Gynecological causes of acute abdominal pain


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Gynecological causes of acute abdominal pain

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Gynecological causes of acute abdominal pain

  1. 1. Gynecological causes of acute abdominal pain Prof. Aboubakr Elnashar, Egypt elnashar53@hotmail.comAboubakr Elnashar
  3. 3. INTRODUCTION Challenging clinical scenario: History and physical examination findings: often nonspecific Early diagnosis important to prevent sequelae of delayed diagnosis PID and ovarian torsion: infertility Ectopic pregnancy: hemoperitoneum Aboubakr Elnashar
  4. 4. Types of pain Acute pain: Chronic pain: Recurrent pain: Cyclic episodic pain rather than acute or chronic pain. Mittelschmerz Dysmenorrhea Endometriosis Aboubakr Elnashar
  5. 5. Organic pain: Pain with an identifiable specific cause Functional pain: without a clearly identifiable cause that is exacerbated by psychosocial factors Aboubakr Elnashar
  6. 6. Typical sites of various causes of acute abdominal pain Aboubakr Elnashar
  7. 7. Typical sites of various causes of chronic or recurrent abdominal pain Aboubakr Elnashar
  8. 8. CAUSES A. Women of reproductive age I. Pregnancy related Ectopic Septic abortion Endometritis: post-partum or post-abortion II. Infection PID TOA III. Complicated ovarian cyst Torsion, rupture, hemorrhage, OHSS IV. Complicated fibroid Degenerating Torsion Aboubakr Elnashar
  9. 9. B. Adolescents Similar + imperforate hymen and transverse vaginal septum C. Postmenopausal women Similar – ectopic pregnancy and ovarian torsion Aboubakr Elnashar
  10. 10. Most common causes of acute lower abdominal pain 1. PID 2. Ruptured ovarian cysts 3. Appendicitis Aboubakr Elnashar
  11. 11. CDC Criteria for Diagnosis of PID. (2006) At least one of the following criteria: 1. Adnexal tenderness 2. Cervical motion tenderness 3. Uterine tenderness Additional diagnostic criteria (enhances specificity if present): 1. Cervical or vaginal mucopurulent discharge 2. Elevated CRP 3. Elevated ESR 4. Lab documentation of cervical infection with N gonorrhoeae or C trachomatis 5. Tem >38.3° C 6. Saline microscopy of vaginal secretions: abundant numbers of WBC Aboubakr Elnashar
  12. 12. The most specific criteria for diagnosing PID: 1. Endometrial biopsy: histopathologic evidence of endometritis 2. Laparoscopy: abnormalities consistent with PID 3. TVS or MRI: thickened, fluid-filled tubes with or without free pelvic fluid or tubo-ovarian complex, or Doppler studies suggesting pelvic infection (e.g., tubal hyperemia) Aboubakr Elnashar
  13. 13. Adenxal torsion  Pain: Twisting Lateral lower quadrant sudden onset  Peritonism  Fever, leucocytosis, N/V US colour Doppler: no flow Right adnexal torsion at the utero-ovarian pedicle. Aboubakr Elnashar
  14. 14. Endometriosis Pain: Acute Abdominal Pain {Rupture of an endometrioma} usually at menstruation Most commonly between 30 and 45 y Usually preceded by premenstrual lower abdominal pain Diagnosis: confirmed at laparoscopy Aboubakr Elnashar
  15. 15. SYSTEMATIC APPROACH Objective: To rule out: urgent life-threatening conditions : ectopic pregnancy, ruptured ovarian cyst, appendicitis fertility-threatening conditions: PID, ovarian torsion Aboubakr Elnashar
  16. 16. I. HISTORY 1. Personal: Age: Adolescents Women of reproductive age Postmenopausal women. Aboubakr Elnashar
  17. 17. 2. Present: Location Radiation Time of onset Duration Relation to menstrual cycle Frequency: constant, intermittent Type: severe, crampy, achy, dull Exacerbating and relieving factors Associated symptoms Treatment tried Aboubakr Elnashar
  18. 18. Minutes Minute to hours to few days Days to weeks Weeks to months Ov cyst rupture Dysmenorrhea PID Endometriosis Ov torsion Mittelschmerz Fibroids TO abscess rupture OHSS Sexual abuse Appendicitis Diverticulitis Cystitis IBS Ureterolithiasis GE PNP Inflammatory BD Neoplasm Ab wall myositis Time of onset Aboubakr Elnashar
  19. 19. Fibroids, Dysmenorhea, UTIMid lower Just above SP Late appendicitis GE, IBS, IBD, diverticulitis RLQ only LLQ only Endometriosis, PID,Both sides Ovarian cyst, ovarian torsion, mittelschmerz, Endometriosis On either one side or the other Location Aboubakr Elnashar
  20. 20. Right-sided pelvic pain challenging and can be confusing {close proximity of the appendix, uterus, right fallopian tube, and right ovary}. imaging to determine etiology. Aboubakr Elnashar
  21. 21. 3. Past: Surgery: abdominal and gynecologic. Gynecologic problems: 53% with ovarian torsion had a known history of ovarian cyst or mass (Houry D, Abbott,2001). Aboubakr Elnashar
  22. 22. 4. Sexual and STI history -Husband symptoms: Risks for PID and ectopic pregnancy. -Recent IUCD: PID risk 1st 3w: 6 times higher After that: similar to that in the general population (Farley et al, 1992) Aboubakr Elnashar
  23. 23. II. PHYSICAL EXAMINATION 1. Vital signs 2. Abdominal 3. Pelvic most important part required for any woman with abdominal or pelvic pain. Aboubakr Elnashar
  24. 24. III. LABORATORY TESTING 1. Urine analysis 2. Pregnancy test Serum is more sensitive than urinary β-hCG Sensitive to 25 mIU/mL 3-4 days after implantation: positive 7 days after implantation, or At time of the expected menses: 98% of the tests: positive. Aboubakr Elnashar
  25. 25. 3. Vaginal wet mount WBCs: support PID. 4. Nucleic acid amplification tests (NAATs) Chlamydia and gonorrhea. Amplify and detect DNA and RNA sequences More sensitive than previous chlamydia and gonorrhea tests. Urine NAATs have sensitivities and specificities similar to those of cervical samples. Aboubakr Elnashar
  26. 26. 4. Other tests Based on the history and physical examination -Rh blood typing (if pregnant) -Urine culture -CBC -ESR: nonspecific marker of inflammation that can be associated with ectopic pregnancy . -Fecal occult blood test. Aboubakr Elnashar
  27. 27. IV. IMAGING Goal: Accurate diagnosis using the least amount of radiation TVS: imaging modality of choice CT or MRI: negative or inconclusive TVS: most sensitive strategy {abdominal or pelvic CT: radiation dose 200 radiographs} Aboubakr Elnashar
  28. 28.  Ectopic pregnancy TVS should be conducted immediately Serum β-hCG level o Discriminatory zone: β-hCG >1,500 mIU per mL gestational sac should be visible if not, ectopic pregnancy should be suspected. However, one half of women presenting with ectopic pregnancy have β- hCG levels less than 2,000 mIU per mL, which can make the distinction between early pregnancy and ectopic pregnancy difficult when an empty uterus is seen on TVS. Aboubakr Elnashar
  29. 29. o Pseudo sac 5 to 10% of ectopic pregnancies. Single echogenic ring. True sac: double echogenic rings (double decidual sac sign). Aboubakr Elnashar
  30. 30. o Heterotopic pregnancy: Ectopic pregnancy simultaneously with an intrauterine pregnancy 1: 7,000 pregnancies ART: 1:100 pregnancies. Aboubakr Elnashar
  31. 31. PID: Most common gynecologic cause of acute pelvic pain Early PID changes: ± not apparent on US later changes: pyosalpinx and tubo-ovarian abscess, will be seen. Aboubakr Elnashar
  32. 32. Tuboovarian abscess. (a) TVS: bilateral dilated folding tubular structures with thickened walls, internal echogenic fluid, and debris. (b) Axial contrast-enhanced CT: dilated tubular structures with thick enhancing walls. Inflammatory stranding of the surrounding fat is most demonstrable on the right (arrow). Aboubakr Elnashar
  33. 33. Pelvic abscess. (a) TVS: a well-defined mass with thick walls and an internal fluid- debris level. (b) Axial contrast-enhanced CT: left adnexal tuboovarian abscess (arrow) with thick enhancing walls and complex internal fluid. The abscess resolved with conservative therapy. Aboubakr Elnashar
  34. 34. Appendicitis: most common cause of nongynecologic pain Can be diagnosed by US US: sensitivity: 75 to 90% CT: sensitivity: 87 to 98%. Normal US: makes appendicitis less likely, but does not rule it out. Aboubakr Elnashar
  35. 35. Other urgent conditions US: sensitive Hemorrhagic ovarian cyst Uterine fibroids Ovarian torsion. Aboubakr Elnashar
  36. 36. TVS: Hemorrhagic ovarian cyst: with the characteristic lacelike echogenic pattern of fibrin strands that form as blood clots and retracts.Aboubakr Elnashar
  37. 37. TVS: Adnexal torsion. an enlarged ovary (maximal diameter, >5 cm) with prominent peripheral nonovulatory follicles and a small amount of free fluid (arrow) around the inferior margin. Aboubakr Elnashar
  38. 38. Color Doppler: Ovarian Torsion Red arrowheads shows absence of blood flow demonstrating ovarian torsion. diagnosis rests on ovarian enlargement with normal ovarian volume being up to approximately 15 cc. Other suggestive findings are multiple peripherally based follicles.Aboubakr Elnashar
  39. 39. TVS: Ruptured ovarian cyst. thick-walled ovarian cyst (corpus luteum) with surrounding anechoic free fluid, a finding indicative of rupture. Aboubakr Elnashar
  40. 40. TVS: Pedunculated fibroid heterogeneous, slightly hypoechoic mass (arrow) that is clearly attached to the anterior margin of the uterine fundus. Aboubakr Elnashar
  41. 41. Degenerating fibroid. (a) Longitudinal TV color Doppler inferior part of the uterus demonstrates a complex cystic mass with internal echogenicity and no internal vascularity. (b) Axial contrast-enhanced CT: an isoattenuating uterine mass with a well-defined complex cystic center (arrow) containing fluid and debris layering, a feature indicative of hemorrhagic degeneration. Aboubakr Elnashar
  42. 42. TVS: Endometrioma large,well-defined, complex cystic mass with low-level internal echoes. Aboubakr Elnashar
  43. 43. V. DIAGNOSTIC LAPAROSCOPY Rarely needed to make the diagnosis. Aboubakr Elnashar
  44. 44. ALGORITHM Aboubakr Elnashar
  45. 45. History, Examination, Pregnancy test Pregnant Yes: evaluate for ectopic: BHCG, TVSNo Right lower quadrant pain or pain migrating from umbilicus to RT lower quadrant Yes: surgical consultation and laparotomy for appendicitis; if diagnosis in doubt: US or CT with IV contrast No Cervical motion, uterine, or adenxal tenderness Yes: Consider PID: TVS for TOANo Pelvic mass on examination Yes: consider complicated ovarian cyst , complicated fibroid or endometriosis: TVS No Dysuria and WBC on urine analysis Yes: Evaluate for UTI or PNP: urine cultureNo Gross or microscopic hematuria Yes: may be 2ndry to vaginal bleeding: consider stone kidney: stone protocol CT No TVS to evaluate for other diagnosisAboubakr Elnashar
  46. 46. CONCLUSION The most common urgent causes are ectopic pregnancy, ruptured or torsion ovarian cyst, PID Early diagnosis is important to prevent sequelae of delayed diagnosis Most diagnosis can be made with History examination , pregnancy test and TVS Aboubakr Elnashar
  47. 47. As the first priority, urgent life- threatening conditions and fertility- threatening conditions must be considered. A high index of suspicion should be maintained for PID when other etiologies are ruled out, because the presentation is variable and the prevalence is high. Aboubakr Elnashar
  48. 48. Benha University Hospital, Egypt Email: Prof. Aboubakr Elnashar Thank you Aboubakr Elnashar