What is the appropriate workup for a 14-year-old male presenting with acute onset of upper abdominal pain, exacerbated by sudden movements, without symptoms of acid reflux or respiratory distress?

Evaluation of Acute Upper Abdominal Pain in a 14-Year-Old Male

A 14-year-old male with acute onset upper abdominal pain requires prompt evaluation with abdominal ultrasound as the first-line imaging modality, followed by appropriate laboratory studies including complete blood count, comprehensive metabolic panel, and urinalysis.

Initial Assessment

When evaluating a 14-year-old male with acute upper abdominal pain that worsens with movement, several key elements from the history are important:

• Pain characteristics: Upper abdominal location, described as an "ache" rather than acid reflux
• Timing: Acute onset during lunch
• Aggravating factors: Sudden movements worsen pain
• Associated symptoms: No trouble breathing, no food intake today
• Absence of reflux symptoms: Distinguishes from GERD

Physical Examination Focus Points

• Vital signs: Check for fever, tachycardia, hypotension
• Abdominal examination: Assess for:
  • Localized tenderness
  • Guarding or rigidity
  • Rebound tenderness
  • Peritoneal signs

Diagnostic Workup

Laboratory Studies

1. Complete blood count (CBC) - to assess for leukocytosis suggesting inflammation or infection 1
2. Comprehensive metabolic panel - to evaluate liver function, pancreatic enzymes, and electrolytes 1
3. Urinalysis - to rule out urinary tract causes 1
4. Lipase - to evaluate for pancreatitis 1

Imaging Studies

1. Abdominal ultrasound - First-line imaging for pediatric patients 1

   • Advantages: No radiation exposure, excellent for gallbladder pathology, appendicitis
   • High sensitivity (96.7%) for detecting abscesses 1

2. If ultrasound is inconclusive:

   • Consider CT with IV contrast for suspected appendicitis or other acute abdominal pathology 2
   • For adolescents, CT provides higher diagnostic certainty, increasing from 70.5% pre-CT to 92.2% post-CT 1

Differential Diagnosis

Several conditions should be considered in a 14-year-old with acute upper abdominal pain:

1. Appendicitis (despite typical RLQ pain, can present atypically)
2. Gallbladder disease (uncommon but possible in adolescents)
3. Gastritis/peptic ulcer disease
4. Pancreatitis
5. Mesenteric adenitis
6. Constipation with referred pain
7. Pneumonia with referred abdominal pain

Management Algorithm

1. If peritoneal signs present (rigid abdomen, severe tenderness, rebound):

   • Immediate surgical consultation 1
   • IV fluid resuscitation 2
   • Broad-spectrum antibiotics if infection suspected 2, 1

2. If no peritoneal signs but significant pain:

   • Complete laboratory workup as outlined above
   • Ultrasound as first-line imaging 1
   • Pain management with appropriate analgesics
   • NPO (nothing by mouth) until diagnosis established

3. If ultrasound inconclusive and symptoms persist:

   • Consider CT with IV contrast 2
   • Surgical consultation if symptoms worsen

Important Considerations

• Adolescents may present with atypical symptoms for common conditions
• Pain exacerbated by movement suggests peritoneal irritation
• The absence of fever does not rule out serious pathology
• Diagnostic imaging has been shown to change management in 42% of patients with acute abdominal pain 1

Common Pitfalls to Avoid

1. Dismissing pain as functional without adequate workup
2. Administering antibiotics without evidence of infection 1
3. Delaying imaging in patients with significant pain
4. Failing to consider extra-abdominal causes of pain 1
5. Relying solely on laboratory tests without appropriate imaging 1

Remember that patients often perceive their symptoms as more urgent than physicians do 3, 4, but this should not lead to dismissal of symptoms, particularly in pediatric patients where communication may be limited and presentation atypical.