Miss Bianca Van Rensberg, a 24-year-old woman, presents with severe lower abdominal pain for the last two days. Possible diagnoses include pelvic inflammatory disease, ruptured ovarian cyst, ectopic pregnancy, and appendicitis. A full medical history, systems review, and clinical examination including pelvic examination and relevant investigations are needed to diagnose the source of the abdominal pain.

1. CSD - GIT
_____________________
Group 5 A
AWINILE MGILANE – MAFUNGWASE DLAMINI – SHIMICA NOWROTHAM
1

2. Case 1 – Lower abdominal pain in
an adult
Miss Bianca Van Rensberg, aged 24 years , presents with severe lower abdominal
pain for the last two days.
What important information is given?
 Gender : Female ( Woman of reproductive age )
 Age : 24 years old
 Presenting symptom : severe lower abdominal pain/pelvic pain
 Onset ( Duration) : 2 days ago
2

3. SYSTEMS AND RELATED
ORGANS INVOLVEDGASTROINTESTINAL MUSKULOSKELETAL
- Appendix - Psoas muscles
- Small bowel - Muscles, ligaments and joints
- Sigmoid colon
REPRODUCTIVE GENITOURINARY
-Fallopian tubes - Ureters
- Ovaries - Bladder
- Uterus - Urethra
- Cervix
- Vagina
3

4. POSSIBLE DIFFERENTIALS/
DIAGNOSISGASTROINTESTINAL MUSKULOSKELETAL
- Appendicitis - Psoas muscle abscess
- Inflammatory mass - Ligaments and joint strain
- Polyps
- Diverticular disease
- Infection
REPRODUCTIVE GENITOURINARY
-Pelvic inflammatory disease - Ureter calculi / stones
- Sexually transmitted disease - Urinary tract infection
- Endometriosis - Tumour / Malignancy
- Ruptured ovarian cyst / ovarian torsion - Cystitis
- Mittelschmerz ( other menstrual related pain)
4

5. Aetiology/ Pathophysiology/
Pathogenesis
* FOR THE PURPOSE OF THIS PRESENTATION WE WILL BE
FOCUSING ON PATHOPHYSIOLOGY OF THE URGENT LIFE-
THREATENING CONDITIONS:
1. Pelvic inflammatory disease
2. Ectopic pregnancy
3. Ruptured ovarian cyst/ ovarian torsion
4. Appendicitis
5

6. Aetiology/ Pathophysiology/
Pathogenesis1. Pelvic inflammatory disease
6

7. Aetiology/ Pathophysiology/
Pathogenesis2. Ectopic pregnancy
7

8. Aetiology/ Pathophysiology/
Pathogenesis3. Ruptured ovarian cyst/ ovarian torsion
8
Risk factors for ruptured ovarian cyst/ ovarian torsion
Hormonal
problems Pregnancy Endometriosis Pelvic infection
Previous ovarian
cyst
Idiopathic
Normal monthly
follicle grows
Follicular cyst develops (
follicle fails to rupture ,
continues to grow )
Corpus luteum cyst
develops when fluid
accumulates inside the
follicle
Ovarian torsion - cyst enlarges, causing
movement and twisting of ovary
Ovarian rupture- rupture causes internal
bleeding, causing cortical stretch
Symptoms /Signs/ Effects
Lower
abdominal pain
Fullness or
heaviness in
your abdomen
Bloating Blood loss
Internal
bleeding
Nausea and
vomiting
Reduced blood
supply to
ovaries

9. Aetiology/ Pathophysiology/
Pathogenesis4. Appendicitis
9

10. IMPORTANT INFOMRATIONTO BE
OBTAINED FROM PATIENTBIOMEDICAL :
• SOCRATES on pain
Past medical history :
• Previous/ current/ chronic pelvic illness, previous similar episodes
• Past surgical history – any abdominal and gynaecological surgeries
• Medical history – medication , contraception ( esp. IUD), recreational drugs.
• Family history – history of GI / GYN family disorders related to abdominal pain.
• Personal history – full menstrual cycle history, dysmenorrhea, Mittelschmerz,
abnormal bleeding outside time of menses
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11. IMPORTANT INFOMRATIONTO BE
OBTAINED FROM PATIENTPast medical history :
• Full sexual history ( no. of partners, coital frequency, if contraception is used during
sex), dyspareunia, postcoital bleeding, vaginal discharge, previous STIs.
• Full GYN history – gravity, parity, abortions, miscarriages., previous ectopic
pregnancies.
SYSTEMS REVIEW:
• General – FEVER, weight loss, nausea
• GIT - Changes in bowel patterns/ disturbances in defaecation , bloody stools or vomit,
dysuria.
• MSK – pain, swelling, stiffness ( muscles and joints of back )
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12. FOCAL POINTS ON CLINCIAL
EXAMINATIONSGENERAL EXAMINATION :
• Vital signs – temperature ( look for fever), blood
pressure ( hypotension), RR, HR,
• General appearance - , tachypnoea, tachycardia,
sweating, pallor, nauseous
Gastrointestinal
EXAMINATION:
 Inspection:
• Bluish discoloration, distension of abdomen,
abdominal scars, umbilicus pushed upwards.
 Palpation:
• Rebound lower abdominal tenderness,
involuntary guarding/ rigidity, Rovings signs (
appendicitis), abdominal mass, McBurney's sign.
 Percussion:
• Pain on percussion
• Tenderness
• Guarding
• Mass
 Auscultation:
• Decreased bowel sounds
12

13. FOCAL POINTS ON CLINCIAL
EXAMINATIONSGYNECOLOGICAL EXAMINATION :
- Examination of breast: N/A
- Examination of abdomen:
discussed
- Pelvic examination :
 Inspection and palpation of vulva:
• Vaginal discharge ( abnormal colour, yellow)
• Vaginal bleeding
 Speculum examination:
• Cervical motion tenderness
• Adnexal Tenderness
• Uterine tenderness
• Adnexal mass
• Cervical bleeding/ inflamed cervix
 Bimanual digital examination:
• Nodules
• Bleeding/torsion
- Rectal examination :
• Rectal tenderness.
13

14. INVESTIGATIONS
1. BIOCHEMICAL ( BASELINE AND ADVANCED) :
• Blood test
• Urine test ( urinalysis)
• Urine pregnancy test
• Vaginal swab
• Erythrocyte sedimentation rate
2. RADIOLOGICAL:
• Transvaginal ultrasonography
• Abdominal and pelvic CT/ MRI
3. OTHER:
• Pap smear
• Laparoscopy 14

15. MCQ
15
A 20 year old , female medical student arrives at the trauma unit at King Edward
Hospital. Her symptoms include fever, nausea and vomiting, and severe constant
pelvic pain. After a full history and relevant examinations , she is found to have
pelvic inflammatory disease. Which of the following organism/s can be found if a
vaginal swab is taken from the patient ?
A.Neisseria meningitidis
B.Klebsiella pneumonia
C.Moraxella catarrhalis
D.Chlamydia trachomatis

16. SUMMARY
16
Approach to a woman with acute pelvic pain

17. REFERENCES
• https://www.medscape.com/answers/253620-184908/what-is-the-pathophysiology-of-
ovarian-cyst-
rupture#:~:text=Each%20month%2C%20a%20mature%20ovarian,the%20rupture%20
site%20following%20ovulation.
• https://calgaryguide.ucalgary.ca/?s=ectopic+pregnancy
• Tallies and Conor
• Lecture slides 
• https://www.aafp.org/afp/2010/0715/p141.html
• https://www.mayoclinic.org/diseases-conditions/ovarian-cysts/symptoms-causes/syc-
20353405
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