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Acute abdominal pain in the emergency Gynaecology setting

“what we have learnt ”Saadia Naeem, Rachana Dwivedi, Ineke van Herwijinen, Jenna Chadwick, T R Sayer

North Hampshire Hospitals NHS trust Basingstoke and North Hampshire Hospital RG24 9NA

Objectives

Conclusions

To assess:1. The time interval between acute admission and diagnosis to surgery.2. The role of ultrasound in acute setting and its correlation with laparoscopic findings.

Retrospective case note analysis of patients presenting with:

• An acute abdominal pain to Gynaecology within the last 2 years• 65 out of 156 notes were included.

We proposed a flow chart in our department to streamline the patient journey

Methods

70% (46) of patients with pain were reported to have ovarian causes; ovarian torsion 16% (7), ruptured cysts 22% (10) and others included follicles/corpus luteum. Other pathologies were pelvic inflammatory disease (PID) 13.5% (9), surgical 13.5% (9) and non specific causes 3% (2).

Acute abdominal pain is a common presentation. In our unit, patients are triaged in the Gynaecology Assessment Unit with ultrasound scanning (USS) if required.

Ultrasound diagnosis of ovarian cysts and adnexal masses varies with different scan expertiseVariations in expertise cause anxiety and unnecessary intervention i.e. follicles being reported as a cyst.With persistent pain and no definite clinical diagnosis, laparoscopy is sometimes used to reinforce negative findings to the patient and discharge them sooner.

Background Results Results

43% (28) of patients had a definitive management plan within 24 hours, 25% (16) were diagnosed within 48 hrs. 32% (21) had diagnostic delay between 3 and 10 days.

There was a positive correlation of 68% between scan findings, laparoscopy and improvement of symptoms.

10 out of 15 laparotomies correlated with

USS (66%). 72 % (13) with negative laparoscopy were <25 years.

The diagnosis of ovarian torsion based on USS was 2/6 (33%): the rest of the torsions had features of cystic mass or enlarged ovarian volume.

Pathology

Time interval

0

5

10

15

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30

within 24 hours within 24-48 hours diagnostic delay 3-10days

Ultrasound correlation

ConclusionsIn women with normal findings on ultrasound, laparoscopy can be a valuable diagnostic tool with persistent symptoms.

It is important to use laparoscopies carefully to reduce unnecessary surgeries. However if torsion is clinically suspected laparoscopy should be performed promptly because scans are not conclusive for excluding torsion.

Reporting for younger patients requires caution as certain terms prompts the patient to believe there is pathology e.g. ‘free fluid’ or ‘follicles’, this leads to further unnecessary investigations.

In the younger population with negative laparoscopy, it is important to address both the psychosocial and environmental factors, to prevent recurrent admissions.

*RCOG - Term cyst should not be used for simple cyst less than 3 cm. greentop guideline62** Nurse Counsellor – specialist nurse trained in counselling patients how to manage ovulatory pain