CASE OF THE MONTH
An unusual case of female abdominal pain Kerri Van Arnem, DSc, PA-C
CASE A 37-year-old African American woman presented to the ED for worsening abdominal pain over the past 3 days. She reports that the pain was initially periumbilical but is now located suprapubic and in the left lower quadrant. She describes the pain as sharp and rates it as a 6 on a 0-to-10 pain intensity rating scale; the pain increases to a maximal intensity of 8. The patient also says that over the past few days she has had more frequent abdominal pain with bowel movements, some anorexia, nausea, vomiting, and flatus. She has had intermittent episodes of constipation and diarrhea over the past few months. She denies radiation of pain, hematochezia, fever, chills, vaginal bleeding or discharge, hematuria, dysuria, or possibility of pregnancy. History She reports regular menstrual cycles in the past and has been in a monogamous relationship with her husband for several years. She denied a history of sexually transmitted infections, diverticulosis, or nephrolithiasis. She has a family history of breast cancer but no family history of ovarian, uterine, or colon cancer. She also states that she has had three cesarean sections and a bilateral tubal ligation. Physical examination The patient’s initial vital signs were normal with the exception of tachycardia at a rate of 131 beats per minute; she was afebrile. Her abdomen was soft with hyperactive bowel sounds but no distension was noted. She had tenderness to percussion and palpation over the left lower quadrant and suprapubic regions. A mass was also palpated in the left lower quadrant. The patient then mentioned that the mass had been there for about 2 months, did not believe that it changed in size or location, and did not cause pain until 3 days ago. No rebound tenderness, McBurney point tenderness, or Rovsing sign was elicited; the patient also did not have costovertebral angle tenderness. A pregnancy test was negative and the patient’s white blood cell count, complete metabolic panel, lactate level, Kerri Van Arnem is a recent graduate of the Army-Baylor Doctorate of Science in Physician Assistant Study in Emergency Medicine residency at Fort Sam Houston in San Antonio, Tex. The author has disclosed no potential conflicts, financial or otherwise. Adrian Banning, MMS, PA-C, department editor DOI: 10.1097/01.JAA.0000443973.61728.7a Copyright © 2014 American Academy of Physician Assistants
FIGURE 1. Transvaginal ultrasound
and urinalysis were unremarkable. A CT scan of the abdomen and pelvis with contrast was ordered and a transvaginal ultrasound was completed (Figure 1). WHAT IS YOUR DIAGNOSIS? • ectopic pregnancy • tuboovarian abscess • ovary/adnexal torsion • small bowel obstruction • torsed pedunculated fibroid tumor • diverticulitis OUTCOME The CT of the abdomen and pelvis showed a 10-cm mass adjacent to the left side of the uterus with the left ovary not well visualized; the radiologist reported a differential of a torsed ovary, hemorrhagic cyst, or adnexal neoplasm. The transvaginal ultrasound showed that the mass was not attached to the ovary and did not demonstrate vascular flow. There was a questionable pedunculated attachment to the uterus. The patient was given analgesics and remained stable and comfortable during her stay. She was taken to the OR later that day for an explorative laparotomy. Subsequently, an abdominal myomectomy for a torsed pedunculated fibroid tumor was performed and later confirmed by pathology.
JAAPA Journal of the American Academy of Physician Assistants
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
www.JAAPA.com
55
CASE OF THE MONTH
DISCUSSION The patient tolerated surgery well and reported resolution of pain at her follow-up appointment. Although a left salpingectomy/oophorectomy had been discussed before surgery, they were not deemed necessary and were not performed. Some complications of uterine fibroids, as occurred in this patient, include acute pain, torsion, and peritoneal signs. Other complications of fibroid tumors include necrosis from torsion or overgrowth of the blood supply, thromboembolism, renal failure, urinary retention, acute vaginal or intraperitoneal hemorrhage, mesenteric vein thrombosis, infection and suppuration, hemorrhagic necrosis during pregnancy, intestinal gangrene, and transformation to leiomyosarcoma.1 Ultimately, the management is surgical. The differential diagnosis of acute lower abdominal pain in women is extensive, and torsion of a fibroid tumor can mimic generalized peritonitis.2 This patient presented primarily with abdominal pain. The tachycardia on initial presentation may have been due to pain, as it resolved with analgesia during her ED stay. Although abdominal pain is a common presentation for torsed fibroid tumors, additional complaints on presentation include menorrhagia, urinary retention, and peritoneal signs. Although ectopic pregnancy was in the differential, it was less likely with a history of a tubal ligation and a negative pregnancy test. Ultrasound findings also were not consistent with an ectopic pregnancy. A tuboovarian abscess was also less likely as the patient did not appear septic, was normotensive, afebrile, did not have leukocytosis, and no CT or ultrasound findings supported this diagnosis. An ovarian or adnexal torsion was also a concern, but the
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patient’s description of pain was not colicky in nature and this condition was later ruled out with transvaginal ultrasound. Because the patient had previous abdominal surgeries, a small bowel obstruction was also on the differential. If an obstruction were present, one would expect abdominal distension, abnormal bowel sounds, peritonitis, leukocytosis, or the inability to defecate or pass flatus. No evidence of obstruction was found on the CT scan. Diverticulitis was ruled out because the patient denied a prior history of diverticulosis or diverticulitis, was afebrile, and no evidence of diverticulitis was found on CT scan of the abdomen. Although fibroid tumors are the most common tumor of the uterus, torsion of a pedunculated fibroid tumor is rare, and an infrequent cause of acute abdominal pain presenting to the ED. Fibroids are more common in women during reproductive years, more common in African American women, and increase with age (most occur after age 30 years). The true incidence is unknown as most remain asymptomatic.2 Presentations and complications can vary. Myomectomy, the definitive treatment for symptomatic fibroids, preserves fertility. For women presenting to the ED with acute abdominal pain, torsion of pedunculated fibroids should be considered in the differential diagnosis, and timely consultation with gynecology obtained. JAAPA REFERENCES 1. Gupta S, Manyonda IT. Acute complications of fibroids. Best Pract Res Clin Obstet Gynaecol. 2009;23(5):609-617. 2. Foissac R, Sautot-Vial N, Birtwisle L, et al. Torsion of a huge pedunculated uterine leiomyoma. Am J Surg. 2011;201(6): e43-e45.
Volume 27 • Number 3 • March 2014
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
An unusual case of female abdominal pain Kerri Van Arnem, DSc, PA-C
CASE A 37-year-old African American woman presented to the ED for worsening abdominal pain over the past 3 days. She reports that the pain was initially periumbilical but is now located suprapubic and in the left lower quadrant. She describes the pain as sharp and rates it as a 6 on a 0-to-10 pain intensity rating scale; the pain increases to a maximal intensity of 8. The patient also says that over the past few days she has had more frequent abdominal pain with bowel movements, some anorexia, nausea, vomiting, and flatus. She has had intermittent episodes of constipation and diarrhea over the past few months. She denies radiation of pain, hematochezia, fever, chills, vaginal bleeding or discharge, hematuria, dysuria, or possibility of pregnancy. History She reports regular menstrual cycles in the past and has been in a monogamous relationship with her husband for several years. She denied a history of sexually transmitted infections, diverticulosis, or nephrolithiasis. She has a family history of breast cancer but no family history of ovarian, uterine, or colon cancer. She also states that she has had three cesarean sections and a bilateral tubal ligation. Physical examination The patient’s initial vital signs were normal with the exception of tachycardia at a rate of 131 beats per minute; she was afebrile. Her abdomen was soft with hyperactive bowel sounds but no distension was noted. She had tenderness to percussion and palpation over the left lower quadrant and suprapubic regions. A mass was also palpated in the left lower quadrant. The patient then mentioned that the mass had been there for about 2 months, did not believe that it changed in size or location, and did not cause pain until 3 days ago. No rebound tenderness, McBurney point tenderness, or Rovsing sign was elicited; the patient also did not have costovertebral angle tenderness. A pregnancy test was negative and the patient’s white blood cell count, complete metabolic panel, lactate level, Kerri Van Arnem is a recent graduate of the Army-Baylor Doctorate of Science in Physician Assistant Study in Emergency Medicine residency at Fort Sam Houston in San Antonio, Tex. The author has disclosed no potential conflicts, financial or otherwise. Adrian Banning, MMS, PA-C, department editor DOI: 10.1097/01.JAA.0000443973.61728.7a Copyright © 2014 American Academy of Physician Assistants
FIGURE 1. Transvaginal ultrasound
and urinalysis were unremarkable. A CT scan of the abdomen and pelvis with contrast was ordered and a transvaginal ultrasound was completed (Figure 1). WHAT IS YOUR DIAGNOSIS? • ectopic pregnancy • tuboovarian abscess • ovary/adnexal torsion • small bowel obstruction • torsed pedunculated fibroid tumor • diverticulitis OUTCOME The CT of the abdomen and pelvis showed a 10-cm mass adjacent to the left side of the uterus with the left ovary not well visualized; the radiologist reported a differential of a torsed ovary, hemorrhagic cyst, or adnexal neoplasm. The transvaginal ultrasound showed that the mass was not attached to the ovary and did not demonstrate vascular flow. There was a questionable pedunculated attachment to the uterus. The patient was given analgesics and remained stable and comfortable during her stay. She was taken to the OR later that day for an explorative laparotomy. Subsequently, an abdominal myomectomy for a torsed pedunculated fibroid tumor was performed and later confirmed by pathology.
JAAPA Journal of the American Academy of Physician Assistants
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
www.JAAPA.com
55
CASE OF THE MONTH
DISCUSSION The patient tolerated surgery well and reported resolution of pain at her follow-up appointment. Although a left salpingectomy/oophorectomy had been discussed before surgery, they were not deemed necessary and were not performed. Some complications of uterine fibroids, as occurred in this patient, include acute pain, torsion, and peritoneal signs. Other complications of fibroid tumors include necrosis from torsion or overgrowth of the blood supply, thromboembolism, renal failure, urinary retention, acute vaginal or intraperitoneal hemorrhage, mesenteric vein thrombosis, infection and suppuration, hemorrhagic necrosis during pregnancy, intestinal gangrene, and transformation to leiomyosarcoma.1 Ultimately, the management is surgical. The differential diagnosis of acute lower abdominal pain in women is extensive, and torsion of a fibroid tumor can mimic generalized peritonitis.2 This patient presented primarily with abdominal pain. The tachycardia on initial presentation may have been due to pain, as it resolved with analgesia during her ED stay. Although abdominal pain is a common presentation for torsed fibroid tumors, additional complaints on presentation include menorrhagia, urinary retention, and peritoneal signs. Although ectopic pregnancy was in the differential, it was less likely with a history of a tubal ligation and a negative pregnancy test. Ultrasound findings also were not consistent with an ectopic pregnancy. A tuboovarian abscess was also less likely as the patient did not appear septic, was normotensive, afebrile, did not have leukocytosis, and no CT or ultrasound findings supported this diagnosis. An ovarian or adnexal torsion was also a concern, but the
56
www.JAAPA.com
patient’s description of pain was not colicky in nature and this condition was later ruled out with transvaginal ultrasound. Because the patient had previous abdominal surgeries, a small bowel obstruction was also on the differential. If an obstruction were present, one would expect abdominal distension, abnormal bowel sounds, peritonitis, leukocytosis, or the inability to defecate or pass flatus. No evidence of obstruction was found on the CT scan. Diverticulitis was ruled out because the patient denied a prior history of diverticulosis or diverticulitis, was afebrile, and no evidence of diverticulitis was found on CT scan of the abdomen. Although fibroid tumors are the most common tumor of the uterus, torsion of a pedunculated fibroid tumor is rare, and an infrequent cause of acute abdominal pain presenting to the ED. Fibroids are more common in women during reproductive years, more common in African American women, and increase with age (most occur after age 30 years). The true incidence is unknown as most remain asymptomatic.2 Presentations and complications can vary. Myomectomy, the definitive treatment for symptomatic fibroids, preserves fertility. For women presenting to the ED with acute abdominal pain, torsion of pedunculated fibroids should be considered in the differential diagnosis, and timely consultation with gynecology obtained. JAAPA REFERENCES 1. Gupta S, Manyonda IT. Acute complications of fibroids. Best Pract Res Clin Obstet Gynaecol. 2009;23(5):609-617. 2. Foissac R, Sautot-Vial N, Birtwisle L, et al. Torsion of a huge pedunculated uterine leiomyoma. Am J Surg. 2011;201(6): e43-e45.
Volume 27 • Number 3 • March 2014
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
