Persistent Lower Abdominal Pain Research Articles

Heterotopic pregnancy after a single embryo transfer with successful perinatal outcome: case report and literature review

A heterotopic pregnancy is a rare and serious pathological pregnancy. In this paper, we report a rare case of heterotopic pregnancy and perform a literature review. A 30-year-old patient with a history of left adnexectomy presented with persistent lower abdominal pain and hemorrhagic shock after single embryo transfer. Emergency laparoscopic exploration revealed a ruptured mass in the right isthmus of the fallopian tube, for which right salpingectomy was performed. After anti-inflammatory treatment and fetal preservation, the intrauterine pregnancy progressed smoothly, and a healthy baby was delivered at 39 weeks gestation. In this case, the patient’s heterotopic pregnancy was possibly due to a natural pregnancy caused by sexual intercourse during treatment, so we recommend that sexual intercourse be avoided during transfer cycles.

IMAGING MANIFESTATIONS OF WANDERING SPLEEN WITH TORSION

BackgroundA wandering spleen (WS) is a rare clinical entity characterized by a spleen located in the lower part of the abdomen or the pelvic cavity rather than the normal anatomical site. The complications of a wandering spleen include splenic torsion, splenic infarction, and adjacent visceral injury. Case reportWe present a case of a male patient admitted to the emergency department with vomiting, nausea, and persistent lower abdominal pain. Computed tomography and ultrasound were performed and were used to diagnose a wandering spleen with torsion leading to splenic infarctions. Subsequently, laparoscopic surgery and pathology confirmed this diagnosis. Why Should an Emergency Physician Be Aware of This?Ultrasound and computed tomography scans play a significant role in diagnosing WS and its complications, allowing an emergency physician to establish treatment options for WS.

Impacted golf tee shaped appendiceal fecalith causing appendiceal non-visualization and mimicking cecal mass: A case report

Introduction: When fecaliths occur in the appendix, they commonly cause obstruction and bacterial overgrowth leading to appendicitis presenting as right lower quadrant pain. Fecaliths can be identified radiographically, and their presence raises high suspicion of appendicitis in the right clinical setting. Case Report: A 25-year-old Caucasian male presented with persistent lower abdominal pain, which was suspected to be a cecal mass on colonoscopy. Radiography by X-ray and computed tomography (CT) scan described a non-visualized appendix and no evidence of a fecalith. Colonoscopy was performed, and biopsies revealed an inflamed colonic mucosa with fecalith-like material. Subsequent right hemicolectomy revealed no cecal mass but an impacted golf tee shaped appendiceal fecalith which caused neither obstruction nor appendicitis due to its unique structure. Conclusion: This case report describes an appendiceal fecalith that grew in the form of a golf-tee starting at the tip, growing to the appendiceal orifice, and deviating from every known clinical and radiographic presentation of appendiceal fecalith with unusual pathogenesis. Specifically, this uncommonly shaped fecalith rendered the appendix difficult to visualize radiographically, mimicked a cecal mass on coloscopy, and caused persistent lower abdominal pain, in the absence of obstruction and without leading to appendicitis. This novel presentation widens the spectrum of appendiceal pathologies and clinical signs and symptoms that may be caused by a fecalith.

Adrenal Insufficiency due to Total Primary Empty Sella Syndrome

A 64-year-old woman was transported suffering from persistent lower abdominal pain, vomiting, and low-grade fever. Magnetic resonance imaging revealed an empty sella (ES) and hormone tests revealed a disappearance of diurnal variation of cortisol, low cortisol and adrenocorticotropic hormone (ACTH) secretion especially in the morning, and poor ACTH-cortisol axis reaction, as well as normal hypothalamus-pituitary gland-thyroid or adrenal gland axis hormone reaction. The cause of ES remained unclear; however, based on a diagnosis as adrenal insufficiency due to inappropriate ACTH secretion caused by total primary ES syndrome, we started hydrocortisone (15 mg/day). Afterwards, she immediately became symptom-free and was discharged. J Endocrinol Metab. 2020;10(5):144-153 doi: https://doi.org/10.14740/jem686

Subacute uterine inversion following an induced abortion in a teenage girl: a case report

BackgroundSubacute uterine inversion is a very rare complication of mid-trimester termination of pregnancy that should be considered in a situation where unsafe abortion occurs.Case presentationWe present a case of subacute uterine inversion complicated by hypovolemic shock following an unsafe abortion in a 17-year-old nulliparous unmarried girl. She presented with a history of collapse, mass protruding per vagina that followed Valsalva, and persistent lower abdominal pain but not vaginal bleeding. This followed her second attempt to secretly induce an abortion at 18 weeks amenorrhea. On examination, she was agitated, severely pale, cold on palpation, with an axillary temperature of 35.8 °C, a tachycardia of 143 beats per minute and unrecordable low blood pressure. The abdomen was soft and non-tender with no palpable masses; the uterine fundus was absent at its expected periumbilical position and cupping was felt instead. A fleshy mass with gangrenous patches protruding in the introitus was palpated with no cervical lip felt around it. We made a clinical diagnosis of subacute uterine inversion complicated with hypovolemic shock and initiated urgent resuscitation with crystalloid and blood transfusion. Non-operative reversal of the inversion failed. Surgery was done to correct the inversion followed by total abdominal hysterectomy due to uterine gangrene.ConclusionOur case highlights an unusual presentation of subacute uterine inversion following unsafe abortion. This case was managed successfully but resulted in significant and permanent morbidity.

Adrenal Insufficiency due to Total Primary Empty Sella Syndrome

A 64-year-old woman was transported suffering from persistent lower abdominal pain, vomiting, and low-grade fever. Magnetic resonance imaging revealed an empty sella (ES) and hormone tests revealed a disappearance of diurnal variation of cortisol, low cortisol and adrenocorticotropic hormone (ACTH) secretion especially in the morning, and poor ACTH-cortisol axis reaction, as well as normal hypothalamus-pituitary gland-thyroid or adrenal gland axis hormone reaction. The cause of ES remained unclear; however, based on a diagnosis as adrenal insufficiency due to inappropriate ACTH secretion caused by total primary ES syndrome, we started hydrocortisone (15 mg/day). Afterwards, she immediately became symptom-free and was discharged. J Endocrinol Metab. 2020;10(5):144-153 doi: https://doi.org/10.14740/jem686

IDIOPATHIC RETROPERITONEAL FIBROSIS: A RARE CAUSE OF ABDOMINAL PAIN AND OBSTRUCTIVE UROPATHY

SESSION TITLE: Wednesday Medical Student/Resident Case Report Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: 10/23/2019 09:45 AM - 10:45 AM INTRODUCTION: Retroperitoneal fibrosis (RPF) is a rare disorder that presents with subtle symptoms. It may be idiopathic or secondary to other causes; with the idiopathic form being either immunoglobulin G4 (IgG4) or non-IgG4 related. The incidence of idiopathic RPF has been reported to be 0.1 per 100,000 person-years with a male-to-female ratio of 1.9:1. Our case aims at highlighting this rare disorder as a cause of abdominal pain in a middle-aged man. CASE PRESENTATION: A 48-year-old man presented with persistent lower abdominal pain, decreased appetite and weight loss for three months. Physical exam was remarkable for mild abdominal tenderness. Laboratory results were remarkable for creatinine 1.6 mg/dL, BUN 56 mg/dL, CRP 35.7 mg/L and ESR 95 mm/hr. CBC, infectious workup, autoimmune panel, serum protein electrophoresis and tumor markers were unremarkable. Serum IgG and immunoglobulin G4 (IgG4) were normal. CT abdomen and pelvis revealed a soft tissue mass surrounding the distal abdominal aorta and inferior mesenteric artery; entrapping the left ureter accounting for left-sided hydroureteronephrosis. The patient underwent left uterolysis and DJ stent placement. Histopathology (H/P) of the mass showed an abundance of fibro-adipose tissue and lympho-plasmacytic infiltration with rare IgG4 positive plasma cells; negative for infection or malignancy. The patient was started on high dose prednisone leading to resolution of clinical symptoms. Serum creatinine level, ESR and CRP also returned to normal. A follow up CT scan showed regression of the mass. DISCUSSION: RPF is a rare fibro-inflammatory disease with poorly understood pathogenesis. Idiopathic RPF accounts for more than 70% of cases, with secondary causes related to retroperitoneal injury, malignancy, infection, drug therapy or genetic factors. Interestingly, a recent study (Zen et al) found a positive correlation between immunoglobin G4 (IgG4) on H/P and idiopathic RPF in 10 cases out of 17 patients. These cases were hallmarked by a unique H/P pattern and elevated serum IgG4 concentration. Our case, however, was the non-IgG4 related type. Patients with IRF most frequently present with abdominal pain, weight loss and features of obstructive uropathy. Elevated inflammatory markers and imaging studies aid in the diagnosis but biopsy is the gold standard. Goals of treatment for RPF is relief of ureteral obstruction and disease regression with glucocorticoids with or without other immunosuppressants. Tamoxifen has been used with success in patients who cannot tolerate glucocorticoids. Biologic therapies such as rituximab and tocilizumab have shown promise in select patients with refractory disease but further research is warranted. CONCLUSIONS: Idiopathic retroperitoneal fibrosis should be kept in the differential diagnosis of a patient presenting with abdominal or flank pain, obstructive uropathy and elevated markers of inflammation. Reference #1: Idiopathic retroperitoneal fibrosis: clinicopathologic features and outcome analysis. Yachoui R, Sehgal R, Carmichael B. Clin Rheumatol. 2016 Feb;35(2):401-7. https://doi.org/10.1007/s10067-015-3022-y. Epub 2015 Jul 25. Reference #2: Idiopathic and secondary forms of retroperitoneal fibrosis: a diagnostic approach. Urban ML, Palmisano A, Nicastro M, Corradi D, Buzio C, Vaglio A. Rev Med Interne. 2015 Jan;36(1):15-21. https://doi.org/10.1016/j.revmed.2014.10.008. Epub 2014 Nov 18. Reference #3: Idiopathic retroperitoneal fibrosis and its overlap with IgG4-related disease. Rossi GM, Rocco R, Accorsi Buttini E, Marvisi C, Vaglio A. Intern Emerg Med. 2017 Apr;12(3):287-299. https://doi.org/10.1007/s11739-016-1599-z. Epub 2017 Jan 9. DISCLOSURES: No relevant relationships by Moses Bachan, source=Web Response No relevant relationships by Muneer Khan, source=Web Response No relevant relationships by Zinobia Khan, source=Web Response No relevant relationships by Mariam Saeed, source=Web Response

Supernumerary right kidney with it own urethra: a case report and literature review

There are only a few reports on supernumerary kidney However, its discovery being difficult in places where diagnostic facilities are not easily accessible. We present a case of A 9 year old girl with a congenital malformation and supernumerary kidney at right upper pole of the right kidney with a mega urethra in which there is pus. The main complaint was a mild, persistent lower abdominal pain associated with virginal reflux. Urine analysis and culture as well as serum blood values were within normal limits. The diagnosis of visceral malformations, particularly a supernumerary kidney is not easy, especially in an environment where diagnostic facilities are not easily accessible.

Bilateral supernumerary kidneys in conjunction with horseshoe anomaly.

Bilateral supernumerary kidney is a very rare urogenital anomaly, with four cases reported in the literature thus far. To the best of our knowledge, bilateral supernumerary kidney in conjunction with horseshoe fusion anomaly is not reported till date. Herein, we report a 63-year-old male patient with persistent lower abdominal pain. Complete radiological evaluation including ultrasound, computed tomography scan, excretory urography and retrograde pyelography were done and the diagnosis was established. The dilemma faced in the diagnosis and management of patients with supernumerary kidneys is discussed.

Omental Torsion Mimicking Acute Appendicitis: A Diagnostic Pitfall of Acute Abdomen

Omental torsion is a rare cause of acute abdomen and often requires surgical intervention. The etiology is uncertain and the clinical signs mimic acute appendicitis. We present a case of a 34-year-old obese male with no previous medical history. The patient was admitted due to persistent lower abdominal pain. He was initially treated conservatively and underwent surgery because of intractable pain. His clinical diagnosis was acute appendicitis. The torsion of the omentum was found during laparoscopy. Preoperative diagnosis by clinical examination alone is almost never possible. It is possible to make a diagnosis with computer tomography preoperatively. We share our experience with this patient and emphasize omental torsion can be a diagnostic dilemma for acute abdomen, especially lower abdominal pain. Laparoscopy is an excellent tool to make the diagnosis and is helpful to therapy.

Persistent lower abdominal pain induced by long peritoneal shunt catheter

Persistent abdominal pain directly induced by a peritoneal catheter of a ventriculoperitoneal shunt, which is associated with no other complications such as bowel perforation, pseudocyst or infection, has not been previously reported. A 65-year-old woman with hydrocephalus developed persistent lower abdominal pain radiating to the perineal area after shunt insertion. Radiography suggested that the distal end of a peritoneal catheter was located in a cul-de-sac of the pelvis. Otherwise, all studies were negative for shunt infection, fluid collection, or other abdominal and pelvic events. The patient's pain resolved completely after surgery in which the peritoneal catheter was shortened. In the presence of unexplained, persistent lower abdominal pain after shunt placement, the need to shorten the peritoneal catheter should be considered.

Unscarred Uterine Cervical Rupture During Second-Trimester Termination Using Misoprostol

Disruption of a prior uterine incision scar after using misoprostol in term pregnancies has been well docu­ mented [1,2]. Nevertheless, second-trimester termina­ tion using misoprostol may result in rupture in an unscarred uterus [3]. This complication is extremely rare and can be life-threatening and lethal if not well managed. Herein, we report a case of uterine rupture after using misoprostol for second-trimester termina­ tion, with no previous uterine surgery. The patient was diagnosed in time and underwent emergency operation. She recovered well 6 days after operation and was then discharged in good condition. A healthy 32-year-old woman was admitted to a local clinic for termination at 21 weeks ofgestation because of intrauterine fetal demise. Her obstetric history con­ sisted of two spontaneous vaginal deliveries and one ectopic pregnancy, which was treated by right salpin­ gectomy. Besides, she had no other medical or surgical history, including no uterine incision or cervical surgery, and did not take any medication before admission. After admission at the local clinic, she was given rni­ soprostol 150 ~g intra-rectally. Twenty-four hours later, an additional dose of misoprostol 100 ~g was given orally. After taking the oral misoprostol, she suffered an acute, sudden and persistent lower abdominal pain, with profuse bloody show followed by hypovolemic shock. She was transferred to our hospital for emergency treatment. At the emergency service, pelvic examination revealed a distended abdomen with board-like abdomi­ nal muscle guarding and pelvic pain with lifting. Ultra­ sonography revealed a dead singleton fetus in breech presentation and partial placenta previa. In addition,

RETROVESICAL HEMATOMA SECONDARY TO CLEAN INTERMITTENT SELF-CATHETERIZATION

A 36-year-old man presented with massive hematuria after performing self-catheterization with a 14Fr catheter while intoxicated with alcohol and cocaine. Since early childhood, he had suffered from incomplete spastic paraplegia and neurogenic bladder dysfunction consequent to spinal cord trauma. However, for the last 10 years he had successfully performed intermittent self-catheterization, only recently having had to use force because of an approximately 8 cm. long stricture of the penile and bulbar urethra. On physical examination and abdominal ultrasound the bladder was filled with blood clots and a 7 cm. retrovesical mass, consistent with hematoma, was present. The bladder was evacuated with a 20Fr hematuria catheter and a 3-way irrigation catheter were inserted. Cystography showed perforation of the bladder (fig. 1). After conservative treatment with antibiotics and catheter drainage for 7 days, repeat cystography demonstrated closure of the perforation site. The patient resumed intermittent self-catheterization and was discharged from the hospital. The patient returned to the hospital 8 days later with persistent lower abdominal pain and subfebrile temperatures (37.5C). Computerized tomography demonstrated a 10 cm. retrovesical mass (fig. 2). The abdomen was surgically explored via a lower abdominal midline incision and approximately 500 cc of retrovesical hematoma were evacuated. The patient declined concomitant bladder augmentation with continent vesicostomy. Convalescence was uneventful.

Chronic pelvic pain caused by residual ovaries and ovarian remnants

To determine the diagnostic effectiveness and treatment of women with chronic lower abdominal pain due to residual ovaries or ovarian remnants. A prospective observational study. Tertiary referral pelvic pain clinic. Seventeen women complaining of chronic pelvic pain of up to 25 years' duration, of whom seven had residual ovaries and 10 ovarian remnant(s). Persistent lower abdominal pain, pelvic tenderness and quality of life one year post-operatively. Six of the seven women with residual ovaries, and nine of the 10 women with presumed ovarian remnants experienced relief of the original pain, loss of pelvic tenderness and an improved quality of life. Residual ovaries after hysterectomy and ovarian remnants are established causes of chronic pelvic pain. Diagnosis and surgical removal is frequently difficult. Management strategies are proposed for both conditions.

Case 37-1968

Presentation of CaseA fifty-eight-year-old man was admitted to the hospital because of abdominal distention and pain.Four months previously he awoke with malaise and lower abdominal pain, and later in the day, while on a trip to another city, he experienced nausea and persistent lower abdominal pain. On the next morning he was slightly improved and able to drive several hundred miles, although he was anorectic and nauseated, with bloating, constipation and lower abdominal pain. Bowel movements were possible only with severe straining. He noticed no change in the character of the stools, and there was no fever, melena . . .