A Collection of Cases With Pain as a Primary Presenting Symptom

Scar Endometrioma

Authors:
Philip Collins, DO, and Rebecca Moore, DO
Rowan University School of Osteopathic Medicine, Stratford, New Jersey

Citation:
Collins P, Moore R. Scar endometrioma. Consultant. 2017;57(9, Suppl.):S6-S7.

A 32-year-old woman presented to a primary care office with left lower-quadrant pain that had been present intermittently for approximately 5 years and had worsened over recent months. The pain had begun not long after she had undergone abdominoplasty.

The pain was located in the lateral portion of the scar from the patient’s previous Pfannenstiel incision from a cesarean delivery. She reported that the pain was worse at certain times, including during menstrual periods, but it never fully went away. She also noted that she sometimes would feel a small lump in the area of the pain. Her gynecologist had performed pelvic ultrasonography, which showed no abnormalities. The gynecologist, suspecting a possible hernia, had referred her to primary care for the remainder of the workup. Findings of a review of systems was otherwise negative.

Physical examination. Physical examination revealed a soft abdomen with mild tenderness to palpation in the left lower quadrant, and a palpable superficial mass measuring approximately 2 × 2 cm in diameter.

Diagnostic tests. A computed tomography scan of the abdomen and pelvis with oral contrast revealed asymmetric enlargement of the left rectus abdominis muscle, possibly due to a mass or hematoma, consistent with the palpable abnormality observed on examination. This finding was discussed with the patient, and she denied any trauma that she could recall. Magnetic resonance imaging (MRI) with intravenous contrast of the abdomen was then ordered, the results of which showed an enhancing 20 × 12-mm lesion within the left rectus abdominis muscle at the level of the low-transverse anterior abdominal wall incision (Figure). Given her history of cesarean delivery and worsening pain with menses, scar endometrioma became the most likely diagnosis.

Treatment. The patient underwent successful surgical removal of the mass by way of an incision through the previous Pfannenstiel incision. Through extensive scar tissue, the mass was found within and below the fascia. The mass was removed as 2 fragments, the first measuring 3 × 2 × 1.5 cm and the second measuring 3.5 × 2.7 × 1.5 cm. Pathology test results confirmed the diagnosis of endometriosis.

Outcome of the case. Following surgical removal of the endometrioma, she quickly recovered, and her symptoms resolved.

Discussion. Endometriosis is a common disorder involving abnormal growth of tissue resembling endometrium present in locations other than the uterine lining.¹ It is estimated to be present in 6% to 10% of women of reproductive age and 25% to 35% of women with infertility.¹ Endometriosis more commonly affects women of reproductive age than postmenopausal women, although the latter has been reported.

Symptoms of endometriosis can vary significantly, ranging from being asymptomatic to causing severe pain. When pain is present, it typically occurs with menses, and many women with it also experience infertility. Most commonly, lesions are found on peritoneal surfaces of reproductive organs and adjacent structures within the pelvis but rarely can be found in other locations. One such location is the scar from prior abdominal surgical procedures.

Scar endometriomas represent a rare form of endometriosis and account for 0.03% to 0.15% of endometriosis cases.² Scar endometriomas are typically found in low-transverse abdominal wall incisions used for uterine procedures such as cesarean deliveries. Diagnosis can be difficult, but the condition should be considered in women who have undergone abdominal surgery.

Ultrasonography has been shown to sometimes identify endometriomas, but the size of the mass can be a factor.² MRI can assist in preoperative planning and also can help to better visualize the soft tissue. Ultimately, the diagnosis must be confirmed with biopsy and/or excision.³

Nonsurgical treatment options include the use of oral contraceptives, gonadotropin-releasing hormone agonists, and aromatase inhibitors.^4,5 However, surgical removal is the treatment of choice for women with severe disease, those who wish to preserve fertility, those with adhesions, and those who wish for curative treatment.¹

While scar endometriomas are a rare finding, the diagnosis must be kept in mind in cases of women with abdominal pain of unclear etiology, especially women of childbearing age with a history of abdominal surgical procedures. This diagnosis should especially be considered when the scar from that surgical procedure becomes tender with menses.⁶ 

References:

1. Sarajari S, Muse KN Jr, Fox MD. Endometriosis. In: DeCherney AH, Nathan L, Laufer N, Roman AS, eds. Current Diagnosis & Treatment: Obstetrics & Gynecology. 11th ed. New York, NY: McGraw-Hill; 2013:chap 56.
2. Francica G, Giardiello C, Angelone G, Cristiano S, Finelli R, Tramontano G. Abdominal wall endometriomas near cesarean delivery scars: sonographic and color Doppler findings in a series of 12 patients. J Ultrasound Med. 2003;22(10):1041-1017.
3. Hoffman BL. Endometriosis. In: Hoffman BL, Schorge JO, Bradshaw KD, Halvorson LM, Schaffer JI, Corton MM, eds. Williams Gynecology. 3rd ed. New York, NY: McGraw-Hill; 2016:chap 10.
4. Wolf GC, Singh KB. Cesarean scar endometriosis: a review. Obstet Gynecol Surv. 1989;44(2):89-95.
5. Schoelefield HJ, Sajjad Y, Morgan PR. Cutaneous endometriosis and its association with caesarean section and gynaecological procedures. J Obstet Gynaecol. 2002;22(5):553-554.
6. Al-Jabri K. Endometriosis at caesarian section scar. Oman Med J. 2009;​24(4):294-295.

NEXT: Atypical Presentation of Angina

Atypical Presentation of Angina

Authors
Adam Braun, BS
David Geffen School of Medicine at the University of California, Los Angeles

Kamran Shamsa, MD, and Jerome Greenberg, MD
Ronald Reagan UCLA Medical Center, Los Angeles, California

Citation:
Braun A, Shamsa K, Greenberg J. Atypical presentation of angina. Consultant. 2017;57(9, Suppl.):S7-S8.

A 34-year-old man presented to an ambulatory medicine clinic with a 3-week history of chest pain. He had a distant history of Hodgkin lymphoma, which had been in remission for 11 years after treatment with the Stanford V regimen of chemotherapy followed by radiation therapy. He reported having been on a recent camping trip at high altitude during which he had hiked 4 miles without any adverse symptoms. Two days later, he had a sudden onset of sharp rib pain while running.

Initially, he had been reluctant to seek medical care, assuming that the pain was insignificant. However, it lingered, was dull at rest (1 of 10 on a pain scale), and worsened with exercise (8 of 10), so he had refrained from exercise. He reported that the level of pain was proportional to his level of exertion but did not radiate to his arms or jaw.

At presentation, the patient denied having pain with inspiration, cough, palpitations, nausea, diaphoresis, recent trauma, or lifting heavy weights. Results of a review of systems were otherwise unremarkable. He had no family history of cardiovascular disease. He lived with his wife, and he reported that he had recently been stressed by a project at work. He consumed approximately 1 alcoholic drink nightly but denied smoking or drug use. The chest pain was reproducible with palpation, and he reported feeling discomfort when resisting abduction of the arms. Results of a cardiac examination were normal.

Even though a recent echocardiogram had revealed completely normal cardiac function, an informal office stress test with electrocardiography (ECG) was performed to rule out cardiac cause. He was escorted to the stairwell and ran up 7 flights of stairs, eliciting a reproduction of the pain. The resulting ECG showed ST segment depression across the precordial leads V₄ through V₆, with 2- to 3-mm ST segment elevation in the aVR lead (Figures 1 and 2).

Given these findings, he underwent urgent cardiology evaluation, including coronary angiography, the results of which revealed extensive coronary artery disease (CAD). The patient then underwent urgent 3-vessel coronary artery bypass surgery, from which he recovered well.

Discussion. Chest pain is a common reason for urgent care visits. Approximately 1.5% of patients who present to primary care for chest pain have unstable angina.¹ Reproducible chest pain on palpation reduces the likelihood of a cardiac cause of chest pain by 80%,² but it does not rule out cardiac etiology. Our patient’s age, his active lifestyle, and his chest pain that was reproducible by palpation initially suggested a musculoskeletal cause.² However, his history of chest radiation for Hodgkin lymphoma predisposed him to accelerated atherosclerosis.³

The list of potential cardiovascular and cardiopulmonary system complications of high-dose radiation to the thorax includes proximal CAD—typically ostial left main and right coronary artery disease—as well as potential valvular complications, mainly aortic valve and mitral valve disease. In one published case, a 42-year-old woman experienced systolic heart failure after having developed radiation-induced valvular and atherosclerotic disease.⁴ Approximately 11% of patients will develop CAD, 8% will develop valvular heart disease, and 5% will develop heart failure within 20 years of high-dose radiation therapy, regardless of the age at which they received treatment.³

Improved surveillance of the cardiovascular and cardiopulmonary complications of high-dose radiation to the thorax would benefit these patients and save lives. This is a well-documented problem, but there is limited evidence for screening protocols. Echocardiography and cardiac stress tests as screening tools have been endorsed by the National Comprehensive Cancer Network at 10 years following treatment in asymptomatic patients.⁵ In our patient, who was 11 years posttreatment, the results of echocardiography were unremarkable, and only a stress test revealed the extent of his disease. This suggests that a combination of echocardiography and stress testing would be more sensitive and beneficial to this population than either modality alone. Future research will be necessary to support which modality is best to diagnose radiation-induced atherosclerosis.

A history of radiation to the chest should always increase suspicion for atherosclerosis, given how greatly it accelerates that process. Informal tests in an office setting are not recommended due to the rare occurrences of cardiac arrest and death during stress testing. An informal stress test had been done in our patient’s case only because the pretest probability of extensive CAD appeared so low in view of his apparent good health and the presumption that he had costochondritis. 

References:

1. McConaghy JR, Oza RS. Outpatient diagnosis of acute chest pain in adults. Am Fam Physician. 2013;87(3):177-182.
2. Panju AA, Hemmelgarn BR, Guyatt GH, Simel DL. Is this patient having a myocardial infarction? JAMA. 1998;280(14):1256-1263.
3. van Nimwegen FA, Schaapveld M, Janus CPM, et al. Cardiovascular disease after Hodgkin lymphoma treatment: 40-year disease risk. JAMA Intern Med. 2015;175(6):1007-1017.
4. Bikhchandani M, Tabrizi R, Shamsa K. Radiation-induced coronary artery and combined valvular disease. Proc UCLA Healthc. 2016;20. https://proceedings.med.ucla.edu/index.php/2016/03/09/radiation-induced-coronary-artery-and-combined-valvular-disease. Accessed August 24, 2017.
5. National Comprehensive Cancer Network. NCCN Clinical Practice Guidelines in Oncology (NCCN^® Guidelines): Hodgkin Lymphoma. Version 1.2017. https://www.nccn.org/professionals/physician_gls/pdf/hodgkins.pdf. Published March 1, 2017. Accessed August 24, 2017.

NEXT: Recurrent Appendicitis

Recurrent Appendicitis

Authors:
Eiyu Matsumoto, MB
University of Iowa Carver College of Medicine, Iowa City, Iowa

Jennifer R. Carlson, PA-C, and Barbara A. Fedor, MD
Iowa City Veterans Affairs Health Care System, Iowa City, Iowa

Citation:
Matsumoto E, Carlson JR, Fedor BA. Recurrent appendicitis. Consultant. 2017;57(9, Suppl.):S8-S9.

A 66-year-old man presented to the emergency department with a 1-day history of right lower-quadrant abdominal pain. He had experienced appendicitis 9 months ago and had been successfully managed with antibiotic treatment only, given that he had a history of multiple comorbidities and was at high risk for surgical procedures. Abdominal computed tomography (CT) scans at that time showed an enlarged appendix measuring approximately 9 mm in diameter with associated mild fat stranding (Figure 1).

Figure 1: Abdominal CT scan 9 months before his the current visit, with  ndings of an enlarged appendix (arrow) 9 mm in diameter with mild fat stranding, suggestive of acute appendicitis.

The patient had severe chronic obstructive pulmonary disease (predicted forced expiratory volume in the first second, 38%), chronic hypoxemia requiring home oxygen therapy at 4 L/min, morbid obesity (body mass index, 52 kg/m²), atrial fibrillation treated with rivaroxaban, obstructive sleep apnea, and compensated cirrhosis from nonalcoholic steatohepatitis (NASH).

He described the pain as acute, sharp, persistent, nonradiating, and associated with nausea. There were no alleviating or aggravating factors. He rated the pain as 4 out of 10. He denied vomiting, diarrhea, hematochezia, hematemesis, constipation, urinary tract symptoms, or fever.

Physical examination. On evaluation, his blood pressure was 121/77 mm Hg, heart rate was 85 beats/min, respiratory rate was 22 breaths/min, temperature was 36.8°C, and oxygen saturation was 96% on oxygen at 4 L/min. Abdominal examination revealed an obese abdomen, right lower-quadrant focal tenderness, and mild focal guarding in the tender area. There was no rebound tenderness or generalized guarding.

Diagnostic tests. His peripheral white blood cell count was 16,000/µL. Abdominal CT scans revealed a dilated appendix measuring 10 mm in diameter (Figure 2) and a mildly enhancing appendiceal wall with periappendiceal inflammatory stranding in the adjacent fat. The findings were concerning for acute appendicitis. There was no evidence of perforation or abscess.

Figure 2: Abdominal CT at the current visit, with  ndings of an enlarged appendix (arrow) 10 mm in diameter with surrounding fat stranding, suggestive of recurrent acute appendicitis.

Outcome of the case. The patient was again managed conservatively with antibiotics only, since he was a poor surgical candidate. He was admitted and was started on intravenous piperacillin-tazobactam. His abdominal pain slowly responded to antibiotic therapy, and he became pain-free on hospital day 5. He was discharged on hospital day 6 on a regimen of oral antibiotics (levofloxacin and metronidazole) for an additional 7 days. He has been doing well without further recrudescence.

Discussion. Appendicitis is the most common reason for emergency abdominal surgery, with a lifetime incidence of 7% to 14%.^1,2 Because appendicitis is a source of pelvic sepsis and subsequent high mortality, appendectomy has been considered mandatory and is the standard of care.^3-5 More than 300,000 US appendectomies are performed annually.^1,2 Appendectomy is laparoscopic in 60% to 80% of cases, with an average hospitalization of 1 to 2 days and a complication rate of 1% to 3%.^6,7 However, the development of this management strategy predates the discovery of antibiotics, and a large series of patients treated nonsurgically with antibiotic therapy in the 1950s had reasonable success rates.⁸ Modern CT establishes the early diagnosis noninvasively, with almost perfect diagnostic accuracy.

Recent studies have tested the hypothesis that uncomplicated (or nonperforated) appendicitis can be successfully treated nonsurgically with antibiotics. One randomized controlled trial enrolling 530 patients aged 18 to 60 years with CT-confirmed uncomplicated acute appendicitis found that most patients randomly assigned to receive antibiotics (vs early appendectomy) did not require appendectomy during a 1-year follow-up period.⁹

However, the authors of a meta-analysis of 5 randomized trials of the treatment of uncomplicated acute appendicitis, with a total of 1430 participants (727 undergoing antibiotic therapy and 703 undergoing appendectomy), observed a 39% risk reduction (RR) in overall complication rates in patients treated with antibiotics compared with those treated with appendectomy (RR, 0.61; 95% CI, 0.44-0.83; P = .002).¹⁰ There was no significant difference in length of hospital stay among the 2 groups. In the antibiotic cohort, 123 of 587 patients (21%) who initially had been treated successfully with antibiotics were readmitted with symptoms of recurrent appendicitis; most (120 of 123) eventually underwent appendectomy. The incidence of complicated appendicitis was not higher in patients who underwent appendectomy after “failed” antibiotic treatment (10.8%) vs those who underwent primary appendectomy (17.9%).¹⁰

Our patient’s case illustrates that some surgeons have already adopted an antibiotic-only strategy for managing selected cases of acute appendicitis. As a result, primary care providers have begun to see recurrent cases of appendicitis. Antibiotic-only treatment for appendicitis is appealing for its noninvasiveness; however, the downside is that it carries a recurrence risk of approximately 20% in the first year, with higher recurrence rates over the course of a lifetime. 

References:

1. Weiss AJ, Elixhauser A, Andrews RM. Characteristics of Operating Room Procedures in U.S. Hospitals, 2011. Rockville, MD: Agency for Healthcare Research and Quality; February 2014. Statistical Brief 170. https://www.ncbi.nlm.nih.gov/books/NBK195245. Accessed August 24, 2017.
2. Addiss DG, Shaffer N, Fowler BS, Tauxe RV. The epidemiology of appendicitis and appendectomy in the United States. Am J Epidemiol. 1990;132(5):​910-925.
3. Flum DR. Acute appendicitis—appendectomy or the “antibiotics first” strategy. N Engl J Med. 2015;372(20):1937-1943.
4. Fitz RH. Perforating inflammation of the vermiform appendix; with special reference to its early diagnosis and treatment. Am J Med Sci. 1886;92:321-346.
5. McBurney C. Experience with early operative interference in cases of disease of the vermiform appendix. N Y Med J. 1889;50:676-684.
6. Andersson RE. Short-term complications and long-term morbidity of laparoscopic and open appendicectomy in a national cohort. Br J Surg. 2014;​101(9):1135-1142.
7. Papandria D, Lardaro T, Rhee D, et al. Risk factors for conversion from laparoscopic to open surgery: analysis of 2138 converted operations in the American College of Surgeons National Surgical Quality Improvement Program. Am Surg. 2013;79(9):914-921.
8. Coldrey E. Treatment of acute appendicitis. Br Med J. 1956;2(5007):1458-1461.
9. Salminen P, Paajanen H, Rautio T, et al. Antibiotic therapy vs appendectomy for treatment of uncomplicated acute appendicitis: the APPAC randomized clinical trial. JAMA. 2015;313(23):2340-2348.
10. Rollins KE, Varadhan KK, Neal KR, Lobo DN. Antibiotics versus appendicectomy for the treatment of uncomplicated acute appendicitis: an updated meta-analysis of randomised controlled trials. World J Surg. 2016;40(10):2305-2318.