Abdominal pain and pallor can occur rarely in a child with malignancy, as with bleeding into an abdominal Wilms tumor, hepatoma, or neuroblastoma The presence of pallor and pain also raises the possibility of vaso-occlusive crisis in a patient with sickle cell disease; splenic sequestration should also be considered Jaundice may be observed in the child with hemolysis or with hepatitis At times, an intra-abdominal vasculitis that causes pain may precede the rash of Henoch– Schönlein purpura or be a prominent finding with Kawasaki disease Chronic abdominal pain in the adolescents may be due to inflammatory bowel disease In these children, inflammatory markers such as erythrocyte sedimentation rate and C-reactive protein levels are commonly elevated In postpubertal females, dysmenorrhea, endometriosis, chronic PID, chronic UTI, or gallbladder disease can be associated with chronic or recurrent abdominal pain Functional abdominal pain may be considered only after exclusion of other conditions; the presence of focal tenderness, rebound, guarding, or fever should prompt consideration of alternative diagnoses Additional Considerations in the Postpubertal Female With Acute Abdominal Pain Among postpubertal females, pregnancy and complications of pregnancy must be considered ( Fig 53.2 ) A menstrual history and ascertainment of sexual activity are essential, and a urine β-hCG sample should be obtained in all females in whom pregnancy is a possibility The diagnosis of ectopic pregnancy must be considered among females with lower abdominal pain occurring within the first trimester of pregnancy (see Chapter 92 Gynecology Emergencies ) Vaginal bleeding occurs in most patients with ectopic pregnancy but is not always present A transvaginal or transabdominal ultrasound should be obtained The diagnosis of ectopic pregnancy is not usually confirmed by ultrasound; however, the presence of an intrauterine gestational sac is reassuring and argues against the diagnosis of ectopic pregnancy A quantitative serum β-hCG sample should be obtained; it may need to be repeated within 48 to 72 hours if the diagnosis remains uncertain In addition, RhoD immune globulin (RhoGAM) should be administered to Rhnegative women Although the diagnosis of ectopic pregnancy should be considered in all pregnant women, crampy lower abdominal pain is commonly reported among women with intrauterine pregnancy Rupture of an ovarian cyst is the most common cause of lower abdominal pain in postpubertal women; however, the diagnosis can be made only after the exclusion of more serious conditions An ultrasound should be obtained if focal