ABDOMINAL PAIN IN POSTPUBERTAL GIRLS

CYNTHIA J. MOLLEN, MD, MSCE, MARY SCHUCKER, RN, BSN, MSN, CRNP, AND NAOMI LOVE, RN, BSN, CPEN

BACKGROUND (EPIDEMIOLOGY, EVIDENCE)

Abdominal pain is a frequent chief complaint in the pediatric emergency department (ED). National data noted 8,137,774 visits to the ED for abdominal pain between 2006 and 2009; 70% of these visits were by females, and over 70% of visits were by adolescent patients. The differential diagnosis for these patients is broad; even once narrowed by age and gender, the provider must consider a long list of potential diagnoses, including gynecologic causes such as pelvic inflammatory disease (PID), ovarian cyst rupture, or ovarian torsion; pain from pregnancy or complications of pregnancy, such as ectopic; and others, such as appendicitis, pyelonephritis, nephrolithiasis, constipation, or trauma.

Of note, an estimated one in eight sexually active adolescent girls develop PID before reaching 20 years of age, and patients with PID are at risk of serious acute and chronic complications such as tubo-ovarian abscesses, infertility, and chronic pelvic pain. The diagnosis of PID can be difficult to make, however, as the clinical presentation may mimic other pelvic and abdominal processes. In order to assist clinicians with these complex diagnostic decisions, the Centers for Disease Control and Prevention has developed standardized guidelines for the diagnosis and treatment of PID; although comprehensive, these guidelines are lengthy and can be difficult to navigate.

Despite evidence-based national guidelines, the prevalence and the risk of complications from PID, multiple studies have demonstrated that the ED treatment of patients with PID is less than ideal. For example, an analysis of data from the National Hospital Ambulatory Medical Care Survey (NHAMCS) from 1992 to 1997 identified 351 records for adolescents diagnosed with a sexually transmitted infection, representing 1.2 million adolescent visits. Of patients diagnosed with PID, only 35% were treated in accordance with the CDC guidelines. Similarly, a telephone survey–based study of 51 ED pediatricians found that management of adolescent girls with PID was often less aggressive than that recommended by the CDC; particularly regarding admission criteria and ensuring adequate follow-up.

With respect to pregnancy testing, although almost 800,000 adolescents give birth each year, a recent study of national data found that only 20% of adolescent females underwent pregnancy testing during their ED visit; of patients with complaints potentially related to pregnancy, the number rose to only 44.5%. Even if a positive pregnancy test is unrelated to the presenting symptoms, identifying pregnancy early allows for initiation of pregnancy precautions and prenatal care if childbirth is desired, earlier detection of life-threatening complications such as ectopic pregnancy, opportunity for consideration of options such as therapeutic abortion or adoption, and increased time for counseling, regardless of the patient’s ultimate choice.

Given the potential for significant sequelae from some diagnoses if not rapidly identified, the chief complaint of lower abdominal pain in the postpubertal female provides an excellent opportunity for pathway development. The identification and management of these diagnoses requires a streamlined, multidisciplinary approach, with the entire care team aware of issues around testing, confidentiality, and appropriate treatment.