Visual Diagnosis in Emergency Medicine WOMAN WITH RIGHT LOWER QUADRANT MASS AND ABDOMINAL PAIN Sam S. Torbati, MD, Shomari Hogan, MD, Elaine Vos, BA, and Elliot Banayan, BA Department of Emergency Medicine, Cedars-Sinai Medical Center, Los Angeles, California Reprint Address: Sam S. Torbati, MD, Department of Emergency Medicine, Cedars-Sinai Medical Center, 8700 Beverly Boulevard, Los Angeles, CA 90048 CASE REPORT A 23-year-old woman presented to the emergency depart- ment (ED) with a 1-day history of sharp right lower quad- rant pain, nausea, vomiting, and anorexia. Vital signs were within normal limits, except for a heart rate of 119 beats/min. Physical examination elicited tenderness to palpation in the right lower quadrant with guarding. There was an absence of referred pain or rebound tender- ness. Laboratory studies were significant for a white blood cell count of 19.2/mL. An ED bedside ultrasound of the right lower quadrant revealed a complex mass with a nonuniform pattern of internal echoes. The appen- dix could not be visualized. A formal transvaginal ultra- sound confirmed the presence of a complex cystic mass Figure 1. Transvaginal ultrasound (coronal view) of the right adnexa showing a thick-walled (white arrows), complex, cystic mass measuring 7.73 cm 7.44 cm, consistent with a teratoma. Note the nonuniform inter- nal echo pattern: Anechoic area representing cystic portion of the mass (C), diffusely echogenic area with fat attenuation (F) representing sebaceous material and hair. Figure 2. Thin band-like echoes, within the sebaceous com- ponent, representing tufts of hair (H). RECEIVED: 9 February 2013; FINAL SUBMISSION RECEIVED: 13 June 2013; ACCEPTED: 15 August 2013 220 The Journal of Emergency Medicine, Vol. 46, No. 2, pp. 220–222, 2014 Copyright Ó 2014 Elsevier Inc. Printed in the USA. All rights reserved 0736-4679/$ - see front matter http://dx.doi.org/10.1016/j.jemermed.2013.08.066
Transcript
The Journal of Emergency Medicine, Vol. 46, No. 2, pp. 220–222, 2014Copyright � 2014 Elsevier Inc.
Printed in the USA. All rights reserved0736-4679/$ - see front matter
WOMAN WITH RIGHT LOWER QUADRANT MASS AND ABDOMINAL PAIN
Sam S. Torbati, MD, Shomari Hogan, MD, Elaine Vos, BA, and Elliot Banayan, BA
Department of Emergency Medicine, Cedars-Sinai Medical Center, Los Angeles, CaliforniaReprint Address: Sam S. Torbati, MD, Department of Emergency Medicine, Cedars-Sinai Medical Center, 8700 Beverly Boulevard, Los Angeles,
CA 90048
CASE REPORT
A 23-year-old woman presented to the emergency depart-ment (ED) with a 1-day history of sharp right lower quad-rant pain, nausea, vomiting, and anorexia. Vital signs
aginal ultrasound (coronal view) of thehowing a thick-walled (white arrows),mass measuring 7.73 cm � 7.44 cm,a teratoma. Note the nonuniform inter-rn: Anechoic area representing cysticmass (C), diffusely echogenic area with
(F) representing sebaceous material
ruary 2013; FINAL SUBMISSION RECEIVED: 13 Junugust 2013
220
were within normal limits, except for a heart rate of 119beats/min. Physical examination elicited tenderness topalpation in the right lower quadrant with guarding.There was an absence of referred pain or rebound tender-ness. Laboratory studies were significant for a whiteblood cell count of 19.2/mL. An ED bedside ultrasoundof the right lower quadrant revealed a complex masswith a nonuniform pattern of internal echoes. The appen-dix could not be visualized. A formal transvaginal ultra-sound confirmed the presence of a complex cystic mass
Figure 2. Thin band-like echoes, within the sebaceous com-ponent, representing tufts of hair (H).
Figure 3. Contrast-enhanced computed tomography scan ofthe pelvis (coronal view) showing a large heterogeneousmass in the midline compatible with a teratoma (black ar-rows) containing attenuation of fat (F), centrally located tuftsof hair (H), and a tooth-like calcification (T). The uterus isshown posterior to the teratoma (U).
Right Lower Quadrant Mass and Abdominal Pain 221
with a heterogeneous pattern of echogenicity located inthe right adnexa consistent with a teratoma (Figures 1and 2), and normal blood flow to both ovaries. Subse-quent to admission for planned teratoma resection the pa-tient developed low-grade fever and peritoneal signs. Anabdominal computed tomography (CT) scan revealed aninflamed and dilated appendix measuring 11mm in thick-
Figure 4. Contrast-enhanced computed tomography scanof the abdomen and pelvis (sagittal view) revealinga markedly inflamed and dilated appendix (black arrows)with periappendiceal fat stranding. The teratoma (whitearrows) is located in the midline of the pelvis, justsuperior to the urinary bladder (B), containing a tooth-like calcification (T).
Figure 5. Contrast-enhanced computed tomography scanof the abdomen and pelvis (coronal view of right lower quad-rant only) showing an inflamed appendix with an enhancedthickenedwall, measuring 11mm in diameter (A) and periap-pendiceal fat stranding (black arrows) lateral to the psoasmuscle (P).
ness (Figures 4 and 5) in addition to a largemidline pelvicmass with mixed attenuation of fat, tufts of hair, and cal-cium compatible with a teratoma (Figures 3 and 4). Thepatient underwent emergent laparoscopic appendectomyand right salpingo-oophorectomy, including resection ofa teratoma containing hair, sebum, and calcifications,without complication.
DIAGNOSIS
Acute Appendicitis with an Incidental Finding ofa Teratoma
The incidence of teratoma in women is approximately 8.9cases per 100,000 (1). The incidence of appendicitis ismuchhigher,with a lifetime risk of 6.7% (2). The incidenceof both diseases in the same patient is unknown. Teratomasare usually asymptomatic (3,4). Symptoms, if present,are generally due to compression and obstruction of sur-rounding organs causing pressure symptoms, abdominalheaviness, or dull pain (4,5). Acute pain in the setting ofa teratoma often represents cyst rupture, bleeding into thecyst, or ovarian torsion (5,6). Ovarian torsion is the most
222 S. S. Torbati et al.
common complication, carrying a 15% risk (6). Ultrasoundis the initial diagnostic modality of choice (4).
Treatment involves ovarian cystectomy oroophorectomy if future pregnancy is no longer desired(7�9). This case demonstrates the difficulties in thediagnosis of acute abdominal pain in women. Althoughimaging can be safely avoided in young men witha characteristic presentation for appendicitis, womenoften require advanced imaging, including a CT scan, todistinguish between pelvic and abdominal pathologies(4,10,11). In this case, a CT scan was required toaccurately diagnose appendicitis, the true cause of thepatient’s acute symptoms.
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5. Blaustein AU, Kurman RJ. Blaustein’s pathology of the female gen-ital tract. Berlin: Springer-Verlag; 2002.
7. Milingos S, Protopapas A, Drakakis P, et al. Laparoscopic treatmentof ovarian dermoid cysts: eleven years’ experience. J Am AssocGynecol Laparosc 2004;11:478–85.
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