ARJ
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A 26-year-old primigravid woman at 30 weeks' gestation comes to the emergency department because of a 22-hour history of increasingly severe right-sided abdominal pain and no appetite. She has vomited twice over the past 5 hours. She has not had vaginal bleeding. Her temperature is 38.1 C (100.7 F). Examination shows exquisite tenderness of the right lateral flank and the fundus. There are no peritoneal signs. Bowel sounds are absent. The fetal heart rate is 141/min. Laboratory studies show:
Hematocrit 36%
Leukocyte count 15,800/mm3
Serum
Total bilirubin 1.2 mg/dL
Amylase 31 U/L
Lactate dehydrogenase 111 U/L
Urine WBC 36/hpf
Which of the following is the most likely diagnosis?
A ) Abruptio placentae
B ) Appendicitis
C ) Cholelithiasis
D ) Colitis
E ) Pyelonephritis
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| DrS
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B ) Appendicitis
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| chemamr
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B.
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| GoStep2
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B.
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| phuluong2k
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B
But i still have confusion with E
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| chemamr
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yes, E should be the number 1 in the differential diagnosis.
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| frontal
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Yes, E comes to mind.
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| DrS
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Don't you think pyelonephritis would be unlikely in the presence of only 3-6 wbc/hpf and how would that cause absent bowel sounds?
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| icefires
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B , as wbc hpf and temp is not substantial.and no rigors or chills.
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| DrS
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ARJ : what is the answer?
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| ckdoc5
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B cant be pyelo with so less wbcs
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| frontal
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Yes, pyelonephritis should not cause absent bowel sounds and neither should appendicitis I guess, unless perforation occurs, a possibilty which can be excluded by the absence of 'peritoneal signs'. So what is the cause for paralytic ileus? An uncommon presentation of colitis? Gallstone ileus (secondary to cholelithiasis) is not an option, plus it's a rare diagnosis. I'm quite confused. It's ARJ's turn to intervene. (Answer and explanation please!)
P.S. : What does a lower than normal serum amylase level mean?
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| chemamr
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an appendicitis can cause decrease/ increase/no change in bowel sounds. (source: Surgery. Scient Princ and Practice. 3rd edition). Increase (diarrhea) is more common in children, by the way.
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| frontal
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Cool. But here it states 'absent'... ?
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| chemamr
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itīs the same way, it can cause it, too.
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| DrS
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Yes, any intra abdominal sepsis can cause a transiet ileus.
By the way normal amylase range is around 25-125 u/l. So its normal in this case.
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| frontal
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Hmmmm.
Okay...From where I read, higher values were normal. Anyway, we must go by the usmle lab values.
ARJ ?
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| chemamr
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letīs wait for the answer by ARJ.
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| DrS
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Yes, ARJ please put us out of our misery. We are all eagerly awaiting the answer and explanation 
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| ARJ
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Sorry for not giving the answer....Little bit busy.
I dont have the answer because its from NBME
Seems like B ) Appendicitis because CMDT mentions as below
1) Appendicitis in pregnancy may present with pain in the right lower quadrant, periumbilical area, or right subcostal area owing to displacement of the appendix by the uterus.
2)B. Laboratory Findings Moderate leukocytosis (10,000-20,000/uL) with neutrophilia is common. Microscopic hematuria and pyuria are present in one-fourth of patients.
This seems to be classic presentation of Appendicitis as mentioned in Bailey
Pregnancy
Appendicitis is the most common extra uterine acute abdominal condition in pregnancy with a frequency of from one in 1500 to one in 2000 pregnancies. Diagnosis is complicated by delay in presentation; early nonspecific symptoms are often attributed to the pregnancy, and the changing location of the appendix during pregnancy. As pregnancy develops during the second and third trimesters, the caecum and appendix are progressively pushed to the right upper quadrant of the abdomen. This displacement can result in flank or back pain, and may be confused with pyelonephritis, while lower abdominal pain may be confused with torsion of an ovarian cyst. Foetal loss occurs in 35 per cent of cases, increasing to 20 per cent if perforation is found at operation.
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