Paediatrics

at a Glance

Lawrence Miall, Mary Rudolf, Dominic Smith

Case Studies

Case 9: Abdominal pain

A 4-year-old girl called Emily is taken by her parents to the family doctor. She has been non-specifically unwell since she had a viral illness a few weeks before. Her mother is worried because she has been complaining of tummy ache. She has been wetting the bed again, having been dry at night since the age of 20 months.

  • (a) What investigation would you do in the first instance to investigate her abdominal pain and bedwetting?

    Show Answer

    A urine sample should be obtained and sent for microscopy and culture.

  • Emily’s mother collects a clean-catch urine sample and takes it to the doctor’s surgery. The doctor performs a dipstick test and then sends the urine to the lab. The results are as follows:

    Dipstick:
    Specific gravity 1010;
    Leucocytes +++;
    Protein ++;
    Nitrites –ve;
    Glucose ++++
    Laboratory results:
    White cells 10–20;
    Red cells: none; Gram stain –ve;
    Culture: mixed growth

    • (b) How do you interpret the dipstick result?

      Show Answer

      The presence of leucocytes and protein are non-specific. The absence of nitrites makes a urinary tract infection unlikely. There is glycosuria.

    • (c) How do you interpret the laboratory result?

      Show Answer

      The microscopy is inconclusive. To diagnose a urinary tract infection there should be >50 white cells and a pure growth of bacteria. The negative Gram stain and mixed growth may reflect contamination.

  • When the doctor rings the family to discuss the result, he finds that Emily has become more unwell, with severe abdominal pain and has been vomiting all night. He decides to visit at home.

    When he arrives at the home Emily is dehydrated and semi-conscious. He calls an ambulance. As a precaution he checks her blood glucose and finds that it is 28 mmol/L. He telephones ahead to the hospital to warn them.

    • (d) What is the diagnosis? What treatment will she require when she reaches hospital?

      Show Answer

      Diabetic ketoacidosis (DKA). She has developed type 1 diabetes and her polydipsia and polyuria led to the secondary enuresis. DKA is sometimes mistaken for non-specific abdominal pain or even an acute surgical abdomen.

      She will be significantly dehydrated due to the vomiting and the osmotic diuretic effect of persistent glycosuria. She is likely to be acidotic. The treatment priority for the hospital Emergency Department is to rehydrate her. A nasogastric tube should be passed to empty the stomach to reduce the risk of aspiration secondary to gastric paresis. Once stabilized, she will need to commence insulin to reduce her blood glucose concentration.

    See Chapters 18 and 28 for further details

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