case report A Rare Case of Simultaneous Ectopic Pregnancy and Appendicitis as “Shouldn’t Miss” Diagnoses
Suk Hee Lee, Kyung Woo Lee*, Tae Chang Jang, Gyun Moo Kim, Young Woo Seo, Seung Hyun Ko
Department of Emergency Medicine, College of Medicine, Daegu Catholic University, Daegu, Korea
*Corresponding author: Kyung Woo Lee, Department of Emergency Medicine, College of Medicine, Daegu Catholic University, 33, Duryugongwon-ro 17-gil, Nam-gu, Daegu, Republic of Korea. Tel: +82536504197; Fax: +82536504930; Email: turtle072@hanmail.net
Received Date: 04 April, 2018; Accepted
Date: 12 April, 2018; Published Date: 20 April, 2018
Citation: Lee SH, Lee KW, Jang TC, Kim GM, Seo YW, et al. (2018) A Rare Case of Simultaneous Ectopic Pregnancy and Appendicitis as “Shouldn’t Miss” Diagnoses. Ann Case Rep: ACRT-175. DOI: 10.29011/2574-7754/100075
1. Abstract
An abdominal pain is one of the most common symptoms in the emergency. Ectopic pregnancy and appendicitis are diseases that need differential diagnosis for childbearing women presenting acute abdomen. But the incidence of simultaneous ectopic pregnancy and appendicitis is extremely low, and the etiology is unclear. We experienced a 21-year-old woman who had right lower quadrant abdominal pain. She had positive finding of urine pregnancy test, nonspecific findings of transvaginal ultrasonography (US), and findings consistent with appendicitis of abdominal US. Emergent laparoscopy was performed, and we confirmed ectopic pregnancy at right fallopian tube and appendicitis. As the first report in Korean Emergency Medicine literature, we recommend that physicians should always consider complex possibilities and perform diagnostic and therapeutic laparoscopy when pregnant women present acute abdomen and have uncertain diagnosis with high suspicion.
2. Keywords: Acute abdomen;
Appendicitis; Ectopic pregnancy; Pregnant women
1. Introduction
An abdominal pain is one of the most common symptoms and accounts for 5~10% of all presentations in the emergency center [1]. Ectopic pregnancy and appendicitis are diseases that need differential diagnosis when childbearing women have abdominal pain. Appendicitis is estimated to occur at an incidence of 1:1,500 and ectopic pregnancy is 16:1,000 [2,3]. The incidence of simultaneous ectopic pregnancy and appendicitis is extremely low. And the etiology is unclear. It is important to consider the potential morbidity and mortality of missed ectopic pregnancy or missed appendicitis. Maternal mortality ranges about 9% with ruptured ectopic pregnancy and fetal mortality ranges from 3~5% with early appendicitis to 20% with perforated appendicitis [1].
This case is about a patient who had right lower quadrant abdominal pain caused by ectopic pregnancy and appendicitis simultaneously.
2. Case Report
A
21-year-old woman who had abdominal pain for 3 days came to our emergency
center. The site of pain was right lower quadrant abdomen and the nature was
squeezing and pricking. She had a positive finding of urine pregnancy test 2
days ago, but the gestational sac was not seen on transvaginal US at a local
obstetric clinic. She had a spontaneous delivery 11 months before and had been
breastfeeding her child. She had a history of irregular menstrual periods, and
reported that she had a 4-day period of large amount of menstrual bleeding 15
days prior to presentation. She did not have a surgical history and underlying
diseases. Her physical examination showed severe tenderness, rebound tenderness
on right lower quadrant area and mild tenderness, rebound tenderness on left
lower quadrant area. Her vital signs were: blood pressure 121/63mmHg, heart
rate 80 beat per minute, respiratory rate 23 per minute and body temperature
36.6℃. Initial laboratory results showed
white blood cell 7.1×109/L,
hemoglobin 119g/L, hematocrit 0.36 Proportion of 1.0, and C-reactive protein
67.62 nmol/L (reference value: 0.76 ~ 28.5 nmol/L). Urine pregnancy test
finding was positive and beta-human chorionic gonadotropin(ß-hCG) hormone level was elevated as the value of
675.87 IU/L. The abdominal US showed dilated tip and edematous wall and
elevated vascularity of appendix consistent with findings of appendicitis (Figures 1-3). She also had two possibilities of normal
pregnancy and ectopic pregnancy based on the finding of local transvaginal US.
General Surgery decided to perform a laparoscopic operation with Obstetrics and
Gynecology. During the operation the gynecologist visualized hemoperitoneum and
edematous change of right fallopian tube, and performed a right salpingectomy
to confirm and remove the ectopic pregnancy. Also, he visualized the evidence
of ruptured corpus luteum cyst of right ovary and it considered the cause of
hemoperitoneum. The general surgeon completed the appendectomy. She did well
throughout the operation and no operative complication was reported. Pathology
of the resected right fallopian tube and appendix consistent with ectopic
pregnancy and acute suppurative appendicitis. She discharged 5 days after the
operation without any complication and visited the outpatient clinic for
follow-up.
3. Discussion
An abdominal pain during pregnancy has many diagnoses to distinguish. It is difficult to diagnose properly because of alterations in laboratory parameters, vital signs, the location of organs in the abdomen and pelvic cavity that occur during a normal pregnancy, and the limitation of available radiological modalities.
It becomes possible to diagnose ectopic pregnancy before the symptoms and signs presented because of the development of US and high sensitivity of ß-hCG hormone test. But US is operator dependent and is often non-diagnostic. Therefore, if there is a high suspicion of ectopic pregnancy based on patient’s history and the result of physical examination without definite US findings, physicians should do additional close follow-up and obtain a repeat ß-hCG hormone test [1].
In our case, the patient had symptoms and signs such as vaginal bleeding, amenorrhea, abdominal pain, McBurney’s sign and findings of abdominal US consistent with ectopic pregnancy and appendicitis. But there was no confirmative diagnosis of ectopic pregnancy. Emergent laparoscopy is needed for the patient suspected ruptured ectopic pregnancy and appendicitis due to diagnostic uncertainty. We recommend that physicians perform diagnostic and therapeutic laparoscopy when pregnant women present acute abdomen and have uncertain diagnosis.
Previously
23 cases reported simultaneous ectopic pregnancy and appendicitis from 1960s to
2008, and several cases reported after 2008(Table 1)
[4]. It is unclear whether appendicitis is
developed with ectopic pregnancy by accident or appendicitis becomes one of the
cause of ectopic pregnancy. There is not a novel theory of the etiology of
appendicitis. But the luminal obstruction and inflammation of appendix is
considered the most possible etiology. The luminal obstruction of appendix is
caused by lymphocyte proliferation and fecalith. It compresses the lumen, and
makes ischemic state of appendix. The inflammation of appendix is caused by
ulceration after gastroenteritis or colitis, and it makes secondary infection
of ulcer by intestinal flora [4]. According to
these processes, some studies reported that appendicitis or the history of
appendectomy made inflammation of reproductive organs near the appendix and it finally
developed ectopic pregnancy [4-8]. It is
uncertain that which comes first but we assume that they are related because
75% of ectopic pregnancy develops at the right side [5,6].
This is the first case report of simultaneous ectopic pregnancy and appendicitis published in Korean Emergency Medicine literature. It is extremely rare and difficult to diagnose. Physicians should always consider complex possibilities for childbearing women presenting acute abdomen, especially pregnant women. Early laparoscopy is recommended instead confirmation of diagnosis if it is highly suspicious and surgeons should check the appendix for excluding appendicitis during the operation of ectopic pregnancy.
4. Conflict of Interest
The authors have no conflict of
interest to declare.
Figure 1: Dilated tip of
appendix on abdominal US( ++ 6.79 mm).
Figure 2: Edematous change
of appendiceal wall on abdominal US (++ 7.09 mm).
Figure 3: Elevated
vascularity of appendix on abdominal US.
|
No. |
Journal |
Age |
Symptom and Sign |
Modality |
Diagnosis |
Management |
|
1 |
Hazebroek EJ et al. [5] |
25 |
Lower abdominal pain Amenorrhea |
US Laparoscopy |
Left tubal ectopic pregnancy, ruptured Acute appendicitis |
Left partial salpingectomy Appendectomy |
|
2 |
Mir IS et al. [4] |
34 |
Periumbilical pain RLQ pain |
US Laparoscopy |
Right tubal ectopic pregnancy Acute appendicitis |
Right salpingectomy Appendectomy |
|
3 |
Ryu ES et al. [9] |
36 |
RLQ pain Vaginal bleeding |
US CT Laparoscopy |
Heterotopic pregnancy ; intrauterine and right fallopiantube Acute appendicitis with serosal hemorrhage |
Missed abortion a week ago Right salpingectomy Appendectomy |
|
4 |
Ankouz A et al. [3] |
38 |
RLQ pain, Amenorrhea Fever |
US Laparoscopy |
Right tubal ectopic pregnancy, perforated Acute appendicitis |
Right salpingectomy Appendectomy |
|
5 |
Thmpson RJ et al. [10] |
27 |
Lower abdominal pain Amenorrhea |
US Laparoscopy |
Ectopic pregnancy, tip of appendix Carcinoid tumor, tip of appendix Acute appendicitis |
Appendectomy |
|
6 |
David P et al. [6] |
41 |
RLQ pain Amenorrhea Fever |
US Laparoscopy |
Right tubal ectopic pregnancy Acute appendicitis |
Right salpingectomy Appendectomy |
|
7 |
Pate JD et al. [1] |
25 |
RUQ, RLQ pain |
US MR Laparoscopy |
Right tubal ectopic pregnancy Acute appendicitis |
Right partial salpingectomy Appendectomy |
Table 1: The cases of simultaneous ectopic pregnancy and appendicitis since 2008.