This document summarizes a case discussion of a 10-year-old girl with 3 months of intermittent abdominal pain. Physical examination found tenderness in the right lower quadrant. Imaging showed a cystic lesion in the lower abdomen that increased in size. Laparoscopic surgery revealed a 6x5x5cm right ovarian tumor consisting of hairs, sebaceous glands and clear fluid, with signs of torsion. Pathology confirmed a mature cystic teratoma of the right ovary. The discussion reviewed approaches to chronic abdominal pain in children, functional and organic causes, and characteristics of ovarian germ cell tumors including mature cystic teratomas.

1. 2023/05/26 醫師公會兒科病例討論會
Abdominal pain for 3 months
in a 10 y/o girl
報告者：張奕蓁 醫師

2. Patient profile
• Name: 柳O恩
• Age: 10-year-old
• Sex: female
• Admission date: 2019/09/17
• Discharge date: 2019/09/20
• Height: 135 cm (15th-50th percentile)
• Weight: 26 kg (15th-50th percentile)

3. Chief complaint
• Intermittent abdominal pain for a long time, and
aggravated for recent 2 days

4. Present illness
● Ped OPD
○ Abdominal intermittent pain
2019/06/19
2019/09/17
Day 0
● Ped OPD
○ Abdominal pain aggravated in 2 days
RLQ, vomiting (+), poor appetite(+)
● LMD several times
○ treated as constipation

5. 2019/06/19
Abdominal X-ray
5

6. 2019/06/19 Abdominal echo
6
→ Admission
● Cystic lesion 6.23cm at lower abdomen with thickening wall

7. Past History
● Drug allergy(-)G6PD(-)
● OP history: left elbow fracture
● Hospitalization history:
○ 2015/2/26 for left elbow subcutaneous wound infection
● Family history: non-contributory

8. Physical examination
• General: acute ill, dry mouth
• Mental state: clear and alerted
• HEENT: conjunctiva: pink; sclera: not icteric;
• Neck: supple, non-palpable lymph node
• Chest and Lungs: bilateral clear
• Heart: regular rhythm, no murmur
• Abdomen: soft, distended; hyperactive bowel sound
tenderness over RLQ, no rebounding pain, no muscle guarding
• Extremities :no weakness, no wasting or spasticity

9. 2019/09/17 Lab data

10. A cystic lesion (4.9cm) posterior to uterus in pelvic cavity 10
2019/09/17 abdominal CT

11. 11
2019/09/17
abdominal CT

12. 12
2019/09/17
abdominal CT

13. 13
2019/09/17
abdominal CT
A cystic lesion (4.9cm)
posterior to uterus in
pelvic cavity

14. 2019/09/17 GYN echo
● Adnexal- a 5 cm cystic mass with homogenous contents 14

15. 2019/09/19 Laparoscopic operation
● Right ovarian tumor
○ 6x5x5cm
○ hairs , sebaceous gland, scalp,
clear fluid content
○ torsion 1/2 circle & hematoma
were noted.
15

16. Pathology
The sections show a picture of mature cystic
teratoma, composed of a cystic mass with
various mature components such as
squamous epithelium, skin adnexae, and
adipose.
PATHOLOGIC DIAGNOSIS:
Cystic teratoma, mature ovary, right,
laparoscopic enucleation
16
Squamous
epitheium
adipose
adnexae

17. # Approach to
Chronic Abdominal Pain
in Children and Adolescent
# Ovarian Germ Cell Tumor
Discussion

18. Chronic Abdominal Pain
18
● Definition
○ Intermittent or constant abdominal pain > 2 months.
○ 10 to 18 percent of children and adolescents.
● Etiology
○ Functional disorders
○ Organic disorders

19. Functional disorders
● Clinical features- without alarm signs
○ Poorly localized or periumbilical.
○ Episodes of pain usually last for < 1 hour, resolve spontaneously
○ Accompanied by autonomic features
(eg, pallor, nausea, dizziness, headache, or fatigue)
○ Triggered during times of stress
(eg, school transitions, caregiver divorce, emotional trauma).
○ Functions normally between episodes
○ May have symptoms of anxiety or depression
(separation anxiety, social phobias, generalized anxiety)
19

20. Functional disorders
20
3 %
2.3 %

21. Functional disorders
21
0.5 %

22. Functional disorders
22
10.7 %
2.4 %

23. Organic disorders - Alarm findings!
23

24. Organic disorders - Alarm findings!
24

25. 25

26. Indications for referral
26
● Suspicion of a serious organic condition such as
○ IBD
involuntary weight loss, growth deceleration, delayed puberty, oral ulcers,
perianal abnormalities, anemia, elevated ESR or CRP)
○ Celiac disease
positive IgA tissue transglutaminase antibodies
● Suspicion of acid-peptic disease with persistent pain despite
> 4 weeks of treatment with H2-blockers or PPI
● Referral to a pediatric surgeon, gynecologist, or mental health specialist…

27. Ovarian germ cell tumor
● Teratoma: somatic cell
○ Mature(cystic or solid)
○ Immature
● Dysgerminoma: immature germ cell
● Yolk sac tumor: yolk sac, primitive placenta
● Mixed germ cell tumors: dysgerminoma + yolk sac
Benign
Malignant

28. Epidemiology
● Ovarian germ cell tumors
○ 20-25 % of ovarian neoplasms overall
○ 5 % of all malignant ovarian neoplasms
○ 70 % of ovarian neoplasms in young females (10-30 y/o)
● Mature cystic teratoma
○ > 95 % of all ovarian teratomas
○ The most common ovarian tumor in females in 10-30 y/o

29. Clinical presentation
● Nonspecific signs and symptoms
○ Abdominal enlargement
○ Abdominal pain
○ Precocious puberty
○ Symptoms of pregnancy

30. Diagnostic evaluation
● Imaging
○ Pelvic ultrasonography
○ Abdominal CT
● Tumor markers

31. Mature teratoma
31
● Mature cystic teratoma(dermoid cyst) - mature differentiated elements
○ Ectodermal
skin, hair follicles, sebaceous glands
○ Mesodermal
muscle, urinary
○ Endodermal
lung, gastrointestinal origin

32. Mature teratoma
32
● Clinical presentation
○ Most are asymptomatic
○ Torsion is not uncommon
○ Rupture with spillage of sebaceous material into the abdominal cavity
→ Shock and hemorrhage

33. Mature teratoma
33
● Malignant transformation
○ 0.2 to 2 percent of mature cystic teratomas
○ Squamous cell carcinoma arising from the ectoderm is the
most common secondary neoplasm
○ Risk factor
■ age > 45 years
■ tumor diameter >10 cm
■ rapid growth
■ characteristic imaging (eg, low-resistance intratumor flow on Doppler)

34. Mature teratoma
34
● Treatment
○ Ovarian cystectomy (preserve ovarian tissue)
→ Avoid torsion, rupture, or development of malignant components.
○ Salpingo-oophorectomy
For patients who have completed childbearing
● Benign cystic teratomas do not recur if surgically resected.

35. Back to our patient
● Referral or further examination should be considered for
pt with chronic abdominal pain poorly responding to initial
treatment
● Mature teratoma
○ The most common ovarian tumor in females in 10-30 y/o
○ Do not recur if surgically resected

36. Thanks!
36