Case 38: Abdominal pain

 

Case 38: Abdominal pain

CASE 38: ABDOMINAL PAIN

History

A 14-year-old girl presents with lower abdominal pain which developed suddenly a day ago.

The pain is over the whole lower abdomen but worse on the right. It was intermittent at first

but is now constant and very severe. She feels unwell in herself with no appetite and vomiting.

She now feels sweaty as well.

She says her bowels opened normally the day before and they are normally regular.

She has had no previous episodes of pain like this. Her last menstrual period started 2 weeks

ago and she has a slightly irregular cycle. She has never had any gynaecological or other

medical problems in the past.

Examination

On examination she looks in pain and seems to find it difficult to get comfortable. Her

temperature is 37.9°C, pulse 112/min and blood pressure 116/74 mmHg. She feels warm

and well perfused. The abdomen is distended symmetrically with generalized tenderness, maximal in the right iliac fossa region. There is rebound and guarding in the right

iliac fossa.

INVESTIGATIONS

Normal range

Haemoglobin 13.8 g/dL 11.7–15.7 g/dL

White cell count 14.2×109/L 3.5–11×109/L

Platelets 390×109/L 150–440×109/L

C-reactive protein 55 mg/L <5 mg/L

Questions

• What is the differential diagnosis?

• How would you investigate and manage this girl?100 Cases in Obstetrics and Gynaecology

92

ANSWER 38

The differential diagnosis of right iliac fossa pain in this case is:

• gynaecological:

• adnexal/ovarian cyst torsion

• ovarian cyst rupture

• ovarian cyst haemorrhage

• ectopic pregnancy

• surgical:

• appendicitis

• urinary:

• urinary tract infection

• renal colic

The girl is acutely systemically unwell with an acute abdomen which would favour the

diagnosis of torsion or possibly ruptured appendix. Cyst rupture and haemorrhage are not

commonly associated with such systemic disturbance, though this is an important differential diagnosis.

Further investigation would include a pregnancy test to exclude pregnancy, and urinalysis

to exclude urinary tract infection or renal colic. An ultrasound should be arranged (transabdominal) to assess for an ovarian cyst or for an inflamed appendix. The ultrasound appearances of adnexal torsion are variable, but there is invariably a unitarally enlarged oedematous

ovary, commonly with a visible cyst or haemorrhage within the ovary. If an adnexal mass

is confirmed, laparoscopy should be performed as soon as possible since adnexal torsion is

associated with loss of the ovarian function if ischaemia is prolonged and necrosis occurs.

Ovarian torsion should be managed with detorsion (ideally laparoscopically), with consideration of fixing the ovary to the uterus or pelvic side wall to reduce the chance of recurrent

torsion. Only if the ovary is gangrenous is salpingoophorectomy indicated.

If the diagnosis is not clear between appendicitis and ovarian torsion then joint laparoscopy

with the surgical team is an appropriate approach.

KEY POINTS

• Suspected ovarian torsion is a gynaecological emergency.

• Torsion is relatively common in young girls and teenagers.

• Ultrasound is useful in detection of an adnexal mass but torsion is a clinically suspected diagnosis and necessitates urgent laparoscopy.