Abdominal Pain in a Female High School Cross-Country Runner

Abstract

HISTORY: A seventeen year-old female high school cross country runner with three weeks of intermittent right upper quadrant abdominal pain. At first, the pain was only associated with running in either practice or meets. It then developed into intermittent, occasional sharp pain even at rest or at night followed by a dull ache that would last anywhere from five to thirty minutes. There were no other associated symptoms. There had been no recent weight loss; menstrual periods were regular. She is not sexually active, and is on no medications. No change in appetite. Running times were not affected. She did report that she had been more fatigued than normal over the same time period as the abdominal pain. She went to her local pediatrician who diagnosed her with “round ligament of the liver pain,” and prescribed NSAIDs. Pain persisted despite regular NSAID use. She had an exchange transfusion as a newborn for benign infantile hyperbilirubinemia. PHYSICAL EXAMINATION: General: Alert, pleasant, cooperative female; in no apparent distress. HEENT: All within normal limits. CV: Heart- regular rate and rhythm, no clicks, rubs, gallops, murmurs. RESP: Normal inspiration/exhalation. Lungs clear to auscultation bilaterally. ABD: Soft, non-distended. No masses, no organomegaly. Generally non-tender to palpation. Pain with vigorous palpation in right upper quadrant, Murphy's sign positive. Skin: No rashes, no jaundice. Musculoskeletal: No rib cage pain with palpation. DIFFERENTIAL DIAGNOSIS: Runner's Stitch/Exercise-related Transient Abdominal Pain Hepatitis C/Viral Hepatitis Gallstone(s) GERD Peptic Ulcer TEST and RESULTS: Complete Blood Count: Within normal limits Iron studies: Within normal limits AST/ALT/Alk.Phos. Within normal limits Electrolyte Panel: Within normal limits EBV titer: Within normal limits Hepatitis A, B, C studies: Within normal limits FINAL WORKING DIAGNOSIS: Peptic Ulcer TREATMENT AND OUTCOMES: Patient was placed on a proton pump inhibitor with complete resolution of her symptoms, both during activity and at rest. She continued to run, having a very successful cross-country season. H. Pylori tests pending at time of submission. Spoke to parents and athlete – athlete admits to being “stressed.” Scheduled down time added to her daily schedule. Athlete believed, upon reflection, that stress exacerbated the pain.