By Tedler D. Depaynos, MD
The patient has been employed in a Call Center and throughout the years she rose from the ranks. She is from a nearby province and has been comfortable staying in a rented apartment all alone. She was going to her work one evening when she felt a slight abdominal pain over the area where she had the scar of a previous appendectomy. She consulted their company physician who diagnosed her to have a simple urinary tract infection. The pain appeared to have been relieved by the prescribed medications. The following evening, however, the pain recurred which was more severe so she had to go undertime as she decided to go home. Before arriving at her place, however, the pain worsened which made her divert the taxi she was riding in to the Emergency Room of the nearest hospital.
The MDs who attended to her found an “acute abdomen” which was practically “rigid” and a gentle touch by the examining fingers would cause pain. Even a little “coughing” or just “deep breathing” elicited pain. “Acute abdomen” would mean “emergency abdominal surgery” but a possible etiology should at least be entertained. In this case the etiology was not definite so they have had to bring her to an abdominal CT Scan to help them give a more precise diagnosis. True enough she was diagnosed to have a right ovarian cyst that probably have ruptured. The leaked contents may have caused severe irritation resulting in severe abdominal pain and the sign and symptoms of an “acute abdomen”.
Because the patient had a history of appendicitis, an OB-Gyne pathology was mainly entertained.
General Surgeons thinking of “acute appendicitis” always consider an OB-Gyne pathology especially ruptured ovarian cyst in female patients because of their similar manifestations. The inflammation of the appendix may be gradual and eventually rupture causing severe irritation and sudden severe pain. This may similarly occur in ruptured ovarian cyst. Unless the rupture is suddenly massive the pain would not be gradual in appearance. A small continuous leakage would cause a persistent pain with increasing severity as more fluid is accumulated in the abdominal cavity causing more irritation. General Surgeons in some cases do an official OB-Gyne referral and vice versa.
Abdominal ultrasound usually do not visualize the appendix even though “acute” or enlarged but ovarian cysts may be better appreciated. Most young doctors however now prefer the CT Scan which is generally more precise if it is available in the medical institution where they are practicing.
With the diagnosis of ruptured ovarian cyst, a “laparoscopic surgery” was initially entertained to be done to this patient to remove the “cyst” but because of the history of a previous operation this was not pushed thru. Resulting abdominal adhesions or scarring may make the procedure difficult. Many young OB-Gyne specialists are now trained to do “laparoscopy” because the incision wound is usually just an inch and the recovery period is much less with just an overnight stay in hospital being sufficientmost of the time. Besides, many patients now prefer the smallest scar possible.
True enough the patient had “abdominal adhesions” which made her operation last longer. The surgeons tried to preserve the involved ovary by just removing the cyst which is always attempted especially if the patient is still young and childless and the specimen is grossly non-malignant looking. Because of the hugeness of the pathology, however, they were forced to excise the whole right ovary. Anyway the left ovary appeared to be normal.
Good for the patient the official histopath result which usually is released after 7 working days revealed a non-malignant lesion. **