1. Acute Abdomen In Adolescent Girls
DR VIDYA THOBBI
PROF AND HEAD
DEPT OF OBG
AL AMEEN MEDICAL COLLEGE
BIJAPUR

2. • Acute abdomen refers to
– Sudden
– Severe pain
– Of unclear etiology
– Duration is less than 24hours
• Condition associated by pain, tenderness and/or
muscular rigidity persisting more than six hours often
requires surgical intervention
• Most of the time it is a medical emergency requiring
specific urgent diagnosis

3. Evaluation of adolescent girls
• Problems encountered in adolescents are
 The distinction between acute and chronic pain
in adolescents is not clear
 Atypical symptoms
 History
oConfused, fearful of societies’ scorn, sexual
promiscuity, communication problems,
anxiety
 Emotional and psychological conflict
 Distressing physical illness
 Physical and pelvic examination of an
uncooperative patient

4. History
A few classic descriptions:
• Diffuse, severe, colicky pain: bowel
obstruction
• “Pain out of proportion to examination”
mesenteric ischemia
• Radiation of pain from epigastrium straight
through to the mid back: pancreatitis, either
primary or from a penetrating ulcer
• Characterizing the pain is the key
– Onset, duration, location, character

5. History
Always obtain a thorough gynecologic history including :
• Menstrual history, mode of contraception (if any), vaginal discharge,
fibroids, pelvic inflammatory disease, sexually transmitted diseases
• History: pregnancies and complications
• Sexual history
• GI symptoms
– Nausea, emesis
– Constipation
– Diarrhea
• Jaundice, alcholic stools, dark urine
• Hypothyroidism
• Prior surgeries (adhesions)
• Urine output
• Constitutional Symptoms: fevers / chills

6. Presentation of acute abdomen
• PAIN
• SHOCK
• VOMITING
• DISTENSION OF ABDOMEN

8. Clinical Diagnosis

9. Etiology of acute abdomen
• Acute pelvic pain may be the manifestation of
 Various gynecologic and non-gynecologic disorders
 From less alarming rupture of the follicular cyst to life
threatening conditions such as rupture of ectopic
pregnancy or perforation of inflamed appendix
• Acute pelvic pain may occur even in
 Normal intrauterine pregnancy and its complications
• This may be explained by hormonal changes, rapid
growth of the uterus and increased blood flow.

10. Etiology of acute abdomen
Most common gynecological causes of acute abdomen
are:
• Acute salpingitis, Acute pelvic inflammatory disease
• Tubo ovarian abscess
• Ectopic pregnancy
• Haemorrhage from a functional ovarian cyst
• Adnexal or ovarian torsion or torsion of pedunculated
myoma
• Septic abortion with peritonitis
• Acute urinary retention due to retroverted uterus
• Dysmenorrhoea / Endometriosis / Hematometra

11. Pelvic inflammatory disease and
TO abscess
• Annually, there are
– Approximately 1 million women who develop pelvic
inflammatory disease (PID)
– An estimated 1 in 8 sexually active adolescent girls develop PID
before reaching age 20 years
• One of the most serious complications of sexually transmitted
diseases.
– Leading to endometritis, salpingitis, salpingo-oophoritis, tubo-
ovarian abscess (TOA) and pelvic peritonitis
• Prompt diagnosis and treatment of this condition are critical
– because complications of PID can be life and fertility
threatening
US National Library of Medicine, National Institutes of Health. Pelvic inflammatory disease (PID).

12. Ectopic pregnacy
• Classic Symptoms
 Abdominal pain
 Amennorrhea
 Vaginal Bleeding
• Diagnosis
 Transvaginal U/S (TVS)
 Presence of a true gestational
sac at 4.5 to 5 wks is the 1st
sign
of IUP
 Cardiac activity is first detected
at 5.5 to 6 weeks
 Serum quantitative HCG
 Absence of an intrauterine
gestational sac at hCG
concentrations >1500-2000 IU/L
suggests an ectopic or nonviable
intrauterine pregnancy
• Management
 Option of medical vs surgical
management if pt is
hemodynamically stable and no
rupture has occurred
 Emergent surgical management if
rupture has occurred and/or patient
is hemodynamically unstable
• Prognosis
 Ruptured ectopic pregnancies
account for 4- 10 percent of all
pregnancy related deaths.

13. Adnexal Torsion
• Torsion of the adnexa
 An acute gynecologic surgical emergency
 Prolonged torsion can lead to infarction of the
tube and ovary involved
 Early diagnosis is important because
• Prompt surgical intervention can result in
ovarian preservation by saving the ovary and
adnexa from infarction
 If left untreated, peritonitis and death may ensue.

14. Etiology of acute abdomen
• Ovarian cysts
 Functional hemorrhagic cysts
 Benign neoplasms dermoid cysts 3.5%
 Malignant neoplasms Germ cell tumors
• Neoplasms and cystic adnexal lesions
complicated by haemorrhage, torsion and
infarction is one of the common diagnoses for
acute abdomen.
Radiologe ; 1997, Jun, 37(6), 459-63

15. • Ruptured corpus luteum cyst
• Ovarian haemorrhage from the corpus luteum of
menstruation or pregnancy
• Life threatening surgical condition
• Can occur at all stages of a woman’s reproductive life
• A corpus luteum cyst predisposes to rupture.
• Culdocentesis is positive for haemoperitoneum and if
hematocrit >12% surgical intervention is indicated for
hemostasis.
Am J Obstet Gynecol. 1984 May 1;149(1):5-9.

16. Adnexal Torsion
• When AT is suspected, urgent surgical intervention is
indicated, and is usually performed by laparoscopy.
• Despite the "necrotic" appearance of the twisted ischemic
ovary, detorsion is the only procedure which should be
performed at surgery.
• Adnexectomy should be avoided as ovarian function is
preserved in 88% to 100% of cases.
• Recent evidence reinforces the role of detorsion in lieu of
oophorectomy or adnexetomy in an effort to preserve
reproductive capacity in a young population.
Clin Obstet Gynecol. 2006 Sep;49(3):459-63.
Curr Opin Obstet Gynecol. 2005 Oct;17(5):483-9.

17. Torsion of Parovarian cyst

18. Torsion of Parovarian cyst

19. To pex or not to pex?
Routine ovariopexy after detorsion does not seem
warranted because the risk of retorsion is very low
when a cause is found and treated.
Mage G, Canis M: Laparoscopic management of adnexal torsion. A review of 35 cases.
J Reprod Med 34:521, 1989

20. • To name a few
 Isolated torsion of the fallopian tube
 Hydrosalpinx
 Ovarian Hyperstimulation Syndrome(OHSS)
 ruptured hematosalpinx
Rare cases of acute abdomen

21. Rare cases of acute abdomen
• Torsion of adnexa is relatively common, but
isolated torsion of the fallopian tube is rare.
• It should be considered in all adolescents who
present with acute pelvic pain
• Prompt laparoscopic intervention may allow for
– early diagnosis, treatment and preservation of the
tube if possible
J Obstet Gynecol. 2006 Dec;45(4):363-5

22. Rare cases of acute abdomen
• Hydrosalpinx
– One of the predisposing factors of adnexal torsion
– Because the incidence of hydrosalpinx in adolescent
virgin patients is very rare, it may cause diagnostic
dilemma, leading sometimes to suboptimal
treatment
• Although very rare in adolescence, it must be
considered in the differential diagnosis
• Aspiration in such cases is not the treatment of choice
and moreover, it may cause complications.
J Pediatr Adolesc Gynecol. 2006 Aug;19(4):297-9.

23. Rare cases of acute abdomen
• Ovarian Hyperstimulation Syndrome(OHSS)
– One of the differential diagnoses for acute abdomen
– The massive world wide development of ART and marked
increase of females with infertility treatment has lead to
difficult medical complications. One of them is OHSS.
– It presents as abdominal discomfort, nausea, vomiting and
ascites.
Rozhi Chir, 2010 Aug 89(7) ; 402-5

24. Rare cases of acute abdomen
• Acute abdominal pain may occur as a result of
ruptured hematosalpinx :
– A complication of an unusual mullerian anomaly
– Laparoscopic excision of a unilateral non
communicating uterine horn is a valid and
recommended treatment approach of this rare
malformation.
J Pediatr Adolesc Gynecol. 2009 Jun;22(3):e9-11.

25. Differential diagnosis
for pain of sudden onset
severe morbidity/mortality
• Rupture of TO abscess or hematoma
• Ruptured ectopic pregnancy
• Hemorrhage and torsion of adnexa

26. Acute abdomen a clinical challenge
• Require all resources to reach accurate
diagnosis, timely management and
proper disposition
• 10% require urgent surgery

27. Lab & Imaging
CBC w diff Left shift
BMP Acidosis, dehydration
Amylase
Pancreatitis, perf DU,
bowel ischemia
LFT Jaundice, hepatitis
UA GU- UTI, stone, hematuria
Beta-hCG Ectopic

28. Lab tests
• Urinalysis and urine pregnancy test are perhaps the
most cost-effective tests
 UPT sent on all women of reproductive age
 Urinalysis interpreted with respect to the clinical
picture
 Pyuria often present without UTI
 Up to 30% of patients with appendicitis have
abnormal urinalysis
• Elevated WBC is neither sensitive nor specific
• Electrolytes are abnormal in <1% of patients

29. Imaging
Test Reason
KUB
Flat & Upright
Free air, stones
Ultrasound Colour Doppler GYN pathology
CT scan, MRI
Anatomic Dx
Diagnostic accuracy
Case not straightforward

30. Ultrasonography in acute
abdomen
• Sonography
– High sensitivity and specificity in visualization of uterine
and adnexal signs of ectopic pregnancy
– Color Doppler
• May aid in detection of the peritrophoblastic flow
– Facilitates detection of ectopic living embryo, tubal ring or
unspecific adnexal tumor
– Corpus luteum cysts and leiomyomas are another cause of
pelvic pain during pregnancy, can be correctly diagnosed
by ultrasound
Acta Med croatica 2002;569[4-5]171-80

31. Ultrasonography in acute
abdomen
• Appendicitis
– The most common surgical emergency and should always
be considered in differential diagnosis if appendix has not
been removed.
– Apart from clinical examination and laboratory tests, an
ultrasound examination is sensitive up to 90% and specific
up to 95% if graded compression technique is used.

32. Ultrasonography of the pelvis showing
bilateral huge multicystic ovaries :
Seen in a 18 yr old girl with acute abdomen

33. Ultrasonography
showing a
haemorrhagic
corpus luteum cyst
Ultrasonography
showing ectopic
pregnancy

34. Ultrasonography
showing isolated
fallopian tube
torsion with
pregnancy
Ultrasonography
showing tubo ovarian
abscess

35. CT in acute abdomen
• Computed tomography (CT) is being found
extremely valuable
 In assessing the causes
 Determining the appropriate treatment (in
particular whether surgery is needed)
 Determining when and how that surgery should
most appropriately be done

36. CT showing rupture of
ectopic pregnancy in
right fallopian tube
CT showing
tubo ovarian
abscess

37. CT showing ovarian torsion

38. MRI in Acute abdomen
• Rapid advances in techniques of magnetic resonance
(MR) imaging have enabled diagnosis of acute abdominal
conditions.
• Ultrasonography (US) is a useful imaging modality for
evaluation of patients suspected to have acute diseases.
– US findings are not always conclusive
• Computed tomography
– Exposes patients to ionizing radiation, which is problematic
among young women
• Magnetic resonance (MR) imaging
– A valuable complement to US when used as an emergency
examination in a patient with suspected acute gynecologic
disease.
– The recent development of fast MR imaging has shortened the
imaging time enough for emergency use.

39. MRI showing hemorrhagic
ovarian cyst with
hemoperitoneum
MRI showing twisted left
ovarian cystic teratoma with
hemorrhagic necrosis in a
girl with pelvic pain and
nausea.

40. MRI showing pyosalpinx

41. Basic Principles
• Signs and symptoms of intra-abdominal disease
usually best treated by surgery
• Proper evaluation and management requires one to
recognize:
1. Does this patient need surgery?
2. Is it emergent, urgent, or can wait?
• In other words, is the patient unstable or
stable?
• Learn to think in “worst-case” scenario
• But remember medical causes of abdominal pain

42. Management
• Up to 7% of patients with abdominal pain may
have a life-threatening process
• Physiologically compromised patients should
be identified in triage and brought
immediately to the treatment area for
resuscitation

43. Management
• All critically ill patients require
resuscitation before beginning a
diagnostic assessment
• What is important is not to make a
specific diagnosis, but to identify
and treat life threatening
conditions
Airway
• Profound shock or
protracted emesis may
compromise airway and
require intubation
Breathing:
• Provide supplemental O2
• O2 saturation monitoring

44. Laparoscopy in acute abdomen
• Despitenewx-raytechniques,orscans,andultrasound,thediagnosisofacuteabdomencanbedifficultattimes.
• Sofar,themostaccuratenon-invasivemethodofdiagnosisisultrasoundbutthatisnotreliable.
• Historyandphysicalexaminationwillgenerallyleadtocorrectdiagnosisoccasionally.
• Diagnosticlaparoscopyisthemost accuratemethodevencomparedtoopen laprotomy.
PerriSG,AltiliaF etal.Laparoscopyinabdominal emergencies.IndicationsandLimitations. ChirItal2002;54:165-78.

45. Inflamed appendix, about to
perforate:
laparoscopic view
Right tubal ectopic pregnancy
at laparoscopy surgery

46. Ovarian torsion
(laparoscopic
view)
Acute on-set of
Hematometra and
Hematosalpinx :
laparoscopic view

47. Image in a 15-year-
old girl with
salpingitis
Laparoscopic
view of acute PID

48. Pelvic pain
A SAFE Approach
SEVERITY AFFECT FAMILY ENVIRONMENT

49. SAFE Approach
• Discussion and assessment of emotional
issues and psychological concerns are integral
component of evaluation and management of
pelvic pain in adolescents

50. TAKE HOME MESSAGE
• Careful history
 Pain, menstrual history, sexual exposure, other GI symptoms
• Remember DDx in broad categories
• Narrow DDx
 Based on history, exam, labs, imaging
• Always perform
 ABC, Resuscitate before Dx
• Don’t forget
 GYN/medical causes, surgical special situations
• For acute abdomen , in adolescent girls think of these commonly
 Adnexal Torsion
 Ectopic pregnancy
 Pelvic infection

51. THANK YOU