exploratory laparoscopy of abdomen for right lower quadrant pain ob-gyn/r1 dr. young amanda walker
TRANSCRIPT
Exploratory Laparoscopy of Abdomen for
Right Lower Quadrant Pain
OB-GYN/R1Dr. 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 DiagnosisRLQ 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