Acute abdomen in adolescent girls

Acute Abdomen In Adolescent Girls

DR VIDYA THOBBIPROF AND HEAD

DEPT OF OBGAL AMEEN MEDICAL COLLEGE

BIJAPUR

• Acute abdomen refers to– Sudden– Severe pain – Of unclear etiology– Duration is less than 24hours

• Condition associated by pain, tenderness and/or muscular rigidity persisting more than six hours often requires surgical intervention

• Most of the time it is a medical emergency requiring specific urgent diagnosis

Evaluation of adolescent girls

• Problems encountered in adolescents are The distinction between acute and chronic pain

in adolescents is not clear Atypical symptoms HistoryoConfused, fearful of societies’ scorn, sexual

promiscuity, communication problems, anxiety

Emotional and psychological conflict Distressing physical illness Physical and pelvic examination of an

uncooperative patient

History

A few classic descriptions:• Diffuse, severe, colicky pain: bowel

obstruction• “Pain out of proportion to examination”

mesenteric ischemia• Radiation of pain from epigastrium straight

through to the mid back: pancreatitis, either primary or from a penetrating ulcer

• Characterizing the pain is the key– Onset, duration, location, character

HistoryAlways obtain a thorough gynecologic history including :

• Menstrual history, mode of contraception (if any), vaginal discharge, fibroids, pelvic inflammatory disease, sexually transmitted diseases

• History: pregnancies and complications • Sexual history• GI symptoms

– Nausea, emesis– Constipation– Diarrhea

• Jaundice, alcholic stools, dark urine• Hypothyroidism• Prior surgeries (adhesions)• Urine output • Constitutional Symptoms: fevers / chills

Presentation of acute abdomen

• PAIN• SHOCK• VOMITING• DISTENSION OF ABDOMEN

Clinical Diagnosis

Etiology of acute abdomen

• Acute pelvic pain may be the manifestation of Various gynecologic and non-gynecologic disorders From less alarming rupture of the follicular cyst to life

threatening conditions such as rupture of ectopic pregnancy or perforation of inflamed appendix

• Acute pelvic pain may occur even in Normal intrauterine pregnancy and its complications• This may be explained by hormonal changes, rapid

growth of the uterus and increased blood flow.


Most common gynecological causes of acute abdomen are:

• Acute salpingitis, Acute pelvic inflammatory disease• Tubo ovarian abscess• Ectopic pregnancy• Haemorrhage from a functional ovarian cyst• Adnexal or ovarian torsion or torsion of pedunculated

myoma• Septic abortion with peritonitis• Acute urinary retention due to retroverted uterus• Dysmenorrhoea / Endometriosis / Hematometra

Pelvic inflammatory disease and TO abscess

• Annually, there are – Approximately 1 million women who develop pelvic

inflammatory disease (PID)– An estimated 1 in 8 sexually active adolescent girls develop PID

before reaching age 20 years• One of the most serious complications of sexually transmitted

diseases.– Leading to endometritis, salpingitis, salpingo-oophoritis, tubo-

ovarian abscess (TOA) and pelvic peritonitis• Prompt diagnosis and treatment of this condition are critical

– because complications of PID can be life and fertility threatening

US National Library of Medicine, National Institutes of Health. Pelvic inflammatory disease (PID).

Ectopic pregnacy• Classic Symptoms

Abdominal pain Amennorrhea Vaginal Bleeding

• Diagnosis Transvaginal U/S (TVS)

Presence of a true gestational sac at 4.5 to 5 wks is the 1st sign of IUP

Cardiac activity is first detected at 5.5 to 6 weeks

Serum quantitative HCG Absence of an intrauterine

gestational sac at hCG concentrations >1500-2000 IU/L suggests an ectopic or nonviable intrauterine pregnancy

• Management Option of medical vs surgical

management if pt is hemodynamically stable and no rupture has occurred

Emergent surgical management if rupture has occurred and/or patient is hemodynamically unstable

• Prognosis Ruptured ectopic pregnancies

account for 4- 10 percent of all pregnancy related deaths.

Adnexal Torsion

• Torsion of the adnexa An acute gynecologic surgical emergency Prolonged torsion can lead to infarction of the

tube and ovary involved Early diagnosis is important because • Prompt surgical intervention can result in

ovarian preservation by saving the ovary and adnexa from infarction

If left untreated, peritonitis and death may ensue.


• Ovarian cysts Functional hemorrhagic cysts Benign neoplasms dermoid cysts 3.5% Malignant neoplasms Germ cell tumors

• Neoplasms and cystic adnexal lesions complicated by haemorrhage, torsion and infarction is one of the common diagnoses for acute abdomen.

Radiologe ; 1997, Jun, 37(6), 459-63

• Ruptured corpus luteum cyst• Ovarian haemorrhage from the corpus luteum of

menstruation or pregnancy• Life threatening surgical condition• Can occur at all stages of a woman’s reproductive life

• A corpus luteum cyst predisposes to rupture. • Culdocentesis is positive for haemoperitoneum and if

hematocrit >12% surgical intervention is indicated for hemostasis.

Am J Obstet Gynecol. 1984 May 1;149(1):5-9.

Adnexal Torsion

• When AT is suspected, urgent surgical intervention is

indicated, and is usually performed by laparoscopy.• Despite the "necrotic" appearance of the twisted ischemic

ovary, detorsion is the only procedure which should be performed at surgery.

• Adnexectomy should be avoided as ovarian function is preserved in 88% to 100% of cases.

• Recent evidence reinforces the role of detorsion in lieu of oophorectomy or adnexetomy in an effort to preserve reproductive capacity in a young population.

Clin Obstet Gynecol. 2006 Sep;49(3):459-63.Curr Opin Obstet Gynecol. 2005 Oct;17(5):483-9.

Torsion of Parovarian cyst

Torsion of Parovarian cyst

To pex or not to pex?

Routine ovariopexy after detorsion does not seem warranted because the risk of retorsion is very low when a cause is found and treated.

Mage G, Canis M: Laparoscopic management of adnexal torsion. A review of 35 cases.

J Reprod Med 34:521, 1989

• To name a few Isolated torsion of the fallopian tube Hydrosalpinx Ovarian Hyperstimulation Syndrome(OHSS) ruptured hematosalpinx

Rare cases of acute abdomen


• Torsion of adnexa is relatively common, but isolated torsion of the fallopian tube is rare.

• It should be considered in all adolescents who present with acute pelvic pain

• Prompt laparoscopic intervention may allow for – early diagnosis, treatment and preservation of the

tube if possible

J Obstet Gynecol. 2006 Dec;45(4):363-5


• Hydrosalpinx– One of the predisposing factors of adnexal torsion– Because the incidence of hydrosalpinx in adolescent

virgin patients is very rare, it may cause diagnostic dilemma, leading sometimes to suboptimal treatment

• Although very rare in adolescence, it must be considered in the differential diagnosis

• Aspiration in such cases is not the treatment of choice and moreover, it may cause complications.

J Pediatr Adolesc Gynecol. 2006 Aug;19(4):297-9.


• Ovarian Hyperstimulation Syndrome(OHSS)– One of the differential diagnoses for acute abdomen– The massive world wide development of ART and marked

increase of females with infertility treatment has lead to difficult medical complications. One of them is OHSS.

– It presents as abdominal discomfort, nausea, vomiting and ascites.

Rozhi Chir, 2010 Aug 89(7) ; 402-5


• Acute abdominal pain may occur as a result of ruptured hematosalpinx : – A complication of an unusual mullerian anomaly– Laparoscopic excision of a unilateral non

communicating uterine horn is a valid and recommended treatment approach of this rare malformation.

J Pediatr Adolesc Gynecol. 2009 Jun;22(3):e9-11.

Differential diagnosisfor pain of sudden onset

severe morbidity/mortality

• Rupture of TO abscess or hematoma• Ruptured ectopic pregnancy• Hemorrhage and torsion of adnexa

Acute abdomen a clinical challenge

• Require all resources to reach accurate diagnosis, timely management and proper disposition

• 10% require urgent surgery

Lab & Imaging

CBC w diff Left shift

BMP Acidosis, dehydration

AmylasePancreatitis, perf DU,

bowel ischemia

LFT Jaundice, hepatitis

UA GU- UTI, stone, hematuria

Beta-hCG Ectopic

Lab tests

• Urinalysis and urine pregnancy test are perhaps the most cost-effective tests UPT sent on all women of reproductive age Urinalysis interpreted with respect to the clinical

picture Pyuria often present without UTI Up to 30% of patients with appendicitis have

abnormal urinalysis• Elevated WBC is neither sensitive nor specific • Electrolytes are abnormal in <1% of patients

ImagingTest Reason

KUB

Flat & Upright Free air, stones

Ultrasound Colour Doppler GYN pathology

CT scan, MRI

Anatomic DxDiagnostic accuracy

Case not straightforward

Ultrasonography in acute abdomen

• Sonography– High sensitivity and specificity in visualization of uterine

and adnexal signs of ectopic pregnancy– Color Doppler

• May aid in detection of the peritrophoblastic flow

– Facilitates detection of ectopic living embryo, tubal ring or unspecific adnexal tumor

– Corpus luteum cysts and leiomyomas are another cause of pelvic pain during pregnancy, can be correctly diagnosed by ultrasound

Acta Med croatica 2002;569[4-5]171-80

Ultrasonography in acute abdomen

• Appendicitis – The most common surgical emergency and should always

be considered in differential diagnosis if appendix has not been removed.

– Apart from clinical examination and laboratory tests, an ultrasound examination is sensitive up to 90% and specific up to 95% if graded compression technique is used.

Ultrasonography of the pelvis showing bilateral huge multicystic ovaries :

Seen in a 18 yr old girl with acute abdomen

Ultrasonography showing a

haemorrhagic corpus luteum cyst

Ultrasonography showing ectopic

pregnancy

Ultrasonography showing isolated

fallopian tube torsion with pregnancy

Ultrasonography showing tubo ovarian

abscess

CT in acute abdomen

• Computed tomography (CT) is being found extremely valuable In assessing the causes Determining the appropriate treatment (in

particular whether surgery is needed) Determining when and how that surgery should

most appropriately be done

CT showing rupture of ectopic pregnancy in right fallopian tube

CT showing tubo ovarian

abscess

CT showing ovarian torsion

MRI in Acute abdomen• Rapid advances in techniques of magnetic resonance

(MR) imaging have enabled diagnosis of acute abdominal conditions.

• Ultrasonography (US) is a useful imaging modality for evaluation of patients suspected to have acute diseases.– US findings are not always conclusive

• Computed tomography – Exposes patients to ionizing radiation, which is problematic

among young women• Magnetic resonance (MR) imaging

– A valuable complement to US when used as an emergency examination in a patient with suspected acute gynecologic disease.

– The recent development of fast MR imaging has shortened the imaging time enough for emergency use.

MRI showing hemorrhagic ovarian cyst with

hemoperitoneum

MRI showing twisted left ovarian cystic teratoma with

hemorrhagic necrosis in a girl with pelvic pain and

nausea.

MRI showing pyosalpinx

Basic Principles

• Signs and symptoms of intra-abdominal disease usually best treated by surgery

• Proper evaluation and management requires one to recognize:

1. Does this patient need surgery?

2. Is it emergent, urgent, or can wait?• In other words, is the patient unstable or

stable?• Learn to think in “worst-case” scenario• But remember medical causes of abdominal pain

Management

• Up to 7% of patients with abdominal pain may have a life-threatening process

• Physiologically compromised patients should be identified in triage and brought immediately to the treatment area for resuscitation

Management• All critically ill patients require

resuscitation before beginning a diagnostic assessment

• What is important is not to make a specific diagnosis, but to identify and treat life threatening conditions

Airway • Profound shock or

protracted emesis may compromise airway and require intubation

Breathing: • Provide supplemental O2

• O2 saturation monitoring

Laparoscopy in acute abdomen

• Despite new x-ray techniques, or scans, and ultrasound, the diagnosis of acute abdomen can be difficult at times.

• So far, the most accurate non-invasive method of diagnosis is ultrasound but that is not reliable.

• History and physical examination will generally lead to correct diagnosis occasionally.

• Diagnostic laparoscopy is the most accurate method even compared to open laprotomy.

Perri SG, Altilia F et al. Laparoscopy in abdominal emergencies. Indications and Limitations. Chir Ital 2002; 54: 165-78.

Inflamed appendix, about to

perforate:

laparoscopic view

Right tubal ectopic pregnancy at laparoscopy surgery

Ovarian torsion (laparoscopic

view)

Acute on-set of Hematometra and Hematosalpinx :

laparoscopic view

Image in a 15-year-old girl with salpingitis

Laparoscopic view of acute PID

Pelvic pain A SAFE Approach

SEVERITY AFFECT FAMILY ENVIRONMENT

SAFE Approach

• Discussion and assessment of emotional issues and psychological concerns are integral component of evaluation and management of pelvic pain in adolescents

TAKE HOME MESSAGE

• Careful history Pain, menstrual history, sexual exposure, other GI symptoms

• Remember DDx in broad categories• Narrow DDx

Based on history, exam, labs, imaging• Always perform

ABC, Resuscitate before Dx• Don’t forget

GYN/medical causes, surgical special situations• For acute abdomen , in adolescent girls think of these commonly

Adnexal Torsion Ectopic pregnancy Pelvic infection

THANK YOU

Health & Medicine

Acute abdomen in adolescent girls