Suganya Karuppana Karuppana,, MD Assistant Clinical Professor David Geffen School of Medicine at UCLA Department of Family Medicine Harbor--UCLA Medical Center Harbor Disclosure ¨ No Conflicts of Interest ¨ ¨ ¨ ¨ Explore the differential diagnosis of patients with acute lower abdominal pain Recognize the clinical history and PE findings which can aid in the diagnosis Review evidence behind clinical decisions in the workwork-up of pelvic pain Utilize interactive case presentations to discuss the evaluation and management of 3 different causes of acute pelvic pain ¨ ¨ ¨ ¨ ¨ CC: Abd pain HPI: 17 yo G0P0 presents to GHS Clinic with abdominal pain, vaginal discharge, and painful sex for past week. No new partners, 2 lifetime partners, Condoms as BCM sometimes. LMP 2 wks ago. D/C is whitish--yellow. Denies n/v, f/c, whitish dysuria/frequency. dysuria /frequency. PMH/PSH: none Meds: None SH: HEADDSSS NC FH: NC Icon ((-) Periumbilica eriumbilical Appendicitis (early) SBO Gastroenteritis Mesenteric ischemia AAA rupture AAA dissection R lower quadrant Appendicitis IBD Ovarian tumor Ovarian torsion Ectopic pregnancy PID Tubo-ovarian abscess Pyelonephritis Perinephric abscess Urolithiasis GI malignancy Diverticulitis Ileocolitis Gastroenteritis Hernia Suprapubic Irritable bowel disease Ovarian tumor Ovarian torsion Ectopic pregnancy PID Tubo-ovarian abscess Dysmenorrhea Colonic disease Diverticulitis Cystitis Nephrolithiasis L lower quadrant Irritable bowel disease Ovarian tumor Ovarian torsion Ectopic pregnancy PID Tubo-ovarian abscess Pyelonephritis Perinephric abscess Nephrolithiasis Sigmoid diverticulitis Ileocolitis Gastroenteritis Hernia GI malignancy Diffuse Gastroenteritis Bowel obstruction Peritonitis Mesenteric ischemia Irritable bowel disease Diabetic ketoacidosis Porphyria Uremia Hypercalcemia Sickle cell crisis Vasculitis Heavy metal intoxication Opiate withdrawal Familial Mediterranean fever Hereditary angioedema ¨ Definition: Polymicrobial infection that originates from upward spread of infecting organisms through the cevix and into the uterus, fallopian tubes, or peritoneal cavity. ¨ Affects 1.5 million women/ yr ¨ Strong association with PID and STI ¨ Serious sequelae of infertility and ectopic •Abd Pain and Dyparunia most sensitive for PID •Lack of these symptoms effectively rules out PID •Ok to evaluate without speculum / bimanual exam ONLY IF NO ABDOMINAL PAIN Laboratory Evaluation of Acute Upper Genital Tract Infection PEIPERT, JEFFREY F. MD, MPH; BOARDMAN, LORI MD; HOGAN, JOSEPH W. ScD; SUNG, JAMES MD; MEYER, KENNETH H. MD May 1996 - Volume 87 - Issue 5, Part 1: 730-6 ¨ 120 women with CDC diagnosis of PID ¨ WBC, ESR, CRP, Wet Mount WBC ¨ Gold standard EMB •Conclusion: •No single lab has good sensitivity & specificity •Wet mount for WBC most sensitivity • Serum WBC most specific •All NL labs= No PID on gold standard EMB •Combinations increase your Specificity and PPV while decreasing your Sensitivity and NPV •No single or combo of tests recommended for Dx •If Negative for all can exclude PID •Test are not available rapidly so if PID is suspected, then treatment should be started •300 women 3 criteria for PID •Randomized to Outpt vs Inpt Treatment •Followed for 5 years Criteria for hospitalization: ¨ ¨ ¨ ¨ ¨ ¨ Surgical emergencies cannot be excluded Pregnant No clinical responds to PO ABX after 72 hrs Unable to follow/tolerate outpatient PO Tx Severe illness, N/V, or high fever Tubo--ovarian abscess Tubo ¨ ¨ ¨ ¨ ¨ ¨ CC: Abd Pain HPI: 23 yo latina female presents to the FMC UC with abdominal pain, N/V, and cramping since this AM. Her LMP was 9 weeks ago. PMH: STI treated with 2 weeks of ABX and a shot 2 years ago. Abnormal Paps PSH: Leep procedure 1 yr ago SH: Smokes 1ppd x 5 yrs, No EtoH/ Rec Drugs FH: Mom used DES during her pregnancy Periumbilica eriumbilical Appendicitis (early) SBO Gastroenteritis Mesenteric ischemia AAA rupture AAA dissection R lower quadrant Appendicitis IBD Ovarian tumor Ovarian torsion Ectopic pregnancy PID Tubo-ovarian abscess Pyelonephritis Perinephric abscess Urolithiasis GI malignancy Diverticulitis Ileocolitis Gastroenteritis Hernia Suprapubic Irritable bowel disease Ovarian tumor Ovarian torsion Ectopic pregnancy PID Tubo-ovarian abscess Dysmenorrhea Colonic disease Diverticulitis Cystitis Nephrolithiasis L lower quadrant Irritable bowel disease Ovarian tumor Ovarian torsion Ectopic pregnancy PID Tubo-ovarian abscess Pyelonephritis Perinephric abscess Nephrolithiasis Sigmoid diverticulitis Ileocolitis Gastroenteritis Hernia GI malignancy Diffuse Gastroenteritis Bowel obstruction Peritonitis Mesenteric ischemia Irritable bowel disease Diabetic ketoacidosis Porphyria Uremia Hypercalcemia Sickle cell crisis Vasculitis Heavy metal intoxication Opiate withdrawal Familial Mediterranean fever Hereditary angioedema ¨ ¨ ¨ ¨ Definition: Any fertilized ovum which implants outside the uterine cavity 97% in Fallopian tubes Leading cause of mortality in 1st trimester ¡ 10 10--15% of all maternal death Increased past few decades ¡ Increased risk factors and diagnosis ¨ ¨ ¨ ¨ ¨ ¨ History: If no risk factors, only abd pain and vag bleeding, there is a 39% risk of Ectopic ¡ Risk increases with risk factors PE 10% have NL exams Only 10% have Adnexal Mass 30% have no vaginal bleeding ¨ Expectant Management ¡ ¨ Medical Management ¡ ¡ ¨ If BB-hCG <1000 and declining, ectopic mass <3 cm, no FHT, reliable for f/u B-hCG <15,000 and reliable for f/u Methotrexate Single vs Multiple Dose Therapy Surgical Management ¡ ¡ Everyone else Contra--indications to Methotrexate Contra ¨ ¨ ¨ ¨ CC: Abd Pain HPI: 12 yo female presents to FMC UC with sudden onset abd pain with N/V x 4 hours. started after running a mile in gym class. Never had this pain before. Started menses this year, irregular, last 3 weeks ago. Not sexually active, no other sick contacts, no recent travel, no new foods, other ROS neg. PMH: Born Full Term, NSVD, No Complications, no Prior Hospitalization PSH: None Meds: None FH/SH: NC Periumbilica eriumbilical Appendicitis (early) SBO Gastroenteritis Mesenteric ischemia AAA rupture AAA dissection R lower quadrant Appendicitis IBD Ovarian tumor Ovarian torsion Ectopic pregnancy PID Tubo-ovarian abscess Pyelonephritis Perinephric abscess Urolithiasis GI malignancy Diverticulitis Ileocolitis Gastroenteritis Hernia Suprapubic Irritable bowel disease Ovarian tumor Ovarian torsion Ectopic pregnancy PID Tubo-ovarian abscess Dysmenorrhea Colonic disease Diverticulitis Cystitis Nephrolithiasis L lower quadrant Irritable bowel disease Ovarian tumor Ovarian torsion Ectopic pregnancy PID Tubo-ovarian abscess Pyelonephritis Perinephric abscess Nephrolithiasis Sigmoid diverticulitis Ileocolitis Gastroenteritis Hernia GI malignancy Diffuse Gastroenteritis Bowel obstruction Peritonitis Mesenteric ischemia Irritable bowel disease Diabetic ketoacidosis Porphyria Uremia Hypercalcemia Sickle cell crisis Vasculitis Heavy metal intoxication Opiate withdrawal Familial Mediterranean fever Hereditary angioedema ¨ ¨ ¨ ¨ ¨ ¨ ¨ ICON (-) Udip (-) Hemacue 12.1 VS: Temp 100.1, BP 102/60, P 125, RR 16 Gen: NAD, Laying still on bed on R side curled Abd Exam: +BS, Voluntary Guarding, No Rebound, TTP LLQ with deep palpation Pelvic Exam: No vaginal lesions or D/C, TTP with palpable mass in L adenxa ¨ Ovarian Cyst or Mass complicated by: ¡ Torsion ¡ Hemorrhage ¡ Rupture ¡ Infection ¨ ¨ ¨ Definition: Ovarian torsion refers to the twisting of the ovary on its ligamentous supports, often resulting in impedance of its blood supply. 5th most common gyn emergency Affects females of all ages ¡ 75% during reproductive years ¡ Mostly prepre-menarchial & early teen yrs ¨ ¨ ¨ 51-84% of pediatric cases have underlying adnexal pathology If cyst, higher risk of torsion >4-5cm Can occur without adnexal pathology ¡ ¡ ¡ ¨ Abnormally long fallopian tubes Adenxal venus congestion (sigmoid distention) Jarring movement of the body when small uterus and large ovary Ratio 3:2 R>L (more space on the right) ¨ ¨ Clinical Pearls: ¡ Torsion Torsion-- Abd Pain and N/V same time ¡ Appy Appy-- pain first then N/V hrs later ¡ Ectopic Ectopic-- usually more severe pain ¡ PID PID-- pain more gradual onset ¡ Kidney stonestone- pain more CVA Imaging: ¡ UTZ with doppler flow most useful ú Though can have flow in ovary torsion ú And can have no flow in normal ovary ¨ ¨ ¨ ¨ ¨ ¨ ¨ ¨ Peipert JF, Boardman L, Hogan JW, Sung J, Mayer KH. Laboratory evaluation of acute upper genital tract infection. Obstet Gynecol 1996; 87 (5 pt 1); 730-6 Ness RB, Soper DE, Holley RL, Peipert J, Randal H, Sweet RL, et al. Effectiveness of inpatient and outpatient treatment strategies for women with pelvic inflammatory disease: Results form the Pelvic Inflammatory Disease Evaluation and Clinical Health (PEACH) Randomized Trial. Am J Obstet Gynecol 2002; 186: 929-37 Lozeau AM, Potter B. Diagnosis and management of ectopic pregnancy. Am Fam Physician. 2005 Nov 1;72(9):1707-14. Crossman SH. The challenge of pelvic inflammatory disease. Am Fam Physician. 2006 Mar 1;73(5):859-64. Gracia CR, Burnhart KT. Diagnosing Ectopic Pregnancy: Decision Anaysis Comparing Six Strategies. J Obstet Gynecol, 2001; 97: 464-70 Banikarim C, Chacko MR. Pelvic Inflammatory Diesase in Adolscents. Semin Pediatr Infect Dis. 2005; 16: 175-80 Cass DL. Ovarian Torsion, Seminars in Pediatric Surgery. Volume 14, Issue 2, May 2005, Pages 86-92 Blake DR, Fletch K. Identification of Symptoms that Indicate a Pelvic Examination is Necessary to Exclude PID in Adolescent Women. J Pediatr Adolesc Gynecol, 2003. 16: 25-30