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An 11-year-old girl presented to the emergency department with a week of generalised abdominal pain, anorexia and reduced stooling. The pain did not disturb sleep, and there was no associated weight loss, urinary symptoms or gastrointestinal bleeding. Examination suggested constipation, and an abdominal radiograph (AXR) was performed (figure 1).
1. What does figure 1 show?
Movicol was started, and the patient was discharged. Two further assessments for abdominal pain were sought in the next fortnight. No further investigations were ordered, and there was no change to management.
Three weeks from the original presentation, she developed leg pain and inability to weight-bear. No urinary symptoms were present. Lower limb examination revealed increased tone with extensor plantars bilaterally. A tender posterior right lower thoracic swelling was noted. A chest radiograph was carried out (figure 2).
2. What does figure 2 show?
3. What management step should be considered next?
Gastrointestinal contrast study
Answers to the questions can be found on page ▪▪▪.
Figure 1 shows absence of the right 10th rib, which should prompt assessment for an underlying infiltrative process. This finding was not appreciated on initial presentation or consultant radiology report. This highlights the importance of a systematic and comprehensive approach to radiograph interpretation to ensure that a significant radiological finding is identified and reported on, even if not obviously related to the presenting complaint.1
Large bowel stool is present, but no significant faecal impaction. While AXR requests for constipation should be discouraged, a role remains for general assessment of paediatric abdominal pain.
Figure 2 shows scoliosis centred at T10, drawing attention to pathological compression of T10, particularly on the right, with right pedicle loss and non-visualisation of the right 10th rib. These findings are strongly suggestive of an infiltrative process.
The recurrent presentations and finding of posterior deformity, which prompted this radiograph, emphasise the importance of documenting a spinal examination when assessing childhood abdominal pain and the necessity to revisit a diagnosis and review investigations when symptoms persist despite treatment.
Spinal imaging is required to assess the aetiology of vertebral collapse and to assess for spinal cord compromise. While MRI is the modality of choice for spinal assessment, a CT is required in this case for disease staging.
Urgent CT chest, abdomen and pelvis was performed (figure 3).
Pain is the most common and earliest symptom in 67% of cases with spinal tumours.2 Young children may not localise pain adequately and complain of abdominal rather than back pain.2 Gait or coordination abnormalities are reported in 42% of cases, and may present as stiffness, increased clumsiness or refusal to walk and regression to crawling in younger children.2 Spinal deformity and sphincter disturbance are present in 38% and 20%, respectively.2 The crucial step for recognising a neoplastic process is to consider it in the differential diagnosis.
Dexamethasone was started and urgent transfer arranged to the local oncology unit. After transfer, she underwent urgent spinal decompression, stabilisation and tumour debulking for spinal cord compression. Tumours commonly implicated in paediatric spinal cord compression include neuroblastoma, Ewing's sarcoma, osteosarcoma, rhabdomyosarcoma, non-Hodgkin's lymphoma and germ cell tumours.3 In this case, histology revealed a Ewing's sarcoma of the rib with extension into the spinal canal. Further treatment has included chemotherapy and radiotherapy, and 10 months later, ambulation for a short distance was possible.
Contributors Case was identified for case presentation at departmental teaching by SMV and LMF. X-ray was identified as suitable for publication by JMA at said teaching. Article was drafted by SMV with review and adaptation by LMF and JMA to result in final manuscript.
Competing interests None declared.
Patient consent Obtained.
Provenance and peer review Not commissioned; internally peer reviewed.
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