Authors: Meena Thayu, MD; Michael Nance, MD; Petar Mamula, MDSeries Editors: David A. Piccoli, MD; Petar Mamula, MD


October 19, 2006

Case Presentation

A 14-year-old Vietnamese-American girl presented with a 4-day history of abdominal pain; nonbloody, nonbilious emesis; and decreased urinary output. The pain was epigastric and sharp, without radiation, and not related to the consumption of food. She also reported a history of low-grade fevers, rhinorrhea, and a nonproductive cough of 3 days' duration. She denied weight loss, change in diet, dysuria, rash, diarrhea, or recent travel.

Her past medical history was significant for a 4- to 5-year history of intermittent abdominal pain. She was evaluated in the emergency department 1 year prior to admission for these symptoms, diagnosed with presumptive gastroesophageal reflux disease, and prescribed ranitidine, which was discontinued after 1 month. She had no previous hospitalizations or surgeries, and was on no medications. The patient's father had a history of peptic ulcer disease, and her maternal grandmother had type 2 diabetes mellitus. The family moved to the United States from Vietnam in 1991.

On physical exam, the patient's weight was 60 kg (75%-90% percentile) and height 150 cm (5% percentile). The vital signs were normal. The patient was alert, awake, and in no acute distress. Sclerae were nonicteric. Pulmonary and cardiovascular exams were normal. The abdomen was soft and nondistended. There was mild tenderness to palpation in the epigastrium, with no hepatosplenomegaly, masses, or ascites. The extremities were warm and well perfused, and the skin showed no evidence of rash. The neurologic exam was normal.

Initial laboratory evaluation showed a normal complete blood count with differential, and normal basic metabolic panel, erythrocyte sedimentation rate, C-reactive protein level, total bilirubin, serum albumin, prothrombin time, and partial thromboplastin time. Her alanine aminotransferase level was 148 U/L (range, 5-30); aspartate aminotransferase level, 176 U/L (range, 10-30); gamma-glutamyl transferase (GGT) level, 298 U/L (range, 12-22); and alkaline phosphatase level was 77 U/L (range, 70-230).

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