Society for Pediatric Pain Medicine

Jared RE Hylton, MD, MS
Assistant Professor
American Family Children’s Hospital, Madison, Wisconsin

An 11 year-female is referred to your chronic pain clinic with complaints of a one month history of intermittent right lower quadrant (RLQ) pain.  The pain is located at a fixed position, does not radiate, and is described as sharp and stabbing with occasional burning quality.  Activity and upright positioning are aggravating factors.  Her pain is not associated with food and she denies diarrhea, blood in her stool, or changes in her bowel habits.  Her pain at its worst is rated as a 8/10 on the Visual Analogue Scale and 2/10 at its best.  She has experienced intermittent nausea associated with severe pain but no vomiting.  She denies fevers, chills, changes or abnormalities with urination, or vaginal bleeding. 

She has been followed by her pediatrician, gynecologist and gastroenterologist with extensive workup that has shown no evidence of abdominal or pelvic pathology including imaging, blood, urine, and fecal tests. She has tried acetaminophen, ibuprofen, amitriptyline and lidocaine patches, all without significant relief.

Upon examination, skin overlying the abdomen appears normal.  Upon palpation, she has significant tenderness of the right lower quadrant (RLQ) with rebound,  with localization of pain to one specific point in RLQ.  She also reports decreased cold sensation in RLQ. From a supine position, you ask the patient to lift her head and shoulders off of the bed and she reports triggering of abdominal pain with this motion.  In addition to enrolling this patient in the interdisciplinary pediatric chronic pain clinic, what else would be considered as a next appropriate step?