Exploratory Laparoscopy of Abdomen for Right Lower Quadrant Pain

OB-GYN/R1 Dr. Young Amanda Walker

Patient

      Female 26-year-old G1P1, C-section, 2000 LMP 5/05/2007 Periods “not as regular as in years past with cycles about every 2 months that last two weeks” Denies possibility of pregnancy

Patient

    Surgical Hx: c-section (2000), repair of fractured hip with implant due to slip cap fem (1991) Current Dx: tobacco disorder, hypothyroidism Current Meds: Synthroid 75mcg oral tablets once daily Allergies: NKDA

HPI

   Presented to LH Geisinger Clinic on May 21, 2007 c/o lingering, mild and intermittent abdominal pain x 2yrs Exacerbated into colicky RLQ pain x 2wks   2 ER visits, 2 negative work-ups for appendicitis in last 2mos, including CT Scans & labs Referred to Dr. Young by PCP to r/o adhesions and endometriosis

Physical Exam

  Abdominal Exam: elicited tenderness to deep palpation in RLQ, maximum pt of tenderness was subumbilical and to the right:  

McBurney’s Point

minimal suprapubic tenderness Pelvic Exam: elicited mild tenderness on palpation of the uterus; pt says “not the same pain”

Differential Diagnosis RLQ Pain

      Mesenteric Lymphadenitis Utereral Colic Pyelonephritis IBS Diverticulitis PID       Ectopic Pregnancy Ruptured Ovarian Cyst Mittleshmerz Endometriosis Ovarian Torsion Appendicitis

Now What?

   Negative Obstetrical & Gynecologic History Negative Obsetrical & Gynecologic Physical Exam Exploratory Laparoscopy

Operating Room

  2-3cm incision in umbilicus & 2-3cm incision suprapubically Used a laparoscope to view ovaries and uterus   Both ovaries and uterus appeared normal Viewed appendix since McBurney’s Point was the maximal point of tenderness

Findings

    Observed all angles of appendix Consensus was that it did not appear acutely inflamed but did not appear “normal” Adhered to and wrapped around the ileum of the large intestine Consulted Dr. Armstrong who was given patient’s history and PE findings and agreed to remove it

Final Diagnosis

 Appendix was chronically inflamed by a luminal obstruction of a “fibrous foreign material”

Patient Follow-Up

 Patient has since reported that her RLQ pain has resolved

Data

    CT Scan is predicted to be 93-98% accurate and 87-100% sensitive Rare case of chronic appendicitis with luminal obstruction was overlooked and undetected Positive McBurney’s Point tenderness was ignored twice Negative CT Scans that led to misdiagnosis and exclusion of appendicitis was accepted twice

Data

   Appendicitis is #1 diagnosis of RLQ abdominal pain in the ER Abdominal pain in women is often assumed to pertain to menses or to originate from female organs “can be a diagnostic dilemma” in women

Lesson?

Treat the Patient, Not the Labs!

Citations

    Feldman. Sleisinger & Fordtran’s gastrointestinal and Liver Disease, 8th ed. Saunders, 2006. www.mdconsult.com

Old, Jerry L M.D., Dusing, Reginald W M.D., Yap, Wendell M.D., Dirks, Jared M.D. Imaging for suspected appendicitis. American Family Physician, 2005; 71 (1). www.mdconsult.com

Piccini, Jonathan P. M.D., Nilsson M.D. Approach to abdominal pain. The Osler Medical Handbook, 2nd ed. www.mdconsult.com

Vanwinter, JT. Chronic appendicitis diagnosed preoperatively as an ovarian dermoid. Journal of

pediatric and adolescent gynecology, 2004;

17(6): 403-406. www.mdconsult.com