A nearly 8 year old female came to the ED with a 
chief complaint of stomach aches for one week.  These 
pains would come and go and were best characterized 
as crampy in nature with no particular location.  She 
also complained of back aches since her ballet 
stretching exercises yesterday.  There was no history of 
fever, nausea, vomiting, diarrhea, or respiratory 
symptoms.  Her bowel movements were regular and 
soft.  
     Exam:  VS T36.8, P98, R24, BP 114/88.  She was 
alert, cooperative, and somewhat anxious.  HEENT 
exam was unremarkable.  Neck supple without 
adenopathy.  Heart regular without murmurs.  Lungs 
clear.  Abdomen was soft, flat, and non-tender.  There 
was no rebound.  Bowel sounds were active.  No 
masses or hepatosplenomegaly were appreciated.  A 
rectal exam revealed no stool in the rectum and no 
masses.  She was observed to have more pain when 
standing or when sitting up.  There was no CVA 
tenderness.  Left flank pain and epigastric pain were 
elicited on straight leg raising.
     An abdominal series was obtained.

View radiographs.


     This radiograph was initially read as showing 
non-specific findings.  Other laboratory results:  CBC  
WBC 2.9, 32 segs, 64 lymphs, 4 monos, Hgb 12.4, Hct 
36.5, platelets adequate.  Amylase 123, SGOT 24.
     Her pain persisted, and review of her radiographs 
revealed subtle compression fractures of the vertebral 
bodies.  Follow-up radiographs were obtained.

View follow-up radiographs.


     This follow-up radiograph showed progressive 
demineralization and multiple compression fractures of 
the thoracic and lumbar vertebral bodies.  This is not 
obvious initially if your attention is directed at the 
abdominal soft tissue.  Upon close inspection, you can 
appreciate multiple vertebral compression fractures of 
her thoracic and lumbar vertebrae.  Note that the 
vertebral bodies appear to be flatter than normal.  It is 
remarkable that her clinical symptoms pointed to the 
abdomen rather than her spine.  Some hepatomegaly is 
also noted on one of the views.  These vertebral 
fractures were felt to be most consistent with acute 
leukemia.  Bone marrow studies confirmed the 
diagnosis of acute lymphocytic leukemia.
     A lateral view of her lumbar spine makes these 
fractures easier to appreciate.  The vertebral bodies are 
obviously flatter than they should be on this view.

View Lateral Lumbar Spine.


Teaching Points:
     Abdominal radiographs are generally non-diagnostic 
for the vast majority of cases.  However, when they 
reveal significant findings, they are often difficult to 
appreciate.  Abnormalities of the bony structures 
include vertebral fractures, pelvic fractures, rib 
fractures, congenital dislocated hips, other hip injuries, 
etc.  If one is not paying careful attention to the bony 
structures, these findings can be easily overlooked, 
although they may appear obvious once the 
abnormalities are identified.  Soft tissue findings include 
fecaliths, intussusception, pneumoperitoneum, subtle 
obstructions, volvulus, mass effects, etc.
     Abdominal  pain is a non-specific presentation for 
many serious diagnoses, but abdominal pain is most 
often the result of a benign cause.  It is often 
useful to observe the patient ambulating since this can 
provide significant clues to the patient's severity.  
Patients who cannot walk upright easily should be taken 
more seriously than those who can ambulate normally.  
Coughing and jumping are useful peritoneal signs for 
children since this tends to distract them away from the 
abdomen.  When the patient is walking, ask the child to 
jump and challenge them to jump higher if possible.  
Then ask them if jumping hurt their tummy.  Ask the 
child to cough and then ask them if the cough hurt their 
tummy.  Negative findings on jumping and coughing 
make the likelihood of peritoneal irritation extremely 
remote.
     In this case, if the examiners had observed the 
patient ambulating, they may have noted some difficulty 
since she did complain of pain with standing.  If the 
examiners asked her to jump, it is likely that she would 
have complained of pain in her back, though in this 
instance, such a maneuver may have worsened her 
compression fractures.  Hopefully, the patient would be 
able to appreciate this and refuse to jump.  It is difficult 
to conceive that this patient with so many vertebral 
compression fractures could tolerate ballet practice the 
previous day and that she presented with such 
non-specific findings.  Often children can be 
extraordinarily stoic despite being in substantial pain.  
This can be deceiving for the examiners.  A good 
practice is to palpate all parts of the abdomen and all 
parts of the back in patients with abdominal pain.