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