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 lower abdominal pain  



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Author13 Posts
  #1

Here's a nice clinical case I've created.

55 yo female presents to your office with a 2 mo h/o mild lower abdominal pain poorly responsive to Ibuprofen and mild dizziness.
History: lost 9 kilos over the past 2 mos, 2 epiodes of mild vaginal bleeding.
Physical: BP = 110 / 60, HR = 110 bpm, RR = 18 bpm, generalized palor, non-tender mass in the RLQ, mild adnexal tenderness, no uterine tenderness, no cervical motion tenderness, mild cervical spotting. HB = 9, HT = 32, ESR = 40, abnormal LFTs.Mildly enlarged, non-tender liver.The rest of the physical exam is unremarkable.
The next most logical invetsigation is: :shock:
The most probable dx is: 8)
This time I'm not going to tell you the answer, as some of you asked me.




  #2

Hi miky..thanks for the cases and thanks for taking time for us to answer too!

Let me try....

Probable Dx: Ovarian carcinoma met to liver
Logical investication: Check tumor markers like CA-125, CEA and others first...and then abdominal/pelvic CT scan.


  #3

my first impression was Pelvic Inflammatory Disease with perihepatitis (Fitz Hugh Curtis Syndrome)
but then there were several things against it - 55yrs age, no mention of whether the female is sexually active or not (although at 55 it might be less likely! :wink: ), no uterine or cervical motion tenderness - the essential diagnostic criteria for PID.

mild dizziness and tachycardia are due to the anemia (sec to chr blood loss)

2 month history with SIGNIFICANT WEIGHT LOSS and Significant Anemia-
malignancy is number one consideration here -
now the question next is - WHERE? since its an OB/GYN ques obviously,
the likely choice has to be among - ovary, uterus and cervix.
patient has had 2 episodes of vaginal bleeding and has mild cervical spotting - so ovary is out. the order would now be - cervix first, uterus second.

nontender RLQ mass, mild adnexal tenderness - probably cervical carcinoma Stage IIB - but not really convincing!

the second thing that has to be explained concomitantly is the enlarged tender liver with abnormal LFTs - are they mets (causing obstructive jaundice)?
but there 's no mention of icterus in the question and neither are there any details of the ABNORMALITY in LFTs

raised ESR - signifies inflammatory process.
but what? no h/o fever, no mention of TLC and DLC either.

with just 2 episodes of mild vaginal bleeding in a postmenpausal woman, such severe anemia simply cannot be explained.
so a stool for occult blood test would be in order. plus RLQ mass suggests consideration of GI malignancy but it won't explain the vaginal bleeding and cervical spotting in the first place!

Ix of choice: cytologic smear of cervix and vagina (that goes for any post menopausal bleeding)
followed by transvaginal ultrasound - if endometrial thickness >4mm, then cervical biopsy and endocervical curettage with endometrial aspiration.
later, if necessary, CT abdomen and Pelvis to see the extent of the cancer

hopefully the above would give us the most probable Dx which i think could be Ca cevix.

but there are a lot of limitations in this question- with more clear cut information the diagnosis should be more straightforward.

drvic


  #4

hi drvic
u r absolutely correct--100%
thanks for ur analysis
rashmi


  #5

hi,

the mass in RLQ is the most intriquing aspect for me, it hasnt really been clarified if the patient is postmenopausal.

so, the mass with the vaginal bleeding and spotting would also raise the suspicion of ECTOPIC PREGNANCY. its a bit unlikely in a patient this old, but you never know.

so, i think additional investigations in this patient should also include abdominal ultrasound combined with b-hcg levels.


  #6

hi buzz

at 55 the woman is more likely than not to be post-menopausal.

ectopic pregnancy won't explain the severe anemia and weight loss PLUS the enlarged liver and abnormal LFTs!

old adage in medicine - try and explain all findings and labs with a single diagnosis or pathophysiologic process

actually its a self made question by miky and i've highlighted the missing bits of info in this question in my previous post.

so its time we heard from THE QUESTION MAKER (mr miky) himself about this :lol:

regards

drvic


  #7

I am impressed of how you approached my case.

Here's the correct answer:

Most probable dx: cancer of the fallopian tubes with MTS to the liver (very rare, but not to be neglected in the daily practice) :shock:
Next investigation is: U/S of the lower abdomen & liver 8)
if a mass seen - next: Laparoscopy & Biopsy or U/S - guided biopsy
if bleeding into peritoneum ( a common local complication of this tumor) - next: emergent Laparotomy.
However, the prognosis is very poor even w/o MTS sad .


  #8

hey that would have been simple if i had added fallopian tubes to my list of possibly involved structures that i had reasoned.

anyway fallopian tube malignancies account for less than 1% of all gynecologic cancers!
usually starts as a dysplasia or carcinoma in situ and then progresses to Adenocarcinoma!

peak ages of presentation are usually 60-66 years. 5-year survival rate is 51% on average

thanks for that one, never thought of FT malignancy!

regards

drvic


  #9

Hi guys...how can we distinguish FT carcer from ovarian cancer from the stem of this q? I don't see anything........can be either of them from my piont of view...please miky respond!


  #10

Dear ELM,
Ovarian cancer rarely presents with vaginal bleeding. Besides, it is usually detected in an advanced stage, where therapeutical measures are severely limited. However, abdominal U/S will generally tell you whether the ovaries or fallopian tubes are involved :idea: . Besides, tumors of the FTs do not generally grow too large.
So, abdominal U/S is the first investigation to consider 8) . If in doubt, you may ask tumoral markers (for ovarian cancer) but I personally believe that's a waste of time :wink: . You may better proceed with Laparoscopy & Biopsy that will likely establish the cell of origin :!: .
If there are S/S of peritoneal irritation, stabilize pt. first (resuscitation - oxygen by mask, iv fluids / blood if necessary, maybe ABs) then go with emergent Laparotomy and biopsy (usually performed during the surgical removal of the mass).

Hope it helped.


  #11

hey dr. vic,

some points i couldnt understand, you yourself said that the vaginal bleeding cannot explain the severe anemia?? so, whats the source of anemia

also, some additional points, its treading dangerous waters to assume that a 55 year old female is post-menopausal and sexually inactive, especially in the US.
also, the most common site of ectopic pregnancy is the fallopian tube, and causes first trimester vaginal bleeding as well as pain and swelling in the abdomen. also, can also lead to intraabdominal bleeding, which might explain the severe anemia.

but, i will have to agree with you, i should have looked at the question more closely, it still wouldnt explain the abnormal LFTs.

good diagnosis, vic
madhu


  #12

If the Ddx are cancer of FLT or cervix or uterus
Won't you collect PAP smear too?
Does everyone answer U/S because the results is faster ?
Or we should do both ?


  #13

Dear Luckiest,

I must remind you that one of the forms of anemia is anemia of chronic disease (ACD) :idea: . As you well know, it can be caused by cancer too, especially with MTS :!: . Besides, anemia can be quite severe if the cancer is not treated (hardly possible in this pt.) Sometimes you need to give your pt. EPO / other drugs to correct the anemia sad .
Pap smear is a screening test!!! :shock: . It is performed only as a first invetigation to determine what other investigations to order. However, it is useless in this case since I mentioned about the abdominal mass, mild anexal tenderness and severe weight loss :!: . Besides, cervical / endometrial cancer are not manifesting through such weight loss except maybe in advanced stages :wink: .
The liver is enlarged, non-tender and with abnormal LFTs - that should make you think of possible liver MTS 8) .
Ovarian cancer can be safely ruled out since it hardly presents with frank vaginal bleeding :wink: . It can however presents with irregular menstrual bleeding, but that can be excluded in a 55 yo pt :wink: . Moreover, ovarian cancer that already sent MTS to the liver is usually accompanied by ascites, which is absent in this pt :!: . Ovarian cancer usually seeds the peritoneal cavity first before liver :!: .
Hope it helped. smiling face





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