Intern Report Case Discussion 1.1

intern-report

History

A 34-year-old woman presents to the Emergency Department complaining of pain in her right side.  The pain had a gradual onset over the last couple of days.  She first noticed the pain while sitting and watching television. There is nothing that exacerbates the pain.  Pain medication does not provide relief.  Currently the pain is 10/10 and radiates from her right flank to her back and into her pelvis.  She describes the pain as stabbing.  She feels nauseated and had an episode of emesis today.  She denies constipation, diarrhea, fever, chills, chest pain, and shortness of breath.  The patient was evaluated in the ED yesterday for the same pain and was diagnosed with a sexually transmitted disease (STD).  She was started on an antibiotic that she doesn’t have with her.  She was instructed to return to the ED if her pain worsened and was uncontrolled with medication at home.  She returns to the ED with worsening pain.

Physical Exam

VS: BP138/88 mm Hg    HR70 beats per minute  RR 18 breaths per minute  Temp 36.5°C, and oxygen saturation of 99% on room air.

General appearance: writhing around on the stretcher, holding her right side, periodically tearful

Head: atraumatic

Eyes: EOMI, PERRLA, anicteric, no pallor

Mouth: mucosa moist, normal tonsils without erythema, vesicles, or exudates

Neck: supple, no lymphadenopathy, no JVD, no goiter

Respiratory: CTA b/l, no wheezes, rales, or rhonchi

Cardiovascular: no murmurs, rubs, or gallops, 2+ pulses in all extremities

Abdomen: obese, soft, tender in the right upper and lower quadrants, no rebound or guarding, mild CVA tenderness on the right, normal bowel sounds

Pelvic: whitish foul-smelling discharge, os is closed, friable cervix with minimal bleeding when swab taken, no cervical motion tenderness

Extremities: no cyanosis, clubbing, or edema

Musculoskeletal: full range of motion throughout

Skin: warm and dry, no rashes

Neurological: A & O x3, CN II-XII intact, normal sensation and strength throughout
Lab Results

CBC and electrolytes within normal limits

U/A: 2-5 trichomonas, trace leukocyte esterase, no nitrites, no blood, 2+ bacteria

Diagnostic Studies

CT Abdomen-Pelvis w/o contrast: 2 cm hypodense mass in left adrenal gland, 4.4 cm cyst in left adnexa, 6.1 cm cyst in right adnexa, gallbladder, kidneys, and appendix all normal in appearance
Pelvic U/S: left ovary is 5×4×3 cm, right ovary is 7×5x5cm containing a 3×4x4cm hypoechoic lesion with no arterial wave form, fluid in the right cul-de-sac

Questions

1. What is the most common type of adnexal mass in the reproductive years?
A.    fibroid
B.    tubo-ovarian abscess
C.    carcinoma
D.    physiologic cyst
E.    endometrioma

2. What is the first step in management of a woman with pelvic pain and unstable vital signs?
A.    consult to Ob/Gyn
B.    send to OR
C.    wide-bore IV access and volume resuscitation
D.    CBC and electrolytes
E.    Pelvic ultrasound

3. What is the gold standard for diagnosis of acute pelvic pathology?
A.    ultrasound
B.    laparoscopy
C.    laboratory tests
D.    CT with contrast
E.    CT without contrast

Discussion

Summary: A 34-year-old woman presents to the Emergency Department complaining of pain in her right side, gradually worsening over the last couple of days.  Diagnostic scans assisted in the identification of ovarian torsion with complete lack of blood flow to the right ovary.  The patient was brought to the operating room for a diagnostic laparoscopy.  The right ovary and tube were found to be torsed four times with a 6 cm hemorrhagic cyst on the ovary.  After untwisting the adnexa, blood flow was not normalized.  Surgeons proceeded with a right oophorectomy.  The patient tolerated the procedure well and was discharged home from the recovery room.

The differential diagnosis of abdominal pain is extremely broad.  Even if the differential is limited to pelvic pathology there are still numerous causes that could be disastrous.  As always, we begin with the history and physical in order to give us an idea of where the pain might be coming from.  The patient in this case was an atypical presentation for ovarian torsion, in that her pain was more in the flank with radiation to the back and pelvis, as well as the fact that her pain was more of a gradual onset.  A more typical presentation would involve acute onset of pain that is more localized in the pelvic area with lateralization to the affected side.  However, because torsion can be intermittent, pain may still not be constantly present.

As is the case with any patient presenting to the Emergency Department, immediate life threats must first be ruled out, and this is typically based on the patient’s vital signs and overall clinical picture.  With our patient, although she was clearly in distress, her vital signs were stable and remained so.  In addition, she did not have peritoneal signs suggestive of a ruptured viscous or inflammation.  Had our patient been unstable a resuscitative approach involving wide-bore IV access, fluid boluses, supplemental oxygen, and cardiac monitoring would have been appropriate.  As that was not the case, the standard approach for a patient with pelvic pain in the ED involves a urine pregnancy test, urinalysis, and pelvic exam.  This assists in the diagnosis of many forms of pathology.  This can be supplemented by basic labs including CBC and electrolytes.

As none of this was diagnostic in our patient, the next step was to move onto imaging.  Given a history of flank pain with radiation to the back and pelvis, a CT scan is a highly sensitive and specific test to check for both nephrolithiasis and appendicitis.  What we found was that the patient had a large cyst on her right ovary, without pathology in the appendix, gallbladder, or kidney.  This lead to the final imaging test, ultrasound with Doppler, which gave us our tentative diagnosis of ovarian torsion.  The confirmatory test, which was both diagnostic and therapeutic, was laparoscopy.

Answers

1. D. During the reproductive years the ovaries produce a dominant follicle in the first half of the menstrual cycle and a corpus luteum after ovulation.  Either structure can become fluid-filled and enlarged, producing a physiologic cyst.  This is the most common form of adnexal mass at this point in the patient’s life.  Fibroids do not form in the adnexa.  TOA, carcinoma, and endometrioma are possible causes of an adnexal mass, but given that a physiologic cyst can form twice a month they are not as likely to be the diagnosis.
2. C. Vital signs are vital.  The first step in management of any patient presenting to the ED with unstable vitals requires aggressive volume resuscitation.  A stat OB/GYN or surgery consult would then be sought if the history or physical exam is suggestive of a pelvic pathology.  Persistent shock would necessitate operative management next, but if the patient stabilizes, a pelvic ultrasound or CT should be used to identify the cause of the problem.  Lab tests are only used in the stable patient, and a pregnancy screen and U/A will provide more information in a patient with pelvic pain than a CBC and electrolytes.
3. B. Laparoscopy is considered the gold standard for diagnosing pelvic pathology.  Like so many other gold standard tests for other pathological processes, it is invasive and therefore not commonly used as the initial diagnostic modality. Ultrasound and CT are often used first and can frequently make the diagnosis in order to avoid an invasive procedure, but laparoscopy is still necessary when the diagnosis is unclear, or when immediate definitive treatment is required.  In addition, CT scan sometimes requires the injection if IV contrast that can lead to nephropathy.  Radiation exposure should also be taken into consideration.  Lab tests will aid in the diagnosis of infection or electrolyte imbalance in a patient with vomiting, like ours, but cannot ultimately make the diagnosis by themselves.

_________________________________________________________________________

References:

Bar-On S, Mashiach R, Stockheim D, Soriano D, Goldenberg M, Schiff E, Seidman DS. “Emergency laparoscopy for suspected ovarian torsion: are we too hasty to operate?” Fertil Steril. 2009 Jan 19. [Epub ahead of print]

Chang HC, Bhatt S, Dogra VS. “Pearls and pitfalls in diagnosis of ovarian torsion.” Radiographics. 2008 Sep-Oct;28(5):1355-68.

Lo LM, Chang SD, Horng SG, Yang TY, Lee CL, Liang CC. “Laparoscopy versus laparotomy for surgical intervention of ovarian torsion.” J Obstet Gynaecol Res. 2008 Dec;34(6):1020-5.

Marx John et al. Rosen’t Emergency Medicine. Philadelphia: 2006, pp248-253.

Vandermeer FQ, Wong-You-Cheong JJ. “Imaging of acute pelvic pain” Clin Obstet Gynecol. 2009 Mar;52(1):2-20.

This case discussion presented by Brian Kern, MD.

2 Responses

  1. Kernel,
    Strong Work.
    – Klever

  2. Just a quick comment about torsion:

    I’m a 3rd year med student on my OB rotation. One of the head honcho gyn docs here spoke on ovarian torsion and said the most sensitive detail you can pick up on U/S is an enlarged ovary, since it is not uncommon that arterial blood flow to the torsed ovary remains intact. The inc. in size is from venous outflow obstruction.

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