"Here we go again," Ron Smith said with a sigh. "This is the third time we've been to the emergency room in five weeks."
He nodded toward his 15-year-old daughter. "Lorna's got a stomachache. She's throwing up. The last time she came here, it was a problem with her appendix."
Lorna lay on the stretcher, looking away from her father. She slid me a blasé look.
"The pain you're having now," I asked, "when did it start?"
"Two days ago. I thought it was from something I ate at a diner."
"Did your friends get sick?"
She shook her head. "No."
"How is the pain this time compared to the other times you were here?"
"Not as bad," she said.
The nurse's chart said Lorna's vital signs were normal and she had no fever. I placed my hands on her abdomen and began to press.
"Tell me where it's sore."
No response. Her belly felt soft against my fingertips, not hard as it does when a patient guards against pain or when an infection irritates abdominal muscles.
A complete exam yielded only two subtle abnormalities. When I listened with my stethoscope, the clicks and gurgles of her bowel sounds were less frequent than normal. Tapping the right lower side of her belly with my fingertips produced a dull sound. The sign meant something solid beneath the tissue, anything from feces to a mass.
And I noticed something else. Lorna and her father did not speak or even look at each other, and I wondered if this could offer us a clue.
In the ER, woman plus abdominal pain equals pregnancy outside the uterus until proven otherwise. Known as an ectopic pregnancy, it occurs when a fetus implants in the wrong place, often causing massive internal bleeding. An emergency physician's biggest responsibility is to rule out just such urgent, dangerous conditions.
I looked at Lorna, who seemed young, innocent, and irked. Awkwardness nearly prevented me from asking my next questions. "Is there any chance you could be pregnant?"
"No," she said.
Abdominal pain is one of medicine's most formidable diagnostic challenges. Most abdominal disorders lack specific symptoms and signs, and even advanced imaging techniques cannot always portray a condition as common as appendicitis. Answers often do not come until a patient undergoes surgery.
I called up Lorna's medical records on the hospital computer. Just as her father said, Lorna had visited the hospital twice over the past month for abdominal pain due to a suspected ruptured appendix. The report also indicated that although the suspected rupture had created a pocket of infection, the illness appeared to be subsiding. So the surgeons made the rare choice not to operate; instead, they gave Lorna a strong mixture of antibiotics. They planned to remove the diseased appendix several weeks later.
But Lorna's father had failed to mention that fluid collected from a pelvic exam during Lorna's first hospitalization had tested positive for the parasite chlamydia. That meant she was probably sexually active, because the parasite is almost always transmitted via sexual intercourse.
Doctors had treated Lorna with the antibiotic azithromycin to kill the chlamydia, but gynecologists suspected that the infection, rather than a ruptured appendix, might have caused Lorna's abdominal pain and hospital admissions.
The attending physician and I returned to perform a pelvic examination. Lorna had no masses and no pain when I manipulated her uterus and felt for her ovaries. I asked if she wanted to tell us anything without her father present.
"No."
Outside the room, the attending physician asked me what I thought. Lorna no longer had abdominal pain, she did not have a fever, and she was already on antibiotics. The possibility of a recurrent bacterial infection was unlikely. Given her sexual activity, we needed to rule out an ectopic pregnancy— unlikely too. I began to think Lorna might have been right about the bad meal.Had the lab tests come out negative and Lorna kept down some food, we might very well have sent her home. But the attending suggested I notify the surgeons who took care of Lorna last time.
"I can't get down to see her for another half hour, " said the surgical resident. "Can you get started on X rays?"
I ordered them and went to lunch. When I returned, I found the surgeon preparing to admit Lorna. He asked for a CT scan, a radiological study that provides slicelike internal images of the body by gathering X-ray transmission data from many different directions.
The X rays showed a blockage in Lorna's small bowel. The surgeon planned to run a tube from Lorna's nose into her stomach to decompress the built-up fluid and gas. Her bowel function, he said, should return to normal in a few days, and she could go home.
The next morning, I learned that Lorna had not gone up to the patient floor. The results of the CT scan had sent her right into the operating room.Despite the lack of a palpable mass on her slender frame, the CT revealed a huge abscess in the right side of her pelvis. Her immune system had corralled microbes into a circumscribed area, so she failed to show signs of infection such as fever, faster heart rate, and intense pain. But the infected fluid had pressed on her bowels, causing tissues to stick together and obstruct fecal movement.
An abscess usually develops next to a diseased organ. When the surgeons drained the fluid and freed the adhering tissues, they found Lorna's abscess had originated not from her appendix but from the fallopian tube near her right ovary. The antibiotic had failed to cure Lorna's infection because it was so advanced. The cause of Lorna's medical troubles was now clear: chlamydia.
Chlamydia is the most commonly reported sexually transmitted disease in the United States, with an estimated 4 million new cases each year. Certain subtypes of the parasite Chlamydia trachomatis infect the epithelial cells lining the reproductive tract. The organisms grow inside the cells, killing them, and the body's immune response leads to inflammation and further local damage.
Chlamydia causes such mild initial symptoms that doctors detect most infections late or incidentally on routine testing. Delays in diagnosis and treatment increase the chance that the pathogen will spread up the reproductive organs to infect the cells that line the tubes and ovaries, causing pelvic inflammatory disease. About 20 percent of such patients end up with chronic pelvic pain. A similar number develop scarring in the fallopian tubes, which prevents conception. Lorna faced some tough possibilities.
I stopped in to see Lorna later that day. She talked a little, but clammed up when her parents appeared. When I left the room, the Smiths followed me.
"What caused this?" asked Mrs. Smith.
Despite Lorna's three hospital admissions, her parents had barely an inkling of their daughter's sexually transmitted infection. Doctors had respected Lorna's legal right to keep medical information about her sexual activity private. I urged her mother to speak with Lorna.
"I try, but I can't. When it was time to give her the menstruation talk a few years ago, she said 'I know it all' and ran out of the room. I was so relieved!"
Parents and physicians often fail to talk with teens about sexual activity and sexual disease transmission. Condoms reduce the risk of infection. Douching after sex increases it. And vaccinations against hepatitis B, which is sexually transmitted, are available.
"It's so hard to know what they're doing," Lorna's father said. "You can't keep them locked up, and we have to work." He looked down the hall. "Anyhow, I hope this will take care of it."
