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Abdominal Pain in a 15-Year-Old Adolescent Girl

Educational Objective
Based on this clinical scenario and the accompanying image, understand how to arrive at a correct diagnosis.
1 Credit CME

A 15-year-old adolescent girl who was taking an oral contraceptive presented to the emergency department with left lower quadrant abdominal pain that had developed gradually over a 3-day period. She had no associated nausea, vomiting, diarrhea, hematochezia, bloating, or anorexia. She reported no precipitating factors for the pain and had no history of pregnancy, abdominal surgery, or abdominal trauma. Over the previous 2 years, the patient had experienced similar intermittent episodes of abdominal pain lasting approximately 1 week. Results from laboratory tests, upper endoscopy, colonoscopy, and an abdominal computed tomography scan performed 1 year prior to presentation were normal.

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Anterior cutaneous nerve entrapment syndrome (ACNES)

C. Inject a local anesthetic into the area of maximal tenderness

The key to the correct diagnosis was recognition that the 1-cm point of maximal tenderness was localized to the outer rim of the rectus abdominis muscle.1 Gabapentin (choice A) is not recommended because the diagnosis of postherpetic neuralgia is unlikely without a rash or dermatomal distribution of abdominal pain. Choice B is incorrect because the abdominal pain caused by celiac artery compression syndrome is typically epigastric and often increases after eating. Measuring urine porphobilinogen level (choice D) is unnecessary because acute intermittent porphyria typically causes diffuse abdominal pain.

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Article Information

Corresponding Author: Kazuki Iio, MD, Division of Pediatric Emergency Medicine, Tokyo Metropolitan Children’s Medical Center, 2-8-29 Musashidai, Fuchu, Tokyo 183-8561, Japan (kazukiiio1026@gmail.com).

Published Online: November 28, 2022. doi:10.1001/jama.2022.20402

Conflict of Interest Disclosures: None reported.

Additional Contributions: We thank James R. Valera, MA (Tokyo Metropolitan Government), for his assistance with editing this manuscript. Mr Valera was compensated for his contributions. We also thank the patient’s mother for providing permission to share the patient’s information.

References
1.
Mol  FMU , Maatman  RC , De Joode  LEGH , Van Eerten  P , Scheltinga  MR , Roumen  R .  Characteristics of 1116 consecutive patients diagnosed with anterior cutaneous nerve entrapment syndrome (ACNES).   Ann Surg. 2021;273(2):373-378. doi:10.1097/SLA.0000000000003224PubMedGoogle ScholarCrossref
2.
Scheltinga  MR , Roumen  RM .  Anterior cutaneous nerve entrapment syndrome (ACNES).   Hernia. 2018;22(3):507-516. doi:10.1007/s10029-017-1710-zPubMedGoogle ScholarCrossref
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Siawash  M , Roumen  R , Ten  WTA , van Heurn  E , Scheltinga  M .  Diagnostic characteristics of anterior cutaneous nerve entrapment syndrome in childhood.   Eur J Pediatr. 2018;177(6):835-839. doi:10.1007/s00431-018-3125-yPubMedGoogle ScholarCrossref
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van Assen  T , Brouns  JA , Scheltinga  MR , Roumen  RM .  Incidence of abdominal pain due to the anterior cutaneous nerve entrapment syndrome in an emergency department.   Scand J Trauma Resusc Emerg Med. 2015;23:19. doi:10.1186/s13049-015-0096-0PubMedGoogle ScholarCrossref
5.
Boelens  OB , Scheltinga  MR , Houterman  S , Roumen  RM .  Management of anterior cutaneous nerve entrapment syndrome in a cohort of 139 patients.   Ann Surg. 2011;254:1054-1058. doi:10.1097/SLA.0b013e31822d78b8PubMedGoogle ScholarCrossref
6.
Jacobs  MLYE , van den Dungen-Roelofsen  R , Heemskerk  J , Scheltinga  MRM , Roumen  RMH .  Ultrasound-guided abdominal wall infiltration versus freehand technique in anterior cutaneous nerve entrapment syndrome (ACNES): randomized clinical trial.   BJS Open. 2021;5(6):zrab124. doi:10.1093/bjsopen/zrab124PubMedGoogle ScholarCrossref
7.
Jacobs  MLYE , Scheltinga  MRM , Roumen  RMH .  Persistent pain relief following a single injection of a local anesthetic for neuropathic abdominal wall and groin pain.   Scand J Pain. 2021;21(3):628-632. doi:10.1515/sjpain-2021-0034PubMedGoogle ScholarCrossref
8.
Mol  FMU , Jansen  CH , Boelens  OB ,  et al.  Adding steroids to lidocaine in a therapeutic injection regimen for patients with abdominal pain due to anterior cutaneous nerve entrapment syndrome (ACNES): a single blinded randomized clinical trial.   Scand J Pain. 2018;18(3):505-512. doi:10.1515/sjpain-2018-0011PubMedGoogle ScholarCrossref
9.
Maatman  RC , Steegers  MAH , Kallewaard  JW , Scheltinga  MRM , Roumen  RMH .  Pulsed radiofrequency as a minimally invasive treatment option in anterior cutaneous nerve entrapment syndrome: a retrospective analysis of 26 patients.   J Clin Med Res. 2018;10(6):508-515. doi:10.14740/jocmr3354wPubMedGoogle ScholarCrossref
10.
Boelens  OB , van Assen  T , Houterman  S , Scheltinga  MR , Roumen  RM .  A double-blind, randomized, controlled trial on surgery for chronic abdominal pain due to anterior cutaneous nerve entrapment syndrome.   Ann Surg. 2013;257(5):845-849. doi:10.1097/SLA.0b013e318285f930PubMedGoogle ScholarCrossref
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