Clinical Review

What is causing her abdominal pain?

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How transvaginal ultrasound can expedite the diagnosis


CASE: A healthy, nulliparous, 20-year-old woman visits her ObGyn to report a 2-day history of right lower quadrant pain. Her last menstrual period was appropriately timed and normal. She is not sexually active. Upon examination, she exhibits minimal left and right lower quadrant tenderness. Examination with the vaginal speculum reveals no vaginal or cervical abnormalities, and bimanual examination reveals a uterus of normal size, with cervical motion tenderness but no adnexal fullness or mass. For this reason, transvaginal ultrasound (TVUS) is performed. It reveals an enlarged, edematous appendix adjacent to a normal-appearing right ovary (FIGURE 1).

No uterine or ovarian pathology is noted. Because the appendix is enlarged on TVUS, Doppler interrogation is added, which shows abundant vascularity of the appendix (FIGURE 2).

What do these findings suggest?
Acute appendicitis is the most likely diagnosis, as both the physical findings and ultrasound imaging point to it. The patient is referred to a general surgeon, who examines her, noting that she is afebrile, with tenderness in the right lower quadrant. She exhibits localized guarding at McBurneys point, with mild rebound. There is no sign of organomegaly. Bowel sounds are normal, with no distention. The patient undergoes laparoscopy, which confirms the diagnosis. The appendix is resected successfully, and rupture is averted (FIGURE 3).

The patient is discharged home on the first postoperative day. At a follow-up visit 2 weeks later, she is fully recovered and has returned to full and normal activity.

Clinicians who are familiar with the appearance of an inflamed appendix on TVUS may be able to expedite the management of women with appendicitis, avoiding the potential delay, expense, and radiation exposure associated with computed tomography imaging of the abdomen and pelvis.

The authors are grateful to Grace J. Horton, RDMS, and Christine L. Bubier, AS, RT(R), RDMS, who generated the images in this case.

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