A 42-year-old woman comes to the emergency department due to diffuse abdominal pain. The pain began 6 hours ago while the patient was playing tennis. She reports that the pain started suddenly in the right lower abdomen and has become diffuse and radiates to her right shoulder. The patient has never had this pain before and has no previous trauma. Two months ago, she was hospitalized for a deep venous thrombosis; the patient had been taking combination oral contraceptives, which were discontinued immediately. She has since been taking an oral anticoagulant daily. The patient has no other medical conditions and has had no prior surgery. Her last menstrual period was 3 weeks ago. She does not use tobacco, alcohol, or illicit drugs. Temperature is 37.2 C (99 F), blood pressure is 80/40 mm Hg, and pulse is 118/min. Physical examination shows a rigid abdomen with diffuse tenderness, rebound, and guarding. Laboratory results are as follows: Which of the following is the most likely diagnosis in this patient?

Question

A 42-year-old woman comes to the emergency department due to diffuse abdominal pain.  The pain began 6 hours ago while the patient was playing tennis.  She reports that the pain started suddenly in the right lower abdomen and has become diffuse and radiates to her right shoulder.  The patient has never had this pain before and has no previous trauma.  Two months ago, she was hospitalized for a deep venous thrombosis; the patient had been taking combination oral contraceptives, which were discontinued immediately.  She has since been taking an oral anticoagulant daily.  The patient has no other medical conditions and has had no prior surgery.  Her last menstrual period was 3 weeks ago.  She does not use tobacco, alcohol, or illicit drugs.  Temperature is 37.2 C (99 F), blood pressure is 80/40 mm Hg, and pulse is 118/min.  Physical examination shows a rigid abdomen with diffuse tenderness, rebound, and guarding.  Laboratory results are as follows:  Which of the following is the most likely diagnosis in this patient?

Quizplus · Accepted Answer

11ec25c8_d896_0560_bc81_29568c1ae91e_MD0003_00 This patient likely has hemoperitoneum due to a ruptured ovarian cyst. Ovarian cysts are common in ovulating women of reproductive age (like this patient who recently discontinued combined oral contraception) and occur when fluid fills the space of the recently released follicle following ovulation (ie, corpus luteal cyst). In general, ruptured ovarian cysts are benign and cause minimal lower abdominal pain. However, in patients on anticoagulation (as in this patient being treated for deep vein thrombosis), cyst rupture can cause significant intraabdominal bleeding (ie, hemoperitoneum). Patients classically have unilateral lower abdominal pain that becomes increasingly diffuse, often radiating to the shoulder (due to phrenic nerve irritation). As blood fills the abdominal cavity, patients also develop peritoneal signs (eg, rigidity, rebound, guarding) and hemodynamic instability (eg, hypotension, tachycardia). Diagnosis can be confirmed by pelvic ultrasound, which typically reveals heterogeneous pelvic free fluid and a possible ovarian cyst (if not completely drained). Patients with peritoneal signs and hemodynamic instability require emergency surgery (eg, diagnostic laparoscopy). (Choice A) Acute appendicitis can cause right lower quadrant pain, possibly with rebound and rigidity (if the appendix is perforated); however, patients typically have fever and leukocytosis, which are not seen in this patient. (Choice B) Acute mesenteric ischemia occurs due to inadequate intestinal perfusion (eg, thromboembolism of the superior mesenteric artery). However, pain is classically out of proportion to the examination (ie, no peritoneal signs). Shoulder pain (indicates abdominal free fluid) would not be present. (Choice C) Ovarian torsion, which can occur with an ovarian cyst, typically presents with acute lower abdominal pain. However, it does not typically cause hemoperitoneum (eg, hypotension, acute blood loss anemia). Shoulder pain is not seen. Ovarian torsion (Choice D) Ruptured ectopic pregnancy can present with hemoperitoneum; however, this patient has a negative quantitative β-hCG level, making this diagnosis unlikely. Ruptured ectopic pregnancy (Choice F) Splenic rupture may cause hemoperitoneum but is typically associated with blunt abdominal trauma. In addition, pain initially begins in the left upper quadrant rather than the right lower quadrant. Educational objective: A ruptured ovarian cyst can cause hemoperitoneum, which presents with abdominal rigidity, rebound, guarding, and referred shoulder pain. Hemodynamically unstable patients with peritoneal signs require emergency surgery. References: Successful conservative management of ruptured ovarian cysts with hemoperitoneum in healthy women. (http://www.ncbi.nlm.nih.gov/pubmed/24608424)

A 42-Year-Old Woman Comes to the Emergency Department Due to Diffuse