Pancreatitis. Cholecystitis.

SC
243. A 17-year-old adolescent female presents to the emergency room with the complaints of
increased jaundice, abdominal pain, nausea, vomiting, and fever. Her examination is remarkable
for jaundice, pain of the right upper quadrant with guarding, and a clear chest. Chest radiographs
appear normal. Which of the following tests is most likely to reveal the cause of this pain?
a. Serum chemistries
b. Complete blood count (CBC) with platelets and differential
c. Ultrasound of the right upper quadrant
d. Upper GI series
e. Hepatitis panel

SC
244. An 8-year-old boy is accidentally hit in the abdomen by a baseball bat. After several
minutes of discomfort, he seems to be fine. Over the ensuing 24 hours, however, he develops a
fever, abdominal pain radiating to the back, and persistent vomiting. On examination, the child
appears quite uncomfortable. The abdomen is tender, with decreased bowel sounds throughout,
but especially painful in the midepigastric region with guarding. Which of the following tests is
most likely to confirm the diagnosis?
a. Serum amylase levels
b. CBC with differential and platelets
c. Serum total and direct bilirubin levels
d. Abdominal radiograph
e. Electrolyte panel
CASES
Case 1: A 17-year-old-female presented with abdominal pain, nausea and vomiting. Physical
exam was significant for right-up-quadrant (RUQ) tenderness. She was admitted to the hospital
for pain management and further workup.

Preliminary diagnosis
Plan of investigations
Differential diagnosis
Clinical diagnosis
Treatment
Prescription of essential drugs

Case 2: A 14-year-old-female presented with 1-week history of RUQ pain, nausea and vomiting.
She noted that pain initially began following high-fat meal. On physical exam, she exhibited
epigastric tenderness and positive Murphy’s sign. Her abdominal pain persisted.

Preliminary diagnosis
Plan of investigations
Differential diagnosis
Clinical diagnosis
Treatment
Prescription of essential drugs

Case 3: A 16-year-old-female presented with 6-month history of epigastric pain with radiation to
the back. She reported some association with meals, but inconsistently. Pain and
symptomatology persisted.

Preliminary diagnosis
Plan of investigations
Differential diagnosis
Clinical diagnosis
Treatment
Prescription of essential drugs
Case 4: A 13-year-old-female presented with a 3-month history of abdominal pain and nausea.
She reported recent bought of pain associated with large Italian meal, but noted that she did
experience pain unrelated to oral intake. She was admitted to the hospital for pain management
and further workup.

Preliminary diagnosis
Plan of investigations
Differential diagnosis
Clinical diagnosis
Treatment
Prescription of essential drugs

Case Report
A 10-year-old girl was referred to our institution for evaluation of recurrent abdominal pain. She
has been suffering recurrent severe right upper quadrant pain and vomiting for three years which
resolved following conservative treatment. The parents reported that her appearance was normal
during the first seven year of her life. Subsequently, they had noted that she appeared thinner and
fatigue. There was no consanguinity and no family history of autoimmune disorders. Her
physical examination revealed no pallor or jaundice. Her heart rate was 98/min., blood pressure
100/60 mmHg and body temperature 36.70C. Abdominal examination revealed mild tenderness
but no hepatosplenomegaly. Her laboratory results were as following; haemoglobin: 11.9 gm/dL,
White Blood Cell: 6.8×109/L, Platelet: 172×109/L, serum triglycerides: 420 mg/dl, calcium 9.9
mg/dL, serum amylase: 1560 U/L and serum lipase: 3230 U/L. Serum alanine transaminase,
aspartate aminotransferase, alkaline phosphatase, gammaglutamyl transferase, albumin and
bilirubin were normal. Viral screens (Hepatitis A Virus, Hepatitis B Virus, Hepatitis C Virus,
Epstein-Barr virus, Cytomegalovirus and Herpes Simplex Virus) were negative.
Abdominal ultrasound showed an enlarged pancreatic head (20×15 mm). The parenchyma was
slightly heterogeneous. No stones in biliary or pancreatic ducts. Magnetic resonance
cholangiopancreatography (MRCP) showed diffusely enlarged pancreas with fat surrounding its
tail and the irregular main pancreatic duct. No pancreas divisum or stones.

Preliminary diagnosis
Plan of investigations
Differential diagnosis
Clinical diagnosis
Treatment
Prescription of essential drugs