Intended for healthcare professionals

Endgames Case Review

A teenage girl with lower abdominal pain

BMJ 2017; 359 doi: (Published 23 November 2017) Cite this as: BMJ 2017;359:j5122
  1. Chiara Zanchi, paediatrician1,
  2. Giorgio Cozzi, paediatrician1,
  3. Caterina Businelli, gynaecologist2,
  4. Egidio Barbi, paediatrician1 3
  1. 1Emergency Department, Institute for Maternal and Child Health, IRCCS Burlo Garofolo, Trieste, Italy
  2. 2Department of Obstetrics and Gynecology, Institute for Maternal and Child Health, IRCCS Burlo Garofolo, Trieste, Italy
  3. 3University of Trieste, Trieste, Italy
  1. Correspondence to G Cozzi giorgiocozzi{at}

A 14 year old girl arrived with her mother at the emergency department complaining of a 6 day history of lower abdominal pain, associated with dysuria and mild fever. She reported no other symptoms. On examination, the girl was tender across the lower abdomen, particularly in the right lower quadrant, where mild guarding and rebound tenderness were present. She was given intravenous paracetamol.

During a brief private talk, she said she was sexually active with her boyfriend and was not using any form of contraception. Laboratory tests showed increased white blood count (13.6×109/L, neutrophils 8.7×109/L), C reactive protein of 5.4 mg/dL, and erythrocyte sedimentation rate of 47 mm/h. Beta-human chorionic gonadotropin levels were negative. Urine analysis showed mild leucocyturia.

An abdominal ultrasound showed normal appendix and ovaries, with a small amount of free pelvic fluid. Gynaecological physical examination showed cervical and uterine motion tenderness and vaginal discharge. A transvaginal ultrasound with colour Doppler analysis showed thickened, fluid filled fallopian tubes with hypervascularity (fig 1).

Fig 1(a)

Ultrasound image shows tubes with thick walls and intraluminal fluid

Fig 1(b)

Colour Doppler shows increased vascularity of the tube


  • 1. What is the most likely diagnosis?

  • 2. How should this patient be managed?

  • 3. What specific issues relate to managing this condition in adolescence?


1. What is the most likely diagnosis?

Short answer

A clinical presumptive diagnosis of pelvic inflammatory disease was made according to the diagnostic criteria stated by the 2015 Centers for Disease Control and Prevention guidelines for pelvic inflammatory disease.12345


Pelvic inflammatory disease should be suspected in any sexually active adolescent girl presenting with a persistent …

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