Adolescent Male with Abdominal Pain.

A 15-year-old boy presented to emergency department (ED) with abdominal pain without fever for 2 days. Local peritoneal signs were found over the McBurney point. Laboratory findings showed a WBC count of 22,800/μL and c-reactive protein level of 2.06 mg/dL (normal <0.5 mg/dL). Abdominal ultrasonography failed to visualize the appendix. However, it detected multiple marblelike objects with hypoechoic rims and hyperechoic centers (Figure 1) over the epigastrium. Abdominal computed tomography (CT) showed an engorged appendix, which confirmed the diagnosis of acute appendicitis. The CT imaging also incidentally revealed multiple small round hyperdensities in the distended stomach (Figure 2A, arrowheads).Figure 2Reconstructed nonenhanced abdominal CT revealing multiple small round hyperdensities (arrowheads) in the distended stomach.View Large Image Figure ViewerDownload Hi-res image Download (PPT) Tapioca pearls of boba tea in the stomach. The patient had ingested bubble tea (Figure 2B) the night before the ED visit. Bubble tea (also called boba tea) is a traditional Taiwanese beverage made with tea, milk, flavorings, and edible tapioca “bubbles” or “pearls.”1Pei Y.L. Chun Chen T. Yu Lin F. et al.The effect of limiting tapioca milk tea on added sugar consumption in Taiwanese young male and female subjects.J Med Invest. 2018; 65: 43-49Crossref PubMed Scopus (2) Google Scholar CT images of tapioca pearls appear as well-defined scattered spherical hyperdensities, usually located inside the stomach (Figure 2A) or duodenum.2Chia-Ying L. Ming-Chun L. Lin G. Poly pearls in the stomach.OMICS J Radiol. 2018; 7: 290Google Scholar Tapioca pearls are less hyperdense than fecaliths or appendicoliths. To our knowledge, there is no literature describing an ultrasonographic finding of tapioca pearls. In our case, ultrasonographic imaging of the tapioca pearls revealed distinct marblelike objects with hypoechoic rims and hyperechoic centers. Acoustic shadows could also be found, depending on the echo densities of the pearls (Figure 1). Acute appendicitis was the definitive cause of abdominal pain in this case. The ultrasonographic findings of tapioca pearls in the stomach (scattered marblelike objects) can be misleading for inexperienced health care providers.