A rare case of right lower quadrant abdominal pain

Isolated fallopian tube torsion without involvement of the ovary is a rare condition most frequently presenting during reproductive years. Imaging, vitals, physical exam, and laboratory findings all fail to help establish a definitive diagnosis. The majority of the diagnoses are made on the operating table. Physical exam most often reveals unilateral and localized abdominal pain, often with nausea and vomiting, but few other reliably common findings. Diagnosis becomes even more challenging due to the fact that isolated tubal torsion occurs often in pregnancy and preferentially on the right, further complicating the clinical picture.We describe a case of isolated tubal torsion, unique in that localized necrosis and inflammation from the torsion triggered a secondary appendicitis. The patient required surgical intervention, and an appendectomy and salpingectomy emergently. Given its elusive and rare nature, awareness and early intervention is required by the emergency physician to recognize tubal torsion, as operative intervention is crucial, and can lead to preservation of fertility and improved fetal survival.     

Granulomatous appendicitis presenting as right lower quadrant pain: CT findings

Background: We present the computed tomographic (CT) findings of granulomatous appendicitis. Methods: Five of 652 (0.9%) patients who had undergone appendectomy for clinically suspected acute appendicitis over a 19-month period proved to have granulomatous appendicitis. One patient had surgery based on a clinical diagnosis of acute appendicitis. Four patients (three men and one woman; age range = 14–39 years) underwent abdominal CT. The CT findings were retrospectively reviewed with special attention to the appendiceal abnormalities. Results: All four patients presented with subacute clinical presentation. Enlarged appendices of 4.5 and 2 cm in diameter with thickened walls of soft tissue density were found in two patients, and periappendicular inflammatory masses were found in the other two. Enlarged mesenteric lymph nodes and right lower quadrant fat stranding was seen in all four patients. Histopathology showed numerous granulomas within the inflamed appendix. Conclusion: Radiologists should be familiar with the rare entity of granulomatous appendicitis in patients examined by CT for suspected acute appendicitis. An insidious clinical presentation with CT findings of an exceptionally large appendix and associated periappendiceal inflammatory changes should raise the possibility of granulomatous appendicitis or carcinoma or lymphoma of the appendix.     

Anterior position of the lower pole of the right kidney: Potential confusion with right upper quadrant mass

A group of patients with anterior position of the lower pole of the right kidney were examined with ultrasound to evaluate a palpable right upper quadrant mass. After it was determined, with the use of ultrasound, that the palpable mass represented the kidney, no further evaluations were necessary. This appearance is seen fairly often in normal individuals and should be considered a normal variant. The possible anatomic explanation for this appearance is discussed.     

ED endovaginal pelvic ultrasound in nonpregnant women with right lower quadrant pain

Introduction

We hypothesized that emergency physician–performed endovaginal ultrasound (EVUS) would change diagnostic decision making in nonpregnant women with right lower quadrant (RLQ) pain.

Methods

A prospective cohort of female patients was enrolled at an urban emergency department (ED). Inclusion criteria were RLQ pain, hemodynamic stability, and a strong suspicion for appendicitis or right adnexal pathology. Treating physicians were queried regarding pre– and post–ED EVUS probability of disease, differential diagnoses, consultation, and management. Positive findings included large cysts or multitissue densities, tubal dilation, uterine enlargement/mass, and extensive peritoneal fluid.

Results

With a positive ED EVUS, mean physician probability increased for gynecologic (24%) and decreased for both surgical (14%) and medical (20%) disease. With a negative ED EVUS, mean physician probability increased for surgical disease (5.3%) and decreased for gynecologic disease (18.6%).

Conclusion

Emergency department EVUS changes physician diagnostic decision making in nonpregnant women with undifferentiated RLQ pain.     

以右下腹痛为主要表现的疾病误诊为急性阑尾炎44例分析

以急性右下腹疼痛为主要表现的疾病,常涉及内、外、妇、儿科多个系统,若临床医生分析主观片面极易造成误诊、误治,处理不当将导致严重后果,我科1995年2月～2 0 0 2年2月将以右下腹痛为主要表现的疾病误诊为急性阑尾炎而手术4 4例。现将误诊原因分析如下。1　临床资料1 1　一般     

Prospective randomized study of analgesic use for ED patients with right lower quadrant abdominal pain

Giving an analgesic to patients with right lower quadrant (RLQ) pain causes greater alteration of abdominal signs predictive of appendicitis than placebo. A randomized double-blinded controlled trial of 68 patients who received either tramadol or placebo. Absence or presence of seven abdominal signs (tenderness on light and deep palpation, tenderness in the RLQ and elsewhere, rebound, cough, and percussion tenderness) and pain (100 mm Visual Analog Scale [VAS]) at 0 and 30 minutes were recorded. The predictive value of each physical finding (PF) was measured using an 11-point PF score weighted by likelihood ratios. There was significant reduction in mean VAS of 14.2 mm (95% CI 5.6 to 22.8) in analgesic group versus 6.5 mm (95% CI 1.6 to 11.4) in placebo group. The analgesic group had less normalization of signs as measured by the PF score in all patients [32 of 154 (20.8%) versus 40 of 121 (33.1 %) (P = .031)] and in those with proven appendicitis [4 of 33 (12.1%) versus 10/22 (45.5%) (P = .014)]. Parenteral use of tramadol in emergency department patients with RLQ pain resulted in significant levels of pain reduction without concurrent normalisation of abdominal examination findings indicative of acute appendicitis.     

CT abnormalities in right lower quadrant inflammatory disease: Review of findings in 26 adults

Abnormal abdominal computed tomographic (CT) examinations, performed on 26 adults who presented with clinical evidence of right lower quadrant inflammatory disease, were retrospectively studied. Final diagnoses, established surgically in each case, included complicated appendicitis (15 patients), diverticulitis of the ileum or right colon (4), previously undiagnosed Crohn's disease (3), perforated cecal neoplasm (2), right tuboovarian abscess (1), and paracolic abscess of unknown cause (1). The CT features in each diagnostic group are presented in detail. Solid or ring calcification within a pericecal inflammatory mass was specific for appendicitis, occurring in 40% of the 15 patients. Without calcification, the differentiation of complicated appendicitis from Crohn's disease or diverticulitis, based on CT features alone, may be difficult in some cases.     

Left lower quadrant pain of unusual cause

The differential diagnosis of left lower quadrant abdominal pain in an adult man includes, among others, sigmoid diverticulitis; leaking abdominal aortic aneurysm; renal colic; epididymitis; incarcerated hernia; bowel obstruction; regional enteritis; psoas abscess; and in this rare instance, situs inversus with acute appendicitis. We report a case of situs inversus totalis with left-sided appendicitis and a brief review of the literature. There were several subtle indicators of total situs inversus present that were missed by the physicians and surgeons who initially evaluated the patient prior to surgery. Computed tomography scan with contrast, however, revealed the diagnosis immediately, and treatment was successfully initiated.     

Minimum training for right upper quadrant ultrasonography

The objective of this study was to assess if 10 right upper quadrant (RUQ) ultrasound (US) examinations could be used as a minimum standard for training. This was a retrospective review of patients with suspected gallbladder pathology who underwent resident-performed RUQ US before operative or department of radiology evaluation. Two hundred twenty-four patients were examined using resident-performed RUQ US followed by gold standard evaluations. One hundred seventy-eight patients were evaluated by 13 residents who met the "minimum training" standard of 10 prior examinations. The results of resident-performed RUQ US for gallstones and/or cholecystitis are shown subsequently. Previous suggestions that 10 examinations could be used as a minimum standard for training in focused abdominal sonography for trauma examinations cannot be used for RUQ US. The ACEP 2001 guidelines for 25 examinations are more consistent with the learning curve suggested by our data.     

腹腔镜在右下腹痛诊断和治疗中的应用体会

目的探讨腹腔镜在右下腹痛的病因诊断和治疗中的作用。方法回顾分析我院经腹腔镜诊断或治疗的90例右下腹痛患者的临床资料。结果术前已明确诊断的54例右下腹痛患者采取腹腔镜治疗后腹痛均完全缓解;31例不明原因的右下腹痛患者经腹腔镜探查后30例获确诊;5例误诊患者,经腹腔镜探查后纠正诊断。所有患者术后无并发症发生。结论腹腔镜是诊断和治疗右下腹痛的有效手段。