Medical Mystery: What would a trampoline have to do with a teenager’s abdominal pain?

A 16-year-old girl was brought to the emergency department (ED) with severe abdominal pain, nausea, and vomiting. The pain started suddenly while she was jumping on the family’s backyard trampoline. Her boyfriend ran into the house to get her mother and they rushed her to the hospital.

The patient arrived sweating and moaning, and looked as if she were about to pass out. The triage nurse immediately took her to a treatment room. Alone with the patient, the nurse found out that the patient’s menstrual period was two weeks late, she was sexually active with her boyfriend, and they were not using condoms.

When the emergency doctor pressed on the right side of her lower abdomen, the teen winced and pushed the doctor’s hand away. The staff quickly inserted an intravenous line to give the patient fluids and pain medication.

On physical examination, the patient had an “acute abdomen,” an intra-abdominal condition of abrupt onset that often requires surgery. Because the patient’s menstrual period was late and the couple were not using condoms, it was important to rule out an ectopic pregnancy.

Ectopic pregnancies occur when the fertilized egg implants in the fallopian tube (the tube that transports the egg from the ovary to the uterus) rather than in the uterus and can cause the fallopian tube to burst. Presenting symptoms often include vaginal bleeding or abdominal/pelvic pain. Ectopic pregnancies are life-threatening emergencies and usually require surgery. A urine pregnancy test was negative, so it wasn’t an ectopic pregnancy.

When patients have abrupt, severe pain in the lower right part of their abdomen, we immediately worry about appendicitis. That’s right where the appendix attaches to the large intestine. This small organ can become clogged and infected, burst, and lead to a life-threatening infection. The patient had an MRI of the abdomen, which showed a normal appendix, so it wasn’t appendicitis, either.

Because the patient was having unprotected sex we were also concerned about pelvic inflammatory disease. PID is an infection of the ovaries, fallopian tubes, and/or uterus that is usually caused by a sexually transmitted disease (STD), such as chlamydia or gonorrhea. PID can lead to chronic pain, infertility, and ectopic pregnancies, and is treated with antibiotics. Although PID can cause severe pain, it usually does not have a sudden onset, so it wasn’t PID — but we did test the patient’s urine for gonorrhea and chlamydia.

With no time to waste, the doctors ordered a pelvic ultrasound to look at the uterus, ovaries, and fallopian tubes, and a Doppler test to examine the blood flow to these organs. They found the teen had a large right ovarian cyst with diminished blood flow to the right ovary. Ailment identified: It was ovarian torsion, which is when an ovarian cyst twists around the tissue supporting it.

An ovarian cyst is a sac or pouch filled with fluid or tissue that forms in an ovary. Ovarian cysts are very common. They usually go away on their own within six to eight weeks and do not cause symptoms. Sometimes they cause pain or irregular menstrual periods.

A large cyst makes the ovary unbalanced. It is the biggest risk factor for ovarian torsion. According to case reports in medical journals, vigorous activity with rapid acceleration/deceleration or a sudden increase in abdominal pressure may cause the ovary with a cyst to twist. One case report in the Journal of Emergency Medicine specifically mentioned trampoline jumping. Surgery is the only way to treat ovarian torsion.

That’s exactly what happened next for our patient. She was taken to surgery, the ovary was untwisted, the cyst was removed. Unfortunately, her urine result showed that she had chlamydia. The ED doctor had a confidential telephone conversation to tell the patient her results. She and her (now ex-) boyfriend were both treated.

The patient and her mother had a nice loooooong talk — about safe sex and contraception. Next, the mother scheduled her daughter an appointment with an adolescent medicine physician — a pediatric specialist who is trained to help teens cope with medical and emotional issues, such as reproductive health, eating disorders, sexual identity and drugs. Kudos to the mother for jumping into action!

When a teenager is diagnosed with a large ovarian cyst, families should be counseled about the symptoms of ovarian torsion and consider avoiding vigorous activity that involves rapid acceleration/deceleration or a sudden increase in abdominal pressure.

Rebecca Matta is a second-year pediatric resident and Rima Himelstein is an adolescent medicine physician at Nemours Children’s Hospital, Delaware.