma.

Cholelithiasis may be a concomitant of hemolytic diseases in children. Fifty percent of children with spherocytosis develop gallstones. Sickle cell anemia and Thalassemia are the next most common causes. In adolescent females cholelithiasis can be found in the absence of hemolytic disease. Risk factors include obesity and pregnancy. Pregnancy is associated with 50% of all adolescent cholelithiasis.

Ultrasonography delineates gallstones and is the study of choice to screen for gallbladder disease.

Radioisotopic scanning evaluates biliary and gallbladder function. Nonvisualization of the gallbladder with no progression of isotope indicates acute cholecystitis.
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