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A lady presented with diarrhea and abdominal pain

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ollie
24 diapositives · 379 Views · Oct 05, 2014

A 20-year-old female presented with lower abdominal pain and diarrhea, indicating potential gastrointestinal or gynecological issues. Initial assessments revealed stable vital signs but necessitated further investigation due to her symptoms, including a positive pregnancy test and findings suggestive of an early pregnancy. Upon returning for worsening symptoms, she exhibited signs of shock, prompting urgent resuscitation. The case highlights the importance of considering ectopic pregnancy in differential diagnoses, especially with risk factors present. Timely ultrasound assessments are crucial for diagnosis and management.

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  1. HKCEM College Tutorial A lady presented with diarrhea and abdominal pain AUTHOR DR. PAULIN NG REVISED BY DR. WONG HO TUNG OCT, 2013

  2. Triage • Female 20 • ambulatory • BP 120/80 mmHg, P 80/min • Temp 36.8 deg C • c/o: lower abd pain and loose stool twice x1/7 Triage Category IV

  3. History • Dull lower abd pain • Loose stool for 2 times • Nausea, no vomiting • No urinary symptoms • PH: well, NKDA Any other things You want to ask The patient? LMP 6 weeks ago, regular period No PV bleed or vaginal discharge

  4. Physical findings • General: stable vitals, not pale • Abd.: mild lower abd tenderness, no peritoneal irritation or loin tenderness, normal bowel sound • Systems reviews: normal Anything else? • PV: no cervical excitation or definite adnexal mass/tenderness

  5. What are the DDx? • Surgical causes • OBGyn causes • Medical causes Any investigations at this point?

  6. Investigations • Urine • WBC (-), nitrate (-) • Preg test (+) • Pelvic USG in ED • TVS • Small GS was noted How useful is USG in female with Lower abd pain?

  7. Use of US in lower abd pain • confirm IU preg • rule in ectopic • ovarian cyst (torsion) • tubo_ovarian abscess • appendix + abscess • Urolithiasis • AAA (elderly)

  8. Disposition • Patient was discharged with the provisional diagnosis of GE and early pregnancy • She was advised to return if symptoms worsen.

  9. Patient returns the next day • Triage note • c/o: syncope and increasing abd pain • vitals: BP 80/40 mmHg, P 120/min • No PV bleed • Category 2 case Diffuse tenderness + guarding of abd++ What has happened?

  10. Resuscitation What to do next?

  11. Initial resuscitation • High flow O2 • 2 wide bore IV lines with Fluid resuscitation • X-match 4 unit, transfuse if necessary • close monitoring of maternal vitals (and urine output)

  12. Investigations • Blood work • Hb, Hct, Plt count, clotting profile • Blood group and X-match What other Ix? Ultrasound

  13. Free Fluid Adnexal mass

  14. Rupture Ectopic pregnancy in Shock What is the provisional diagnosis?

  15. Disposition • Immediate resuscitation • Inform GYN on call • Admission

  16. Pitfalls • Ectopic pregnancy cannot be ruled out by: • absence of amenorrhoea • negative urine pregnancy test • denial of sexual activity • passing of tissue mass • contraception e.g. IUD • Beware of Pseudosac in pelvic US exam. A female pt with abd pain has EP until proven otherwise!

  17. Pseudosac Sac is thin. No double ring of decidua.

  18. Ectopic Pregnancy • defined as any gestation occurring outside the uterine cavity • 95% are tubal pregnancies, others involve ovary, cervix, or abdominal cavity

  19. Importance of Ectpoic Pregnancy • the incidence has doubled in past decade • causes 12% of maternal death in US • symptoms range from minimal to frank shock • high index of suspicion is required

  20. Clinical Presentations • should always be considered in the differential diagnosis of acute pelvic pain • classical triad may not be present : • Abdominal pain +/- referred pain at shoulder tip, • PV bleeding • Amenorrhoea

  21. Who are High Risk ? • previous ectopic pregnancy • current IUCD use • prior tubal surgeries • history of PID • prior infertility and the use of ovarian induction therapy

  22. USG findings of Ectopic Pregnancy • absence of Intrauterine sac • adnexal mass ± fetus • free fluid in cul-de-sac

  23. USG finding of definite Intrauterine Pregnancy • gestational sac with sonolucent center surrounded by thick, concentric, echogenic ring in the endometrium and containing a fetal pole, yolk sac or both

  24. Thank You