By Tedler D. Depaynos, MD
It was a surprise when an engineer-contractor coffee mate whom we thought to be still in Palawan suddenly appeared and joined us. We knew that several months earlier he was there with his wife for vacation so that we were curious why they returned there for another vacation. They could have gone to other places like Boracay or even Hongkong. While sipping our coffee, he related the reason why.
While they were in Metro Manila last December doing some early Christmas shopping, his wife suddenly felt a severe but vague abdominal pain. She could not localize the pain and when she thought of going to the hospital, the pain suddenly subsided. It became tolerable and so they were able to come home and she went on with her usual activities. There were occasions when severe pain would recur but lasting only for an hour or less until after 2 weeks the pain became continuous and generalized aggravated by movement and coughing. He then rushed her to the hospital.
Pain could be elicited by palpating all the quadrants of the abdomen but there was more rigidity at the right lower quadrant where the appendix was located. The chest x-ray was negative and although the abdominal x-rays revealed partial ileus or paralysis of the intestines and minimal ascitis or fluid in the abdominal cavity, the abdominal ultrasound was not definite. Acute appendicitis was the initial impression but after hydrating the patient she was noticed to be getting severely anemic which was confirmed by a series of blood tests. Acute appendicitis however does not bleed that massively causing severe anemia so that a bleeding pathology probably on the right female organs or adnexia was entertained. A ruptured ovarian cyst was considered and a malignant lesion was feared. Ectopic pregnancy was likewise considered but the pregnancy test was negative and no signs or symptoms of pregnancy were elicited. Besides the patient and her husband could no longer think of pregnancy as the cause for they had been attempting it for the past 8 years that they have been married.
Because of the continuous abdominal pain and rigidity which implied peritoneal irritation, the patient underwent emergency surgery.
The right fallopian tube was filled and oozing with blood which had obviously filled the abdominal cavity resulting in the ascitis and causing the severe anemia. A tumor in that area is rare so that an ectopic pregnancy was considered. True enough this was confirmed in the specimen that was sent to the laboratory. The pregnancy test perhaps was done late already.
A fertilized ovum is supposed to travel to the uterus to be implanted. In this case, it was stopped at the fallopian tube where it got “implanted”. It could happen to any normal female, but according to statistics, it is more common in females who had a history of “pelvic inflammatory disease” or PID especially those whose fallopian tubes were inflammed called “salphingitis”. Like in this patient severe bleeding may occur which necessitated blood transfusion. In some cases bleeding may become a serious complication specially those who are not agreeable to blood transfusion because of their beliefs.
Classical treatment in these cases is open abdominal surgery where the source of bleeding is excised. As a rule however an attempt to save the fallopian tube is always done. The other fallopian tube in this patient appeared grossly normal and likewise her ovaries. The elective removal of the normal appendix was not thought of.
Our coffee mate together with his wife never entertained pregnancy as the cause of their problem. They were dumbfounded but still thankful that the lesion was not cancerous. They were then praying and hoping that if ever there would be another pregnancy, it would be normal so that they would at least have one child.
They returned to Palawan because probably the pregnancy occurred there. Besides it was the advice of a distant relative after butchering a native chicken and taking a shot of cheap gin. The relative even emphasized that they should again enter the “cave”. We just widened our grin and as we finished our black, unsugared coffee, we wished them success. **
