Tuesday, June 4, 2013

Acute Abdomen - Intriguing

At around 7 am today, there was a 11 year old girl who was brought into emergency at NJH.

She has been having severe abdominal pain since the last 3 days. She was writhing in pain. Very typical of how patients with ureteric colic do.

NK had been having similar complaints since the last 5 years. It occurs once every 4-5 months. Elsewhere, she had been diagnosed to have chronic pancreatitis. During one of such episodes someone had also done an appendicectomy on her. She also had a CT Scan of the abdomen taken elsewhere which appears normal. 

We have her given her non-steroidal analgesics and anti-spasmodics which seemed not to have any impact on her.

The investigations are as follows –

Hemoglobin: 7.6 gm%

Total Counts: 14,900/cu mm

Differential Counts: P83%, E3% L17% Metamyelocytes 2%

ESR: 90 mm/1st hour

Platelets: 178,000/cu mm

Peripheral Smear:
RBCs: Moderate anemia, Hypochromia +++; Anisocytosis +++; Microcytosis: +++; Poikilocytosis ++; Few ovalocytes; Tear drop cells seen
WBCs: Total count – mild leucocytosis; neutrophilia, toxic granulations+
Platelet: Adequate

Serum Creatinine: 0.76 mg%

SGPT: 33.5 IU/ml

Urine Albumin: 1+

Urine Microscopy: Epithelial cells: 4-5; Pus cells: 1+; RBCs: 1+; Bacteria seen.

Ultrasound Abdomen: Pancreas with heterogenous echoes and peripancreatic collection. All other organs were within normal limits. There was no evidence of any gall bladder or renal calculi.

As per our instructions, the parents arranged for one pint of blood.

I look forward to further suggestions. We’ve already suggested that they move ahead to a paediatric specialist hospital in Ranchi. However, considering into fact that they have already been evaluated at multiple speciality hospitals primarily in Patna and Banaras, they are not much interested. They have invested quite a heavy amount of money in her treatment, going to the extent of selling their property and land.

It seemed to me that they do not have any more funds to go further.

I write this in Acute Care. She’s sleeping very peacefully. Over the day, we’ve found out that she responds very well to opioid analgesics rather than to Non-steroidal analgesics.

And of course, we would value prayers. 


  1. it looks like a straight forward case of recurrent acute pancreatitis.. because of typical history, heterogenous echotexture of pancreas and peripancreatic collection..

    there may be a component of chronic pancreatitis also,despite previous ct being normal, because ct is not the ideal modality for CP..

    get serum amylase,lipase levels and CECT abdomen to strengthen the diagnosis

    at present, its only conservative management..give as much feed as tolerated and supplement with iv fluids,analgesics

    for anemia, u can deworm her with albendazole and start hematinics

    for etiology of pancreatitis at this age, work up for hyperparathyroidism(Ca,PTHlevels), pancreas divisum (MRCP),gallstones...

  2. She might suffer from talasemia. It is a rare form of hematologic hereditary disease. It can cause abdominal abnormalities as well.