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Episode 79: A 19-Year-Old with Pelvic Pain
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Episode 79: A 19-Year-Old with Pelvic Pain
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T00H08M16S
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https://cadmoreoriginalmedia.blob.core.windows.net/0203de31-862c-4b5a-b033-ea695d9f6792/Harrisons Podclass- Episode_79 with tag.mp3?sv=2019-02-02&sr=c&sig=qj3gRnUWrtfumDK0kALb60GLg23W6jdK4vgZezGxpR0%3D&st=2024-05-04T09%3A53%3A02Z&se=2024-05-04T11%3A58%3A02Z&sp=r
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2022-02-28T00:00:00.0000000
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Language: EN.
Segment:0 .
[upbeat intro music] [Dr. Handy] Hi, welcome to Harrison's Podclass, where we discuss important concepts in internal medicine. I'm Cathy Handy. [Dr. Wiener] And I'm Charlie Wiener, and we're coming to you from the Johns Hopkins School of Medicine. Welcome to episode 79, a 19-year-old with pelvic pain. Okay, Cathy, today's patient is a 19-year-old woman who is seen in the emergency department for pelvic pain.
She reports one week of pain, but has developed more severe pain on the right side of her lower abdomen over the past day with accompanying fever. Also, she reports pain that is new in her right upper quadrant, that's been present for the past day, and this is notable because that's actually worsened by deep breathing.
[Dr. Handy] Okay, lots to think about here. Lower right quadrant abdominal pain in a woman can be related to the GI tract, or the urinary tract, or the reproductive tract. So we really need more history, definitely labs and a physical exam that potentially covers all of those to help distinguish. [Dr. Wiener] Okay, well, let me tell you more about the pain. The pain is in her right lower quadrant, it's not radiating, and the pain in the right upper quadrant is worsened as I mentioned with deep breathing, but other than that nothing else that she can identify brings on the pain.
She does have a past medical history that's notable for mild asthma treated with PRN inhalers. She's never had a urinary tract infection before. She reports regular periods that typically last about four days, and her only medication is an oral contraceptive. She is sexually active with multiple partners and does not typically use any other form of birth control. She reports that she's never felt this type of discomfort before.
She exercises regularly, she has a vegan diet and does not consume alcohol, or illicit drugs. [Dr. Handy] What about her physical exam findings? I would focus on the cardiopulmonary exam because sometimes pathology there is experienced as abdominal pain, obviously the abdominal exam, and then I would do a pelvic exam in her as well. [Dr. Wiener] So she's a thin-appearing woman who appears uncomfortable.
Her temperature's 101.3 Fahrenheit, her blood pressure is 110/75, her heart rate is 105 and her respirations are normal with a room air saturation of 98%. Her lungs and her heart are normal, but she definitely has some right-sided pain with deep inspiration. There's no rub on the right side. On abdominal examination, she has bowel sounds.
Her right upper quadrant is tender to direct palpation, but there's no rebound or guarding. Her right lower quadrant is not tender. There's no palpable masses in her abdomen. A pelvic examination is performed and it shows normal cervical appearance, but there is cervical motion tenderness, and adnexal tenderness is present on the right side. No masses are palpated.
[Dr. Handy] So she has fever, tachycardia, right upper quadrant tenderness with palpation, pleuritic pain and cervical motion and adnexal tenderness, which is leading me to consider either two separate processes, abdominal and pelvic, or a single process that could be affecting both. [Dr. Wiener] Okay. [Dr. Handy] Tell me more about her labs, so renal and liver function tests, urinalysis, pregnancy test and complete blood count.
[Dr. Wiener] Her urine pregnancy test is negative, but leukocytosis is present. Her white cell count is 12,000 with neutrophil predominance, renal and liver function tests are both normal. [Dr. Handy] So I still have a high index of suspicion for a pelvic process like pelvic inflammatory disease given her history and physical exam. Now, while ectopic pregnancy is less likely with a negative pregnancy test, the possibilities of what this could be are still very broad.
[Dr. Wiener] Okay, well, the question asks, which of the following is true regarding her right upper quadrant tenderness? Option A says, the CT imaging of the abdomen will likely show diverticulitis; option B says, laparoscopic examination will show inflammation of her liver capsule; option C says, she requires a surgery consult to manage acute cholecystitis; option D states, the diagnosis can be made by sending hepatitis A serologies; and option E says, the diagnosis should be made by sending a fluorescent treponemal antibody absorb test, or a test for syphilis.
[Dr. Handy] All right. So we aren't getting any more information, so let's go through the answer choices to see if we can decide which ones make sense and which ones are less likely. [Dr. Wiener] Okay. Where do you want to start? [Dr. Handy] Option A which asks about diverticulitis, and option D which mentions hepatitis A, I think both of those are unlikely. Diverticulitis in a 19-year-old with the constellation of symptoms described, I really think is unlikely.
Additionally, hepatitis A is less likely given her history, the abnormal pelvic exam and the normal LFTs. I also don't think C is the best choice because while the right upper quadrant pain, fever and leukocytosis could be from acute cholecystitis, it would not explain the pelvic symptoms or the pleuritic pain, really. [Dr. Wiener] Okay. So you're left with inflammation of the liver capsule or syphilis as the cause of her symptoms.
[Dr. Handy] So putting this all together, fever, pleuritic chest pain, right upper quadrant pain and pelvic pain in a young, sexually active woman, the most unifying diagnosis would be that this is acute pelvic inflammatory disease with perihepatitis or inflammation of the liver capsule. [Dr. Wiener] You mean the Fitz-Hugh-Curtis syndrome? That's a complication of pelvic inflammatory disease, right? [Dr. Handy] Yes, and for historical accuracy, the syndrome which was named in the early '30s is for two, not three people, so it's Dr. Fitz-Hugh and Dr. Curtis.
[Dr. Wiener] Okay, well tell me more. [Dr. Handy] Perihepatitis develops in 5-10% of women with acute pelvic inflammatory disease or PID. The symptoms arise during or after the onset of PID symptoms and may overshadow the pelvic symptoms, often leading to a presumptive diagnosis of acute cholecystitis. Laparoscopic examination will demonstrate acute salpingitis with perihepatic inflammation, ranging from edema and erythema of the liver capsule, to exudate with fibrinous adhesions between the visceral and the parietal peritoneum.
When treatment is delayed and laparoscopy is performed late, dense, violin string adhesions can be seen over the liver. [Dr. Wiener] Since this is a complication of pelvic inflammatory disease, I presume the sexually transmitted infections or STIs are the most likely causative. [Dr. Handy] Yes, although perihepatitis was for many years specifically attributed to gonococcal salpingitis, most cases are now attributed to chlamydial salpingitis.
In patients with chlamydial salpingitis, serum titers of micro-immunofluorescent antibody to chlamydia trachomatis are typically much higher when perihepatitis is present than when it is absent. So you have to look for both infections and typically treatment regimens target both Neisseria and chlamydia. Syphilis does not cause this syndrome.
[Dr. Wiener] Okay. What about the imaging and labs in these cases? [Dr. Handy] While PID must be suspected in any sexually active woman with mucopurulent cervicitis and pelvic tenderness, you often have to rule out acute cholecystitis and acute appendicitis. Results of liver function tests and right upper quadrant ultrasonography are nearly always normal.
A CT may show salpingitis and interestingly, periappendicitis, that is appendiceal serositis without involvement of the intestinal mucosa has been found in about 5% of patients undergoing appendectomy for suspected appendicitis, and it can occur as a complication of gonococcal or chlamydial salpingitis. [Dr. Wiener] Interesting, so some of these patients wind up getting an appendectomy, but are found to have pelvic inflammatory disease.
[Dr. Handy] Right, exactly. [Dr. Wiener] You want to mention treatment briefly? [Dr. Handy] Sure, so typically acute salpingitis or PID are treated with ceftriaxone and azithromycin, as I mentioned, targeting gonorrhea and chlamydia. [Dr. Wiener] Okay. So the teaching point here is that perihepatitis or the Fitz-Hugh-Curtis syndrome, is a complication of pelvic inflammatory disease and can mimic acute appendicitis or acute cholecystitis.
The presence of mucopurulent cervicitis and pelvic tenderness in a young woman with subacute pleuritic right upper quadrant pain and normal ultrasonography of the gallbladder points to the diagnosis. [Dr. Handy] You can read more about this in Harrison's internal medicine chapter on sexually transmitted infections. [outro music] [Mr. Shanahan] This is Jim Shanahan, publisher at McGraw Hill.
Harrison's Podclass is brought to you by McGraw Hill's Access Medicine, the online medical resource that delivers the latest trusted content from the best minds in medicine. Go to accessmedicine.com to learn more.