Unusual Cause of Right Inguinal Fossa Pain; Photo Quiz

Clinical Scenario This 11-year old girl presented in the emergency department with a history of intermittent abdominal pain for the last 30 hours. She had one episode of vomiting in the emergency department upon arrival. She did not complain of diarrhea or urinary tract symptoms. She had not yet started having period. She was afebrile (37°C), had normal blood pressure (110/75mmHg), a mild tachycardia (130bpm), normal respiratory rate (20bpm) and oxygen saturation (99%). On clinical examination her abdomen was soft with a mild generalized tenderness, a more pronounced intense pain in the right iliac fossa and a positive McBurney sign. We also felt a mass in the area that we thought of as an appendiceal mass. The rest of the physical exam was unremarkable. Labaratory findings included normal hemoglobin (14g/dl) and MCV (95), elevated white blood cells (16,22×103 μL, with neutrophils 85.9% and C-reactive protein (85). Clotting was within normal limits (PT 11sec, INR 0.9, aPTT 31sec). Urine dipstick was also clear of infection. The upright abdominal X-ray showed an air-fluid level on the left side of the abdomen. Ultrasound was non diagnostic. The appendix was not visualized and no mass was identified but there was a large quantity of free fluid between enteral loops in the right iliac fossa. The patient was transferred to theatre and the intraoperative findings are shown in Fig. 2. After the operation a more thorough history taking and clinical examination was made. At first her weight was found to be 34kg (<50th centile) and her height 1,42 (<50th centile). She admitted having two previous episodes of abdominal pain of lesser intensity last year that were attributed by her GP to constipation. There was a significant weight loss (2kg past two months) that was attributed to “anxiety” in school.