1. Exploratory Laparoscopy of Abdomen for Right Lower Quadrant Pain OB-GYN/R1 Dr. Young Amanda Walker

2. Patient  Female  26-year-old  G1P1, C-section, 2000  LMP 5/05/2007  Periods “not as regular as in years past with cycles about every 2 months that last two weeks”  Denies possibility of pregnancy

3. Patient  Surgical Hx: c-section (2000), repair of fractured hip with implant due to slip cap fem (1991)  Current Dx: tobacco disorder, hypothyroidism  Current Meds: Synthroid 75mcg oral tablets once daily  Allergies: NKDA

4. HPI  Presented to LH Geisinger Clinic on May 21, 2007  c/o lingering, mild and intermittent abdominal pain x 2yrs  Exacerbated into colicky RLQ pain x 2wks  2 ER visits, 2 negative work-ups for appendicitis in last 2mos, including CT Scans & labs  Referred to Dr. Young by PCP to r/o adhesions and endometriosis

5. Physical Exam  Abdominal Exam: elicited tenderness to deep palpation in RLQ, maximum pt of tenderness was subumbilical and to the right: McBurney’s Point minimal suprapubic tenderness  Pelvic Exam: elicited mild tenderness on palpation of the uterus; pt says “not the same pain”

6. Differential Diagnosis RLQ Pain  Mesenteric Lymphadenitis  Utereral Colic  Pyelonephritis  IBS  Diverticulitis  PID  Ectopic Pregnancy  Ruptured Ovarian Cyst  Mittleshmerz  Endometriosis  Ovarian Torsion  Appendicitis

7. Now What?  Negative Obstetrical & Gynecologic History  Negative Obsetrical & Gynecologic Physical Exam  Exploratory Laparoscopy

8. Operating Room  2-3cm incision in umbilicus & 2-3cm incision suprapubically  Used a laparoscope to view ovaries and uterus  Both ovaries and uterus appeared normal  Viewed appendix since McBurney’s Point was the maximal point of tenderness

9. Findings  Observed all angles of appendix  Consensus was that it did not appear acutely inflamed but did not appear “normal”  Adhered to and wrapped around the ileum of the large intestine  Consulted Dr. Armstrong who was given patient’s history and PE findings and agreed to remove it

10. Final Diagnosis  Appendix was chronically inflamed by a luminal obstruction of a “fibrous foreign material”

11. Patient Follow-Up  Patient has since reported that her RLQ pain has resolved

12. Data  CT Scan is predicted to be 93-98% accurate and 87-100% sensitive  Rare case of chronic appendicitis with luminal obstruction was overlooked and undetected  Positive McBurney’s Point tenderness was ignored twice  Negative CT Scans that led to misdiagnosis and exclusion of appendicitis was accepted twice

13. Data  Appendicitis is #1 diagnosis of RLQ abdominal pain in the ER  Abdominal pain in women is often assumed to pertain to menses or to originate from female organs  “can be a diagnostic dilemma” in women

14. Lesson? Treat the Patient, Not the Labs!

15. Citations  Feldman. Sleisinger & Fordtran’s gastrointestinal and Liver Disease, 8th ed. Saunders, 2006. www.mdconsult.com  Old, Jerry L M.D., Dusing, Reginald W M.D., Yap, Wendell M.D., Dirks, Jared M.D. Imaging for suspected appendicitis. American Family Physician, 2005; 71 (1). www.mdconsult.com  Piccini, Jonathan P. M.D., Nilsson M.D. Approach to abdominal pain. The Osler Medical Handbook, 2nd ed. www.mdconsult.com  Vanwinter, JT. Chronic appendicitis diagnosed preoperatively as an ovarian dermoid. Journal of pediatric and adolescent gynecology, 2004; 17(6): 403-406. www.mdconsult.com