Question of the Week # 478

478) You are evaluating a 24-year-old female patient who presented with severe abdominal pain two hours prior to admission. She states the pain began in the periumbilical region and has moved to the low abdomen, and she had one episode of emesis with nausea, but no diarrhea. Her last menstrual period was normal and began 27 days ago. On examination, she has a temperature of 98.9, heart rate of 118 beats per minute, and respirations 20/min. Her blood pressure is 100/80. Examination of the abdomen reveals diffuse tenderness to palpation, and she is guarding moderately and has diminished bowel sounds. Complete blood count reveals a hemoglobin of 12 g/dL and a hematocrit of 38%. White blood cell count is 12,500/mm3 with a left shift. Urinalysis reveals 2-5 WBC/hpf. Which of the following is the next best step in management of this patient?

A. Flat and upright abdominal film

B. Pelvic ultrasound

C. Urine b HCG

D. CT abdomen and pelvis

E. Serum beta HCG

15 Responses

  1. c

  2. Flat and upright Abdominal Xray to r/o perforation which needs emergency lap. Rest of the tests can be performed later. Torsion Ovary is another possibility, however given the presentation is less likely and should be investigated next in priority.

  3. First have to exclude pregnancy & for early detection serum HCG is preferred. So answer is ‘E’.

  4. E. She is tachy, afebrile , need r/o ectopic or rupture , afterwards look for CT abdo pelvis .

  5. The menstruation occurred 27 days ago and may have continued for 4-5 days as regular cycle. However if there is a chance for pregnancy here. It can only happen within 14-15 days and the chance for ectopic and positive b hcg on urine are very very less. In either case we can do X ray because, even if it were ectopic, X ray doesn’t harm the fetus which already needs to be removed to save the patients life. still go with Xray. which can be obtained readily. Pelvic U/s can also be done bedside, but can’t r/o perforation. So I still think of Xray.

    • X ray will not harm the patient, and any harm to fetus can be ok here as it is ectopic anyway.

  6. I apologise for poorly opinionated previous response. Here I realise that since the patient is hemodynamically stable, there seems less need for emergency lap. As the afebrile left shift in CBC suggests more towards pregnancy and least possible other causes, I agree with majority of the doctors opinions here to confirm pregnancy test, as 14 -15 days is enough time to cause pregnancy and in 8days, b hcg in urine is detectable to significant levels.

  7. I guess serum hcg is safe bet from urine hcg.

  8. Tough question.
    Surgeons, physicians, pediatricians, obstetricians and lawyers will love this question.

    Ok, we know this is a clear clinical picture of acute appendicitis.
    Surgeons will need proof this is not a perforated appendix. A surgeon will decide to leave a post operative drain if there is a perforated appendix.
    Radiologist will need proof this patient is not pregnant. They will not like a law suit, and they will like to use low-dose imaging algorithms if this lady is pregnant.

    We need both, so we follow the sequence – bedside pregnancy test (option C) and then x-ray (Option A)

    Best next step is to follow the sequence.

    My answer is option C.

    Why not do serum beta HCG or CT scan? This is a time sensitive case. An inflamed appendix can rupture unprecedentedly.

    Why not pelvic ultrasound? The diagnosis of appendicitis is not contested. If it were, the question will give a detailed pelvic and gynecological exam. This is not a gynecological emergency (ectopic pregnancy). If the question writer wanted us to think about ectopic pregnancy, the clinical picture will suggest shock or sexual history, or history of P.I.D (pelvic inflammatory disease) may be included.

    Readings & references:
    Acute appendicitis -http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1562475/

    American college of radiology guideline for imaging pregnant or potentially pregnant adolescents and women with ionizing radiation –
    http://www.who.int/tb/advisory_bodies/impact_measurement_taskforce/meetings/prevalence_survey/imaging_pregnant_arc.pdf

    Evaluation and management of acute abdominal pain in the emergency department – http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3468117/

    Plain Abdominal X-ray in acute abdominal pain: past, present, future – http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3396109/

    Antibiotics versus appendectomy in the management of acute appendicitis – http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3195652/

    Treatment of suspected acute perforated appendicitis with antibiotics and interval appendectomy – http://www.ncbi.nlm.nih.gov/pubmed/24650475

    The utility of peritoneal drains in patients with perforated appendicitis – http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4512985/

    • i would go with usg .since both ectopic and appendicitis have equal possibilities usg would be my choice.since both could be looked for at the very first test.and if uncoclusive sent for b hcg in the mean time!

  9. Where can we find answers and explanation to all these questions?

  10. Dr red would be good to have answer as confirmation, but based on this medical history, an ectopic pregnancy is high on the differential diagnosis of perforated appendix, ruptured ovarian cyst, PID, acute salpingitis. Pregnancy must be ruled out so a CT scan and abdominal x-ray should be avoided until pregnancy is R/O with simple urinary bHCG, and if positive, pelvic ultrasound.

  11. Ultrasound rt ans

  12. Usg abdomen

  13. B hcg levels in urine.. to confirm pregnancy.. followed by US to see ectopic..

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