Case report

1. Noon Conference
Anton Manyak
12/03/2018

2. © 2016 Virginia Mason Medical Center 2
Objectives
Acute Pelvic Pain in Women
• Differential diagnosis
• Discuss diagnostic tests
• Review illness script

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Question 1
A 22-year-old college student comes to the emergency department with severe right
lower quadrant pain. She says the pain started about six hours ago and has progressively
worsened. She has no significant medical problems and her only medication is oral
contraceptive pills. She is sexually active with one partner, her boyfriend. Her last
menstrual period was two weeks ago.
Vital signs are: temperature 37 °C (98.6 °F), blood pressure 120/70 mmHg, pulse 80
beats per minute. Abdominal examination is significant for focal tenderness in the right
lower quadrant. Pelvic exam reveals exquisite tenderness in the right adnexa, a closed
cervical os, and clear vaginal discharge. Laboratory studies show:
Beta-hCG – Negative
Leukocyte count – 7,300/mm3
Hemoglobin – 14.0 g/dL
Which of the following is the most likely etiology of this patient's symptoms?
A. Acute appendicitis.
B. Diverticulitis.
C. Ovarian torsion.
D. Ruptured ectopic pregnancy.
E. Tubo-ovarian abscess.
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Differential Diagnosis
• GI - appendicitis
• Gyn - adenomyosis, uterine fibroid,
ectopic pregnancy, endometriosis,
ovarian torsion, ovarian cyst
rupture, tubo-ovarian abscess, PID
• Urinary – UTI, kidney stone
• Rare – porphyria, sickle cell crisis,
lead poisoning, polyarteritis nodosa
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Question 2
What is the most common cause of
acute pelvic pain in women?
A. Appendicitis
B. Ectopic Pregnancy
C. Endometriosis
D.Ovarian Cyst
E. Pelvic Inflammatory Disease
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Diagnostic Tests
Pelvic Exam
U/A
Beta HCG/Urine pregnancy test
Transvaginal U/S
CT Abd/Pelvis w/ contrast
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Illness Scripts
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Appendicitis Ovarian Torsion
Pathophysiology Fecalith obstructing the appendix outlet
Rotation of ovary around its axis cutting off
blood supply
Epidemiology
10-30
More common between 10-20
M > F (1.4:1)
F > M
Higher risk if mass > 5cm is present
Time course Acute Acute
Clinical
presentation
Fever, periumbilical -> RLQ pain, N/V,
Obturator/Psoas/Rovsing sign, rebound
tenderness
Pelvic and adnexal pain, N/V, adnexal mass
Diagnostics
Labs: leukocytosis
Imaging: U/S or CT (best)
Explorative laparoscopy
Imaging: TVUS similar to CT/MRI, less
expensive, and can show blood flow
Therapeutics
Surgery
Antibiotics?
Surgical emergency

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11. © 2016 Virginia Mason Medical Center
References
https://www.aafp.org/afp/2010/0715/p141.html
https://www.uptodate.com/contents/ovarian-and-fallopian-
tube-
torsion?search=ovarian%20torsion&sectionRank=2&usage_ty
pe=default&anchor=H4&source=machineLearning&selectedTitl
e=1~71&display_rank=1#H850127
https://www.uptodate.com/contents/acute-appendicitis-in-
adults-clinical-manifestations-and-differential-
diagnosis?search=appendicitis%20%20epidemiology&sectionR
ank=1&usage_type=default&anchor=H5346248&source=mac
hineLearning&selectedTitle=1~150&display_rank=1#H534647
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