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Quiz

Emergency Medicine

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

JAMA

Published Online: November 28, 2022

JAMA Clinical Challenge

Article Information and Disclosures

Kazuki Iio, MD^1,2;

Yu Ishida, MD²

Author Affiliations

¹Division of Pediatric Emergency Medicine, Tokyo Metropolitan Children’s Medical Center, Fuchu, Tokyo, Japan
²Department of Pediatrics, Tokyo Medical University Hachioji Medical Center, Hachioji, Tokyo, Japan

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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

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.0000000000003224 PubMed Google Scholar Crossref

Scheltinga MR , Roumen RM . Anterior cutaneous nerve entrapment syndrome (ACNES). Hernia. 2018;22(3):507-516. doi:10.1007/s10029-017-1710-z PubMed Google Scholar Crossref

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-y PubMed Google Scholar Crossref

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/s13049-015-0096-0 PubMed Google Scholar Crossref

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.0b013e31822d78b8 PubMed Google Scholar Crossref

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/zrab124 PubMed Google Scholar Crossref

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-2021-0034 PubMed Google Scholar Crossref

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-2018-0011 PubMed Google Scholar Crossref

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/jocmr3354w PubMed Google Scholar Crossref

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.0b013e318285f930 PubMed Google Scholar Crossref

AMA CME Accreditation Information

Credit Designation Statement: The American Medical Association designates this Journal-based CME activity activity for a maximum of 1.00  AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Successful completion of this CME activity, which includes participation in the evaluation component, enables the participant to earn up to:

1.00 Medical Knowledge MOC points in the American Board of Internal Medicine's (ABIM) Maintenance of Certification (MOC) program;;
1.00 Self-Assessment points in the American Board of Otolaryngology – Head and Neck Surgery’s (ABOHNS) Continuing Certification program;
1.00 MOC points in the American Board of Pediatrics’ (ABP) Maintenance of Certification (MOC) program;
1.00 Lifelong Learning points in the American Board of Pathology’s (ABPath) Continuing Certification program; and
1.00 credit toward the CME [and Self-Assessment requirements] of the American Board of Surgery’s Continuous Certification program

It is the CME activity provider's responsibility to submit participant completion information to ACCME for the purpose of granting MOC credit.