Endometriosis With Salpingitis

Simulating Acute
Appendicitis

Preseptor : dr. Heny Damajanti, Sp.Rad., M.Sc

1. Servasius Gilland Gavrila 19360144

2. Uswatun Hasanah 19360154
3. Verta Vera Syaulatia 19360156
4. Vivi Yolandha 19360157
5. Winda Surya Ningsih 19360158
Anatomi Ginekologi
Anatomi Appendix
Introduction
Right iliac fossa (RIF) pain is a common clinical
problem. Acute appendicitis is the commonest cause for
RIF pain andmemergency abdominal surgery. Clinical
symptoms and signs of appendicitis are often non-specific
and can mimic a variety of commonly encountered disease
processes leading to false negative diagnosis. Prompt and
accurate diagnosis with early surgical intervention is
essential to minimise morbidity. Misdiagnosis of appendicitis
is maximal in women of child bearing age because of
frequent clinical overlap of appendicitis with various
gynaecological conditions.
 Case Report
A 37-year-old lady presented at our emergency department with
chief complaints of pain RIF for one day duration associated with
three episodes of vomiting in last 12 hours. She denied any
history of urinary or bowel complaints. Her menstrual cycle had
been regular; however, she often used to have dysmenorrhoea. diagnosis of
She had her last menstrual period seven days back. On clinical acute
examination, she was febrile (temp: 100°F) and had tachycardia
(pulse rate: 92 per minute). Local examination revealed appendicitis
tenderness in the RIF and hypogastric region with rebound
tenderness especially around the McBurney’s point. An urgent
total leucocyte count showed leukocytosis (TLC 12300 per cu
mm).

There is a partially distended urinary bladder revealed bilateral complex adnexal

masses with internal echoes abutting the uterus. The uterus, however, was found
to be normal. Free fluid was present in RIF as well as pouch of Douglas. There
was probe tenderness over this tubular structure. Although, the images of the
tubular structure as mentioned above were not typical for classical appendicitis,
based on the clinical profile and ultrasonographic findings, possibility of atypical
appendicitis in association with pelvic endometriosis was raised. The attending
surgical specialist was informed about pros and cons of the ultrasonographic
findings who decided in favour of surgery. At surgery, the appendix was found to
be normal. What was thought to be an atypical appendicitis on USG was actually
an inflamed and kinked right fallopian tube extending from the right iliac fossa
reaching almost up to the midline with the ampullary end directed medially.
There were multiple areas of endometrial implants on the fallopian tube.
 Discussion
Acute appendicitis remains the most
common surgical emergency with a life-
time occurrence of 7%.
Despite being a common problem and
technological advancement in the recent
past, acute appendicitis may still pose a
diagnostic dilemma even to the best of
clinicians. Laboratory investigations,
though useful, are often non-specific.
Rarely, endometriosis involving the
terminal ileum can mimic clinical features
of appendicitis. The RIF and hypogastric
pain which our patient had can be
retrospectively explained by rupture of
endometriotic cyst in the right adnexa
and/or inflamed right fallopian tube.
Dilated right fallopian tube mimicking the
appearance of an appendix and suggests
presence of undulating mucosal folds in the
fallopian tube as a differentiating factor from
appendix. Our patient had salpingitis resulting in
overall thickening and enlargement of tubal
diameter. The atypical sonographic features in this
case were: the proximal end of the tubular
structure could not be traced to the caecum,
diameter of the tubular structure was 7 mm which
could be considered borderline for a diagnosis of
appendicitis and the structure was rather too long
to be a normal sized appendix.
Figure 1 (A, B) Ultrasonogram of pelvis (transverse &
longitudinal sections) demonstrating bilateral complex
adnexal masses with internal echoes. UT: uterus, UB:
urinary bladder, TR: transverse, SAG: sagittal
Figure 2 High resolution ultrasonogram of right
iliac fossa and hypogastric region demonstrating
a blind ending tubular structure with diameter of
7 mm.
Salpingitis

Salpingitis is a type of pelvic inflammatory disease

(PID). PID refers to an infection of the productive organs.
It develops when harmful bacteria enter the reproductive
tract. Salpingitis and other forms of PID usually result
from sexually transmitted infections (STIs) that involve
bacteria, such as clamydia or gonorrhea

Salpingitis causes inflammation of the fallopian tubes.

Inflammation can spread easily from one tube to the other, so
both tubes may become affected. If left untreated, salpingitis can
result in longterm compliccations.
Not every woman who gets this
condition will experience Risk Factor
symptoms

• Foul-smelling vaginal discharge Salpingitis is usually caused by bacterial

Symptoms
• Yellow vaginal discharge infections acquired via vaginal
• Pain during ovulation, intercourse.
menstruattion, or sex
• Spotting between periods • Have had an STI
• Dull lower back pain • Have unprotected sex
• Have multiple sexual partners
• Abdominal pain
• Have one partner who has multiple
• Nausea sexual partners
• Vomiting
• Fever While rare, abdominal infections or
• Frequent urination procedures, such as appendicitis or
IUD insertion, may cause salpingitis
 Endometrio
sis
Endometriosis is when the tissue that makes up the
uterine lining (the lining of the womb) is present on
other organs inside your body. Endometriosis is
usually found in the lower abdomen, or pelvis, but
can appear anywhere in the body. Women with
endometriosis often have lower abdominal pain, pain
with periods, or pain with sexual intercourse, and
may report having a hard time getting pregnant. On
the other hand, some women with endometriosis may
not have any symptoms at all.
 Symptoms
Edometriosis
Pain, including pelvic or lower abdominal pain
and pain with menses, is the most common
symptom of endometriosis. Women may also
have pain with intercourse. The symptoms are
often “cyclical” meaning that the pain is worse
right before or during the period, and then
improves. Women may have constant pelvic or
lower abdominal pain as well. Other symptoms
include subfertility, bowel and bladder
symptoms (such as pain with bowel
movements, bloating, constipation, blood in the
urine, or pain with urination), and possibly
abnormal vaginal bleeding.
Acute Appendicitis

Acute appendicitis is inflammation of

the appendix, the narrow, finger-shaped
organ the branches off the first part of
the large intestine on the right side of
the abdomen. Although the appendix is
a vestigal organ with no known function,
it can become diseased. In fact, acute
appendicitis is the most common
reason for abdominal surgery in the
world.
Symptoms
• Vague discomfort or tenderness near the navel
(early in an attack), migrating to right lower
quadrant of the abdomen
• Sharp, localized, persistent pain within a few hours
• Pain that worsens with movement, deep breathing,
coughing, sneezing, walking or being touched
• Constipation and inability to pass gas, possibly
alternating with diarrhea
• Low fever (below 102°F). A high fever (possibly
accompanied by chills) may indicate an abscessed
appendix
• Rapid heartbeat
 HSG

D
D
D
Figure 1 - Both tubes are completely opaque, with positive
Cotté proof, with multiple parietal diverticular formations
in the cornual isthmic portion (white arrows).
 HSG

D
D
D
Figure 2 - Patient with a history of left tubal pregnancy. The x-ray shows
multiple saccular formations in the cornual isthmic portion of both tubes
(contained inside the white circle). The right uterine tube is fully opaque
with peritonization of the contrasting medium (positive Cotté proof) while
the left tube is fully obstructed (negative Cotté proof).
 Insert Your Image

Figure 1 Ultrasound images from one patient with moderate acute salpingitis verified by laparosocopy. (A) and (B) show gray
scale ultrasound images of the left tube, (C) and (D) show colour Doppler images of the same tube. The lesion is a sausage-
shaped thick-walled unilocular cystic structure with a very small amount of echogenic fluid inside. We interpret the white oval
ring in (B) as the mucosa of the inflamed tube. As seen in (C) and (D), the tube is extremely well vascularized in Doppler
ultrasound examination. Please note the ring of colour in (D). We interpret this as rich vascularisation surrounding a
transverse section through the inflamed tube. We observed this finding also in other cases of moderate salpingitis, see Figs 2
and 3.
Insert Your Image

Figure 2 Ultrasound images of moderate acute salpingitis verified by

laparosocopy in a second patient. (A) A sausage-shaped solid structure
corresponding to the inflamed tube. (B) The rich vascularisation of the same
structure and rings of colour are discernable, see also Figs 1 and 3.
Thank You